Functional Outcome After Surgical Treatment of Esophageal Perforation

Background. The functional results after treatment of intrathoracic esophageal perforations have been poorly documented.

Methods. A retrospective review of 42 patients who underwent treatment of intrathoracic esophageal perforation associated with benign esophageal disease was performed.

Results. Of 42 patients treated for esophageal perforation, 25 underwent primary repair, 15 underwent esophagectomy and reconstruction, 1 underwent cervical esophagostomy and drainage followed by esophageal resection, and 1 had drainage alone followed by primary repair. Among the patients treated with primary repair, at least one additional operation was required in 13 patients. Of the 15 patients treated with esophagectomy and reconstruction, none required further operative treatment. Follow-up averaged 3.7 years, and of the 36 survivors available for follow-up, 18 (50%) required at least one esophageal dilation postoperatively, and 3 (8.3%) have required regular dilations. Subjectively, 19 of 36 patients (53%) indicate that their swallowing is better than before perforation, it was the same in 12 (33%), and worse in 4 (11%).

Conclusions. In conclusion, approximately one third of patients surviving primary repair of esophageal perforations have continued difficulty with swallowing, which often requires esophageal dilations or esophageal reconstructive procedures, or a combination of both. Optimal long-term results are achieved when primary repair is performed in patients with motor disorders or a “normal” esophagus. Esophagectomy is a better option in those patients with strictures or diffuse esophageal disease.     

Comparison of three computer scanning modes as an interface method for persons with cerebral palsy.

Occupational therapists are becoming increasingly involved with interface assessments. This involvement is improving the ability of persons with physical disabilities to interact with computers, augmentative communication aids, and other devices. The ability to use these devices facilitates participation in activities that would otherwise be much more difficult to pursue, such as communication, education, work, and recreation. The purpose of the present study was to systematically compare three basic modes of scanning--automatic, inverse, and step--with the use of a single-subject experimental design. Six subjects--3 with spastic and 3 with athetoid cerebral palsy--from a local school volunteered for the study. Results indicated that the 3 subjects with spastic cerebral palsy had the greatest difficulty using the automatic scanning mode. The 3 subjects with athetoid cerebral palsy had the most difficulty using the step scanning mode. The results of this study suggest that clients should attempt each scanning mode and that their performance with each mode be compared to ensure the most appropriate recommendations.     

A comparison between the Regnauld arthroplasty and osteotomies of the first ray for the treatment of hallux valgus

This article is a retrospective study comparing the efficacy of Regnauld arthroplasty to first ray osteotomies for the treatment of hallux valgus. One hundred consecutive cases of Regnauld arthroplasties were compared with 100 consecutive first ray osteotomies. One hundred fourty-one patients were available for follow-up, and based on clinical/radiographic examinations, 72 were treated with the osteotomy protocol (group A) and 69 with Regnauld arthroplasty (group B). Age at surgery, clinical symptoms, and preoperative radiologic findings were similar for the 2 groups; there was a preponderance of female patients (90%). The average follow-up was 49 months in group A and 51 months in group B. Clinical evaluation showed in the osteotomy group a more stable correction (79% v 49%), greater pain reduction (measured in a visual analog scale from 0 = pain free to 10 = deep intolerable pain), increased residual articular excursion of the first metatarsophalangeal joint (27 degrees of active dorsiflexion from neutral position v 8 degrees ), and less presence of central metatarsalgia (15% v 34%) (P <.05). The radiographic evaluation expressed more stable correction values in group A for the following parameters: joint preservation, sesamoid position, intermetatarsal angle (7 degrees v 12 degrees ), abduction angle of the hallux (14 degrees v 20 degrees ), and proximal articular set angle (8 degrees v 18 degrees ) (P <.05).     

Hand hygiene and glove use behavior in an Italian hospital.

In an Italian hospital, we observed that hand hygiene was performed in 638 (19.6%) of 3,253 opportunities, whereas gloves were worn in 538 (44.2%) 1,218 of opportunities. We observed an inverse correlation between the intensity of care and the rate of hand hygiene compliance (R2=0.057; P<.001), but no such association was observed for the rate of glove use compliance (R2=0.014; P=.078). Rates of compliance with hand hygiene and glove use recommendations follow different behavioral patterns.     

Atypical hemolytic uremic syndrome in human immunodeficiency virus-1-infected children

We describe the clinical and pathological findings of the hemolytic uremic syndrome (HUS) in two children with human immunodeficiency virus (HIV) infection. Both patients presented with microangiopathic hemolytic anemia, thrombocytopenia, and subsequently developed renal failure. The diagnosis of HUS was confirmed by renal histopathology in both patients. None of these children presented with bloody diarrhea, evidence of circulating antibody response to Escherichia coli O157 lipopolysaccharide, or other known risk factors for HUS, except for the presence of HIV infection. Each patient was treated with intravenous plasma infusion and renal replacement therapy. Their clinical course was characterized by non-oliguria and lack of significant hypertension throughout the acute phase of the disease. Despite these favorable clinical parameters, both patients developed end-stage renal failure. The etiology of this atypical HUS characterized by poor renal survival remains unknown and the role of HIV infection in its pathogenesis, although possible, is unclear. Received March 5, 1996; received in revised form and accepted October 15, 1996     

Detection of moderate and severe coronary artery stenosis with technetium-99m tetrofosmin myocardial single-photon emission tomography

The aim of this study was to determine the diagnostic accuracy of technetium-99m tetrofosmin myocardial imaging for the localization of coronary artery stenoses of different degrees of severity. Stress-rest single-photon emission tomography (SPET) was performed on separate days in 80 patients (64 males, 16 females; mean age 61 years; 43 patients with previous myocardial infarction; 18 patients with pharmacological stress), within 6 months of coronary angiography. Scintigraphic images were blindly and independently evaluated by three observers. Coronary stenosis was defined as a >50% narrowing in luminal diameter; severe stenosis was defined as a proximal stenosis of >75% or a peripheral stenosis of >90%. Coronary angiography revealed normal coronary arteries or insignificant coronary stenosis in 13 patients and significant coronary stenoses in 67 patients. The sensitivity and specificity of ^99mTc-tetrofosmin SPET in respect of severely stenosed vessels were, respectively, 80% and 65% for the left anterior descending artery (LAD), 100% and 46% for the right coronary artery (RCA) and 58 and 78% for the left circumflex artery (LCx) territories. Considering all the significantly stenosed vessels, a significant decrease in sensitivity was observed for LAD territories (to 59%, P=0.05), and a nonsignificant decrease for RCA (88%) and LCx (47%) territories while specificity values remained essentially unchanged. No significant changes in sensitivity or specificity were observed when regions with previous myocardial infarction were excluded. In conclusion, the sensitivity of ^99mTc-tetrofosmin SPET for the localization of individual stenosed vessels is only moderate when all significant stenoses are considered, but the ability of this technique to predict the location of severe coronary artery stenoses seems satisfactory, with the exception of the low specificity in respect of RCA territories. Received 26 April and in revised form 7 June 1997     

Micrografting in the treatment of severely burned patients

The micrografting technique, employed to treat patients with extensive TBSA burns and reduced areas of healthy donor skin, was assessed simultaneously with traditional mesh grafts (STSG) or Tiersch grafts in the treatment five severely burned subjects (average TBSA burned 35.6 per cent; average per cent of full thickness wounds 32.6 per cent).

At the first clinical control on day 6 post-surgery 93 per cent of the micrografted area was in situ and healthy: epithelialization of the wound sites was complete at day 21. Meshed STSG yielded 90 per cent attachment at day 6 post-surgery, with epithelialization complete at 12 ± 2 days post-surgery.

Functional results were equivalent no matter what technique was used, while aesthetic results were better in the areas where micrografting was carried out.

Although the micrograft technique is labour-intensive, if the expansion needed is at least 1:6, the aesthetic and functional results obtained are comparable to, or better than, those with meshed grafts. Also, large segments of micrograft are not compromised if a small area of mesh becomes detached, and epithelialization is faster and more uniform, enabling a reduction in both infection and length of hospital stay.