Hirschsprung's disease in young adults

Hirschsprung's disease is rarely seen in the young adult, and presents unique problems in management because of the massive dilatation and hypertrophy that occur proximal to the aganglionic rectum or the rectosigmoid colon. The diagnosis, which may be suspected by barium enema, is confirmed by suction or full-thickness biopsy of the rectum that may be complemented by anal manometry. Based on our experience with eight patients, a two-stage surgical reconstruction is recommended, with a preliminary sigmoid colostomy through the normally innervated colon and an associated defunctionalized stoma constituting the initial operation. The distal colonic stoma permits cleansing of the caudal colon while the normally innervated proximal colon reverts to near normal caliber, usually within 2 to 6 months. This approach is in accord with the recommendation of Fairgrieve. Reconstruction using a Duhamel or Soave procedure has given good results. The Duhamel procedure seems preferable when a considerable discrepancy remains between the ganglionic and aganglionic segments of rectum.     

Factors relating to the sensory acuity of limbs with peripheral vascular insufficiency

We examined several possible causes for the high incidence of poor sensory acuity in the limbs of 176 patients with moderate to severe peripheral vascular insufficiency. We investigated the relationships of diabetes, alcoholism, and smoking, as well as the severity of peripheral vascular disease, to the integrity of basic sensory modalities such as two-point discrimination and perception of light touch. The presence or absence of diabetes exerted the strongest effect on peripheral sensation. In patients who did not have diabetes, sensation in the limbs was most strongly affected by whether the patient was an alcoholic. Smoking did not have a significant effect on limb sensation. Among nondiabetic, nonalcoholic patients, there was a weak residual effect related to the severity of the peripheral vascular insufficiency. Even among these patients, however, systemic factors predominated in determining the loss of sensation. We also examined the extent to which loss of sensation might be related to the development of ulcers. Among patients who were not diabetic, there was a highly significant relationship between loss of sensation and the presence of limb ulceration. Surprisingly, however, there was no discernable relationship between the presence of ulcers in diabetic patients and the degree of loss of peripheral sensation. This result suggests that a large percentage of ulcers seen in diabetic patients are not of neurogenic origin.     

Work therapy and return to work

In summary, data were selected for 1 year on patients treated in the Work Tolerance Program at the Hand Rehabilitation Center in Philadelphia. The type of information obtained has been used to obtain a profile of the patient population in the Work Tolerance Program. Statistical analysis was used, not only to formulate patient demographics, but also to evaluate the length of treatment of patients in the Work Tolerance Program. This period averaged 6 weeks. The statistical analysis also revealed there was significant interaction between the type of injury and the patient's diagnosis, and the rate of return to work. The patients with injuries to bone and nerve required longer periods of treatment until they returned to work than did patients with injuries to soft tissue or combination injuries. Our statistical analysis revealed that in 1982, 75 per cent of the patients in the Work Tolerance Program returned to work to regular or modified jobs. The length of time from injury to return to work was 63 per cent longer for patients with Workers' Compensation coverage than for patients with private insurance coverage. Because the statistical analysis that 60 per cent of the patients treated in the Work Tolerance Program were Workers' Compensation insured, and 80 per cent of the patients treated in the Work Tolerance Program were secondarily referred, it should be recognized that all patients with severe hand injuries would benefit from an immediate referral to a Hand Rehabilitation Center of excellence to facilitate their therapeutic management and expedite their recovery from time of injury to return to work. This study was restricted to the analysis of length of treatment and rate of return to work. Future studies should study the effect of early referral and the application of specific treatments.     

Choice of general practice for postgraduate training among medical graduates and undergraduates in Nigeria

A questionnaire survey of career choices was carried out among 112 medical graduates, after one year's internship (group I), during their National Youth Corps programme in Kaduna, Lagos, Cross River and Oyo states of Nigeria, and 365 final-year medical undergraduates (group 2) in the colleges of medicine in the corresponding states. A total of 13% in group I and 40% in group 2 were undecided as regards their first choice. Obstetrics and gynaecology was the most popular first choice in both groups. General practice ranked fifth among group I, but displaced surgery to rank second among group 2. The differences were statistically significant. A total of 41% of group I and 46% of group 2 preferred to work in a teaching hospital, reflecting the high preference for surgical specialties. Twenty-six per cent and 33.7% of respondents in groups 1 and 2 respectively wished to own their own practice or work in the private sector. General practice is a new specialty and its growth is supported by a national postgraduate training programme. A shift towards general practice is seen compared with previous studies of career preference among Nigerian medical graduates and students. This may be due to a changing balance of supply and demand in the medical work-force, or a better assessment of the nation's health problems and manpower needs.