Venous isthmus plasty for coarctation of inferior venacava

A male aged 40, presented with hour glass type of obstruction of the supra hepatic segment of the inferior venacava (ivc). This segment was exposed by a posterolateral thoracotomy. A linear venotomy after proximal and distal clamping revealed a shelf like fibrous tissue obstructing the venacava. This shelf was excised. Venotomy was closed using a patch of Goretex graft. Immediate postoperative follow up is gratifying with patentivc. This is a new surgical approach for coarctation ofivc.     

Use of real-time telemedicine in the detection of diabetic macular oedema: a pilot study

PURPOSE: The high prevalence of diabetic retinopathy (21-36%) and 2 yearly reviews recommended by the National Health and Medical Research Council for diabetics with no retinopathy creates a considerable burden for review in rural and regional Australia. Screening for diabetic retinopathy using telemedicine has significant implications. If effective, such a tool would have an impact on finance and resource allocation. The purpose of the study was to establish if telemedicine could distinguish clinically significant macular oedema (CSME) from eyes free of this form of disease. METHODS: A study population with representative examples of normal fundi and the different grades of retinopathy was chosen from existing records. The specificity and sensitivity of telemedicine diagnosis was compared with fundus photography and examination by an experienced ophthalmologist as a 'gold standard', in a blinded manner. Real-time telemedicine assessment was performed with live video and audio connections with the transmitting and receiving units set in different areas of the ophthalmology department. The transmission end consisted of a video camera mounted on a slit lamp and the receiving unit consisted of a 21' LCD monitor. A video conference link was established using three ISDN lines capable of 128 kb per second transfer per line allowing for a total of 348 kb per second when utilizing all three lines for high resolution images. Fundus photographs were taken with a Zeiss FF 450 Plus Digital imaging system. RESULTS: For telemedicine, sensitivity was 38% (95% CI, 35-40%) and specificity was 95% (95% CI, 91-99%). For photography, sensitivity was 75% (95% CI, 71-79%) and specificity was 95% (95% CI, 91-99%). CONCLUSIONS: In this pilot study, sensitivity of detection of CSME by photography was considerably better than for live-link telemedicine. This study tends to confirm the continued superiority of examination of the patient by an experienced ophthalmologist as the best method of screening for CSME, a sight threatening form of diabetic retinopathy.     

Pediatric renal transplantation into the abnormal urinary tract

Many children with end-stage renal disease have significant urinary tract problems other than irreversible loss of native kidney function. These significant other urinary tract problems if not corrected prior to transplantation, may significantly increase recipient mortality, graft loss, and patient morbidity. These other urinary tract problems may cause hydroureteronephrosis in the transplanted kidney, lead to an increased incidence of graft rejection, be the source of sepsis after subsequent immunosuppression, and cause hypertension. In addition, pre-existing urinary diversion, large interabdominal masses, or previous cancer require specific pre-transplant management plans. Potential pediatric transplant recipients with other significant urinary tract problems can be classified according to three parameters: anatomical extent, pathology, and pathophysiology of the significant other problems. Particular attention must be paid to pre-existing lower tract problems. Strategy must be worked out pre transplant as to how the lower urinary tract is going to store, hold, and empty urine. The means for assessing the potential recipients and strategies and techniques for correcting pre-existing problems have been summarized in this article.     

The attitude of employers to people with inflammatory bowel disease.

Many patients with inflammatory bowel disease are anxious about their future prospects of employment. Personnel managers at 61 major national and 136 principal local employers in Leicester and Cardiff were asked to provide details about their attitude to people with inflammatory bowel disease and the type of health care they offer to employees. Over one million people were employed by these companies. A poor response rate of 27% suggested at best disinterest in the subject on the part of employers. In those who did reply the attitude to people with inflammatory bowel disease was often positive, although up to a quarter (25%) would not continue to employ people if they developed these conditions and many (30%) would not provide time off work to attend hospital clinics. Only 60% of respondents would consider providing lighter duties to affected employees. In general there is a surprisingly negative attitude to promotion of people with chronic diseases such as epilepsy, multiple sclerosis or liver disease. This seems less so in inflammatory bowel disease.     

Posterior reversible encephalopathy syndrome in the pediatric renal population

Posterior reversible leukoencephalopathy syndrome (PRES) clinically presents with seizures, severe headaches, and mental and visual changes. Our goal was to describe the clinical features, triggering factors, neuro-imaging findings, and electroencephalogram (EEG) findings in a pediatric cohort with renal disease. We retrospectively analyzed the records of 18 children with the diagnosis of PRES between January 2001 and June 2006 at the University of Miami/Holtz Children’s Hospital, USA. There were 22 PRES episodes. The most common clinical presentation was generalized tonic–clonic seizures in 59% (13/22). The most common identified trigger of PRES was hypertensive crisis in 59% (13/22). Almost half of the children had no evidence of on-going uncontrolled hypertension; 44% (8/18) had normal funduscopic examination findings, and 50% (9/18) had no or mild left ventricular hypertrophy. Two of the 18 patients had recurrent PRES episodes, three episodes each. Diffuse slowing was the most common finding on the EEGs. Atypical magnetic resonance imaging (MRI) findings were more prevalent in the imaged cases (62% vs 25%, P < 0.05). All the computerized tomography (CT) scans were normal, despite the positive MRI findings in four cases when both types of imaging was used. All the episodes had total clinical resolution. In conclusion, despite the diverse initial trigger, acute hypertension seems to be the common pathogenic pathway for pediatric PRES. MRI seems superior to CT, with better sensitivity due to its high resolution and diffusion-weighted imaging. The lesions do not necessarily have to be in the posterior white matter and may not be totally reversible.     

Immunohistochemical typing of non-Hodgkin's lymphoma-comparing working formulation and WHO classification

The recent WHO classification of non-Hodgkin's lymphoma is based on the morphology and immunohistochemical expression of the lymphoma cells and to a lesser extent, on the molecular and cytogenetic findings. Fifty-three cases of non-Hodgkin's lymphoma were included in the study. Of these, seven cases were primary extra nodal lymphomas. Twenty two patients had peripheral blood and/or bone marrow involvement. A detailed morphological assessment was done and classified using the International working formulation. The two most common types encountered were diffuse large cell lymphoma and small lymphocytic lymphoma. Immunohistochemistry was done using labeled streptavidin-biotin peroxidase complex with CD3, CD20, CD15, CD30, CD 45 (leukocyte common antigen), Cyclin D1, EMA (epithelial membrane antigen). 38 cases (72%) showed B cell expression and 12 cases (22.5%) showed T cell expression. Three cases did not express either marker. B-cell diffuse large cell lymphoma (26%) was found to be the predominant B cell non-Hodgkin's lymphoma. The commonest T-cell lymphoma was T lymphoblastic lymphoma (67%) followed by peripheral T cell angioimmunoblastic lymphoma (25%). Immunohistochemistry is a useful and necessary diagnostic modality and helps subdivide prognostically different types of non-Hodgkin's lymphoma.