Diagnosis of recurrent cervical carcinoma after radical hysterectomy

A standard surveillance program for cervical carcinoma patients treated with radical hysterectomy is reviewed. Between 1962-1984, 249 patients with stage IB cervical carcinoma treated with radical hysterectomy and pelvic lymphadenectomy were entered in the surveillance program. Of the 27 patients (11%) diagnosed with recurrent carcinoma, 17 (63%) were identified by clinical history, 22 (81%) by physical examination, five (18%) by vaginal cytology, six (22%) by chest radiography, and eight (30%) by renal contrast imaging. Combined clinical history and physical examination identified 24 patients (89%) with recurrent carcinoma. Disease recurrence was detected by vaginal cytology in one asymptomatic patient with a normal examination. The recommended surveillance procedures for patients with cervical carcinoma after radical hysterectomy include clinical history, physical examination, and vaginal cytology. Chest radiography and renal contrast imaging should be reserved for symptomatic patients.     

Interposition of the gallbladder — or the absent common hepatic duct and cystic duct

Interposition of the gallbladder is a rare anomaly, but its diagnosis is important since it represents a surgically correctable cause of jaundice. The patients present with jaundice, abdominal pain and sometimes an enlarged gallbladder. Radiological diagnosis may be difficult since the condition may be mistaken for a choledochal cyst, hydrops of the gallbladder or Caroli's disease. The ultrasound, cholangiogram and surgical findings of dilated intrahepatic ducts adjacent to a normal or enlarged gallbladder with no dilatation of the common bile duct are presented in two children with this condition.     

Fetal growth sustained by parenteral nutrition in pregnancy

Severe maternal nutritional deprivation has been associated with intrauterine growth retardation, premature labor, and increased perinatal mortality and morbidity. The authors present four cases in which total parenteral nutrition was used successfully to support fetal growth in such diverse complications as twin pregnancy with maternal jejunoileal bypass, regional enteritis, and acute pancreatitis. Maintenance of fetal growth as evidenced by serial sonographic examination allows achievement of fetal lung maturation before delivery. In all the cases presented there was no perinatal mortality or morbidity. The main clinical implication of the report is the possible application of total parenteral nutrition to maintain adequate growth in fetuses small for gestational age because of maternal nutritional deprivation.     

Determinants of occupational disability following a low back injury: a critical review of the literature

The aim of this research was to determine prognostic indicators of work disability in occupational back pain as reported in the literature, by systematically searching the research literature, assessing the methodological quality of the research, and synthesizing the findings into a concise summary. An article was considered eligible for review if research participants had an injury of the back, the article was based on original research, published in English, and involved a cohort with back pain less than 6 months post injury with at least one follow up assessment. Each article was independently reviewed by two blinded reviewers using 19 appraisal criteria for methodological quality of prognostic studies. Nineteen studies met the methodological standard to be included. Time since onset, demographic factors, functional disability, psychological distress, pain reports, previous episodes, and work environment were identified as important prognostic factors. Most studies compartmentalized the factors they considered. What is needed is a comprehensive multivariate biopsychosocial job-related model of work disability.     

Bilious vomiting in the newborn: How often is it pathologic?

Background/Purpose: Intestinal obstruction is one of the most common reasons for admission to a neonatal surgical unit and frequently is manifest by bilious vomiting. Not all cases of neonatal bilious vomiting are caused by intestinal obstruction. This study aimed to investigate the outcome of neonates with bilious vomiting. Methods: A prospective audit was undertaken of all neonates with a history of bilious vomiting referred to a regional pediatric surgical unit during a 2-year period (1998 to 2000). Infants with bilious nasogastric aspirates but no vomiting were not included. Demographic details, symptomatology, investigations, and final diagnoses were recorded. Subsequent clinical progress was ascertained by out-patient review or telephone interview. Results: Sixty-three consecutive neonates (35 boys, 28 girls) were identified with a median gestational age of 40 (range 31 to 42) weeks and median birth weight of 3.5 kg (range 1.67 to 4.64). Median age at presentation was 26 hours (range, 9 hr to 28 days). A surgical cause of bilious vomiting was identified in 24 (38%): Hirschsprung's disease (n = 9), small bowel atresia (n = 5), intestinal malrotation (n = 4), meconium ileus (n = 3), meconium plug (n = 1), colonic atresia (n = 1), and milk inspissation (n = 1). Nineteen of these had both abdominal signs and an abnormal plain abdominal radiograph, and 4 had an abnormal abdominal radiograph only. In one infant with intestinal malrotation, clinical examination and plain radiography were unremarkable. After definitive surgery, all 24 infants were well at a median age of 14 (7 to 28) months. No surgical cause for bilious vomiting was found in 39 (62%) neonates whose symptoms resolved with conservative management. Conclusions: These data emphasize the maxim that bilious vomiting in the newborn should be attributed to intestinal obstruction until proved otherwise. However, in this prospective audit, bilious vomiting was not caused by intestinal obstruction in 62% of cases, and most of these infants suffered no further sequelae. J Pediatr Surg 37:909-911.     

Splenectomy after paediatric trauma: could more spleens be saved?

AIMS: Guidelines for the emergency management of paediatric splenic trauma became widely available in 1993. A regional survey was undertaken to assess the application of Advanced Paediatric Life Support guidelines to children who had undergone splenectomy after trauma. PATIENTS AND METHODS: All children who had undergone splenectomy for a ruptured spleen at 8 district hospitals and 2 teaching hospitals in our region between January 1994 and January 1999 were identified from histopathology departmental records. With appropriate permission their case notes were reviewed. RESULTS: Eleven children (9 males) were identified, all from district hospitals, with a median age at presentation of 11.8 years (range, 6.6-16.8 years). All presented within 6 h of blunt abdominal trauma. Median systolic blood pressure, pulse rate, haemoglobin concentration and injury severity score (ISS) on admission were 115 mmHg (range, 80-140 mmHg), 108 bpm (range, 84-150 bpm), 12.1 g/dl (range, 10.7-12.8 g/dl) and 17 (range, 17-29), respectively. Three children had additional relatively minor injuries. On admission, 3 children received an intravenous fluid bolus of 20 ml/kg and the remainder received only maintenance fluid requirements or less. Five children were investigated by ultrasound imaging, one by double contrast CT scan, and three by laparoscopy. Two children had no imaging studies prior to laparotomy. Laparotomy was performed by a consultant surgeon in 7 cases and by a specialist registrar in 4 cases. Ten children underwent total splenectomy and one child had a partial splenectomy. Median hospital stay was 7 days (range, 5-10 days). The child with an ISS of 29 developed a persistent pancreatic fistula and subsequently required a distal pancreatectomy. All children received Pneumovax and penicillin prophylaxis. CONCLUSIONS: All children made a full recovery without surgical morbidity. However, none of these cases fulfilled the recommended criteria for laparotomy in children with blunt abdominal trauma and splenectomy may have been avoidable.     

Modulation of the in vivo effects of gabapentin by vigabatrin and SKF89976A

Gabapentin (GBP) has been shown to reduce paired-pulse inhibition in the dentate gyrus of the urethane-anesthetized rat, which is a proconvulsant effect, and to shorten the afterdischarge duration, which is an antiepileptic effect. The mechanism by which GBP exerts these effects is not known, but a number of possibilities have been proposed. Here we tested the ability of vigabatrin (VGB), a GABA transaminase inhibitor, and SKF89976A, a selective GAT-1 blocker, to alter the effectiveness of GBP in the dentate gyrus in urethane-anesthetized adult Sprague-Dawley rats. VGB, alone at 100 mg/kg, had no effect on the evoked potentials or paired-pulse inhibition in the dentate gyrus, but did block lengthening of the afterdischarge. Pretreatment with VGB had no effect on the ability of GBP to reduce paired-pulse inhibition, but blocked the effect of GBP on seizure duration. SKF89976A, alone at 10 mg/kg, increased paired-pulse inhibition and blocked the lengthening of the afterdischarge in the seizure model. Pretreatment with SKF89976A had no effect on the actions of GBP on either paired-pulse inhibition or seizure duration. These results suggest that the action of GBP is not mediated through an inhibition of the GAT-1 transporter and probably not through an increase in basal levels of GABA. The data also suggest that the combination of VGB and GBP may be clinically less effective than the use of GBP alone.     

Lymph nodes of patients with regional metastases from head and neck squamous cell carcinoma as a predictor of pathologic outcome: size changes at CT before and after radiation therapy

BACKGROUND AND PURPOSE: Viable tumor in a neck dissection specimen is important in predicting prognosis and directing treatment. Our purpose was to clarify the importance of size changes of regional metastases from head and neck squamous cell carcinoma on CT scans obtained before and after radiation therapy (RT) as a predictor of pathologic outcome. METHODS: Thirty-seven heminecks in 34 patients who underwent pre-RT CT, RT, post-RT CT, and post-RT neck dissection were reviewed. Thirteen hemineck specimens were pathologically positive. Decrease ratios of the largest axial dimension of the lymph nodes between the pre- and post-RT CT studies were calculated. RESULTS: Six of 37 heminecks had a decrease ratio greater than 50%. These yielded negative specimens after planned neck dissection. In two of 37 heminecks, the largest axial dimension of the largest node increased between studies, resulting in negative decrease ratio. One (decrease ratio, -20%) had a positive specimen, and the other (decrease ratio, -3%) had a negative specimen. No interval change in size in the largest node was noted in one of the 37 heminecks; its specimen was positive. Average decrease ratios were 41.2% (range, -3% to 62%) in the negative specimen group (n = 24) and 27.2% (range, -20% to 50%) in the positive specimen group (n = 13). Univariate analysis revealed that the decrease ratio was not a significant predictor of a positive surgical specimen (P =.154). CONCLUSION: Heminecks in which the decrease ratio was greater than 50% tended to have a negative surgical specimen. However, this trend was not statistically significant.