An unusual case of surgical emphysema

A 64-year-old man underwent laryngectomy, partial pharyngectomy and right block dissection of the neck for a squamous cell carcinoma of the right pyriform fossa with an involved right neck node. He had received pre-operative radiotherapy. The operation was uneventful. A 'Drevac' wound drainage system (Astra Meditec) was inserted in each side of the neck.     

Risk of subsequent cytological abnormality and cancer among women with a history of cervical intraepithelial neoplasia: a comparative study

A longitudinal study of 1,281 women with a histological diagnosis of cervical intraepithelial neoplasia (CIN) during 1974–76 is presented. After 12 years of follow-up, 30 percent of the women had further cytological abnormalities reported. The rate of subsequent abnormality was highest during the first 12 months of follow-up; thereafter, there was no evidence of any decline in the rate of subsequent abnormality with increasing duration of follow-up. Women from the CIN cohort had twice as many later cytological abnormalities as an age-matched cohort of women who were negatively screened during 1974–76 (excluding abnormalities within 12 months of entry to the study and after adjustment for smear frequency). The CIN cohort remained at substantially greater risk for a subsequent diagnosis of squamous cell carcinoma of the cervix compared with the control group of negatively-screened women (rate ratio 19.8, 95 percent confidence interval 2.4–163.6, P < 0.01). These results indicate that women who have received surgical intervention for CIN continue to have substantial morbidity from cervical abnormalities during medium-term follow-up.Dr Mitchell is Epidemiologist and Deputy Director, Victorian Cytology (Gynaecological) Service, PO Box 253B, Melbourne 3001, Australia; Dr Medley is Director, Victorian Cytology (Gynaecological) Service: Dr Carlin is Lecturer in Statistics, Department of Commuity Medicine, University of Melbourne. Address reprint requests to Dr Mitchell. Dr Mitchell is supported in part by grants from the National Health and Medical Research Council and the Anti-Cancer Council of Victoria.     

Tumor necrosis factor-alpha and lipopolysaccharide enhance interferon-induced antichlamydial indoleamine dioxygenase activity independently.

In macrophages, interleukin-1 (IL-1) and lipopolysaccharide (LPS) enhance the antichlamydial effect of interferon-gamma (IFN-gamma) by increasing indoleamine 2,3-dioxygenase (IDO) activity in a dose-dependent manner. Our objectives were to characterize the antichlamydial effect of tumor necrosis factor-alpha (TNF-alpha) on IFN-induced IDO activity and to establish the relationship between LPS and TNF-alpha in IDO potentiation. TNF-alpha inhibited chlamydial growth in a dose-dependent manner only in IFN-treated macrophages. Furthermore, excess tryptophan reversed the effect of combined cytokine treatment, indicating that IDO alone was responsible for chlamydial inhibition. The promonocyte THP-1 cell line, previously used to model the effect of IL-1 on IDO mRNA expression, was treated with IFN-gamma and increasing concentrations of LPS or TNF-alpha. IDO mRNA was quantified by RT-PCR, and IDO activity was measured by HPLC at 24 and 48 h after treatment, respectively. Both LPS and TNF-alpha enhanced IDO activity and IDO mRNA expression, with maximal IDO induction at 100 ng/ml LPS or 5 ng/ml TNF-alpha. Anti-TNF-alpha failed to neutralize the effects of LPS treatment, and insufficient TNF-alpha or IL-1 was produced by LPS-treated THP-1 cells to account for the enhancing effect of LPS, indicating that the effect of LPS on IDO was independent of TNF-alpha and IL-1.     

Abortion Incidence and Postabortion Care in Rwanda

Abortion is illegal in Rwanda except when necessary to protect a woman's physical health or to save her life. Many women in Rwanda obtain unsafe abortions, and some experience health complications as a result. To estimate the incidence of induced abortion, we conducted a national sample survey of health facilities that provide postabortion care and a purposive sample survey of key informants knowledgeable about abortion conditions. We found that more than 16,700 women received care for complications resulting from induced abortion in Rwanda in 2009, or 7 per 1,000 women aged 15–44. Approximately 40 percent of abortions are estimated to lead to complications requiring treatment, but about a third of those who experienced a complication did not obtain treatment. Nationally, the estimated induced abortion rate is 25 abortions per 1,000 women aged 15–44, or approximately 60,000 abortions annually. An urgent need exists in Rwanda to address unmet need for contraception, to strengthen family planning services, to broaden access to legal abortion, and to improve postabortion care.     

Brown Bowel Syndrome Secondary to Jejunoileal Bypass: The First Case Report

A 58-year-old woman with a surgical history of jejunoileal bypass in 1980 for weight reduction sought medical attention with multiple complaints. The patient had not been taking any nutritional supplements since her bypass surgery, 26 years previously. She was found to have osteomalacia, chronic diarrhea, secondary hyperparathyroidism, and hyperoxaluria with a frequent history of nephrolithiasis. Because of her severe osteodystrophy and metabolic complications, reversal of her jejunoileal bypass was recommended. Reversal of the jejunoileal bypass with a sleeve gastrectomy was performed. Laparotomy revealed brown discoloration of the entire alimentary limb with atrophy of the bypassed intestinal limb. Histologic examination of the resected small bowel demonstrated brown pigment deposits within smooth muscle cells of the bowel wall. The pigment stained positive with Fontana-Masson most likely representing lipofuscin. We report a case of brown bowel syndrome complicating jejunoileal bypass, the first case reported in the literature to the best of our knowledge.     

Perforation of the inferior vena cava with aortic and vertebral penetration by a suprarenal Greenfield filter

Various complications have been reported after insertion of the Greenfield filter. This report describes an unusual complication after suprarenal placement of this filter: spreading of the filter struts, with perforation of the inferior vena cava, and penetration of the aorta and a vertebral body, followed by fracture of one of the struts.     

High prevalence of stress hyperglycaemia in children with febrile seizures and traumatic injuries

Although hyperglycaemia is relatively frequent in the course of severe illnesses and may be looked upon as the possible result of an uncoordinated insulin response to the increased glucose that the body may need during periods of stress, it is generally agreed that it does not constitute a prediabetic condition. Numerous studies have aimed to explain the pathophysiology of this occurrence but none has looked at which conditions are more prone to develop stress hyperglycaemia (SH). Therefore, the aim of this study was to evaluate the main clinical conditions that may be associated with SH in children. A total of 1199 children was studied: 833 children (439 M, 394 F, mean age 5.2 +/- 4.5 y) admitted for an acute illness or injury constituted the stress-exposed group, while 366 children (222 M, 144 F, mean age 6.2 +/- 4.6 y) admitted for elective minor surgery represented the stress-unexposed group and were considered as the control group. SH was defined as plasma glucose concentrations > or = 8.3 mmol l(-1) during an acute illness. Stress-exposed patients had significantly higher glycaemic levels than controls (5.6 +/- 1.4 vs 4.7 +/- 0.7 mmol l(-1); p < 0.0001). SH was found in 41 (4.9%) stress-exposed patients and in none of the controls. SH was significantly more prevalent in children affected by febrile seizures (12.9%) or traumatic injuries (11.7%; p < 0.008 and p < 0.02, respectively, vs other diagnoses). A significant correlation was found between glycaemia and systolic pressure (r = 0.1; p < 0.01), white cell count (r = 0.12; p < 0.0003) and body temperature (r = 0.16; p < 0.0001). SH was more frequent in patients with body temperature > 39 degrees C (14%) than in those with a temperature < or = 39 degrees C (4%; p < 0.0008). SH was more prevalent in clinical conditions of fever associated with seizures or pain (12.9% and 12.5%, respectively) than fever alone (4.4%). After a mean period of 3.5 +/- 0.6 y of follow-up none of the hyperglycaemic patients had developed diabetes mellitus. Conclusion: Traumatic injuries, febrile seizures or conditions in which an elevated body temperature may be found are frequently associated with SH in children. In the presence of these conditions specific studies directed towards unmasking a prediabetic state may be unnecessary.