Management of thoracic empyema in childhood: does the pleural thickening matter?

AIMS: To determine the clinical course and long term outcome of empyema treated without decortication. METHODS: Fourteen consecutive admissions to one hospital were studied; radiological resolution and lung function were subsequently followed. The children were aged 2-14 years. All were treated with intravenous antibiotics and chest drain only. RESULTS: All patients had extensive pleural thickening evident on chest x ray examination at the time of discharge, which resolved entirely over a period of 2-16 months. Lung function was measured in 13 children, and showed no evidence of restrictive or obstructive deficit: mean (SD) values as per cent predicted for height were: forced expiratory volume in one second (FEV1) 107.5 (9.6), forced vital capacity (FVC) 95.5 (8.8), total lung capacity (TLC) 98.6 (20.7). Individual children all had values in the normal range (80-120 per cent predicted). CONCLUSION: Results suggest that decortication is not necessary in children to prevent long term problems with pleural thickening, and should be undertaken on the basis of the clinical picture (failure of fever resolution), rather than radiological appearance.     

Internet resources for spine surgeons

To classify web sites on common spinal disorders as to their utility for the spine surgeon and patient. Five common spinal disorders were used to generate lists of relevant sites. These sites were categorized as to their relevance for patients and surgeons, their sponsoring organization, and their comprehensiveness. A total of 56,249 web sites were found using the five key words on five search engines. Using the "And" operator, a total of 227 web sites were generated. The majority of sites were patient oriented. Physician- or organization-sponsored sites were the most common. Ten sites were found to have comprehensive information for both patients and spine surgeons. Many web sites exist that discuss disorders of the spine. Currently there is not any one web site that contains comprehensive information for both the spine surgeon and patient.     

Differential expression of the enzyme that esterifies retinol, lecithin:retinol acyltransferase, in subtypes of human renal cancer and normal kidney.

PURPOSE: Retinoids, a group of compounds, including vitamin A (retinol), and related metabolites, have been shown to regulate the growth and differentiation of many types of cells. IFN-alpha and either 13-cis-retinoic acid or liposomal all-trans retinoic acid have been used in the treatment of patients with metastatic renal cell carcinoma. We knew that samples from renal cell carcinomas contained greatly reduced levels of retinol and retinyl esters relative to samples from normal human kidney. This prompted us to examine the levels of LRAT (lecithin:retinol acyltransferase) protein in various subtypes of human kidney cancers relative to normal human kidney by immunohistochemistry. EXPERIMENTAL DESIGN: We examined 31 partial or radical nephrectomy specimens diagnosed with kidney tumors between 1997 and 1998. Representative paraffin-embedded tissue blocks from each tumor, with each containing adjacent nonneoplastic renal parenchyma, were used for immunohistochemical analysis with affinity purified antibodies to human LRAT protein. RESULTS: LRAT protein was detected at high levels in the epithelial cells in the tubules and the lining of Bowman's capsule in the glomeruli of normal, nonneoplastic kidney sections. Among the 31 tumors, there were 13 cases of conventional (clear cell) renal cell carcinoma (RCC; including 2 multilocular cystic RCCs), 7 papillary RCC, 6 chromophobe RCC, 1 RCC, unclassified, and 4 renal oncocytoma. All tumors showed diffuse immunoreactivity for LRAT. In each case, the staining was uniform throughout the tumor, with only minimal variation in the staining intensity between different areas. All 4 renal oncocytomas, 2 of 6 chromophobe RCCs, 1 conventional (clear cell) carcinoma, 1 RCC, unclassified, and 2 conventional RCCs, which were of the multilocular cystic-type stained strongly (3+) for LRAT. In contrast, the remaining conventional RCCs and the papillary RCC samples stained much less intensely for LRAT. Of the 10 tumors that stained 3+ for LRAT in the study, 9 were either benign tumors or tumors with low malignant potential. CONCLUSIONS: These data show that LRAT expression is higher in renal tumors with an indolent biological behavior. Additional studies will ascertain if LRAT possesses any prognostic or therapeutic role in renal cancer.     

Klippel-feil syndrome-appropos of a case

Klippel-FEIL syndrome is a congenital skeletal malformation characterised by the fusion of various cervical and occasionally thoracic vertebrae, leading to low hair line and short neck. Occasionally it is associated with hearing loss and Sprengel deformity with winging of scapulae. This case is being reported for its rarity     

Tumours of the parapharyngeal space

A series of 14 parapharyngeal tumours has been studied with regard to their symptology, pre-operative evaluation and surgical management. High resolution computed tomography is now the best initial diagnostic study because it helps to determine the size and extent of the tumour, differentiate tumours of parotid and extraparotid origin, demonstrate degree of tumour vascularity, separate benign from malignant lesions, plan the surgical approach and predict prognosis.     

Allograft tracheoplasty technique for management of refractory tracheal stenosis

OBJECTIVES: Extensive tracheal airway defects represent a clinical dilemma. Although resection and reanastomosis and staged tracheoplasty may prove beneficial in some cases, recurrent or extensive circumferential stenosis remains a reconstructive challenge. We report the use of the allograft tracheoplasty technique for the reconstruction of recurrent, extensive defects of the trachea and cricoid. METHODS: Nine consecutive patients with recurrent tracheal stenosis were treated with the two-stage allograft tracheoplasty technique. A retrospective review was performed to evaluate for prior surgery, length of stenosis, surgical technique, and outcome. All 9 patients underwent multiple surgical procedures for acquired tracheal stenosis (average, 3.4 procedures) before undergoing the allograft tracheoplasty technique. Before surgery, all patients were tracheotomy-dependent. RESULTS: The patients were assessed 8 to 39 months after allograft tracheoplasty. The primary airway disorders included postintubation stenosis (n = 6), surgical resection for malignancy (n = 1), and idiopathic stenosis (n = 2). Three defects involved 30% to 60% of the cricoid cartilage, and 4 defects were complete circumferential tracheal defects. Five patients underwent an island deltopectoral flap for closure of the tracheoplasty site. One patient had a superficial wound infection at the cartilage recipient site, and 1 patient had a hematoma at the deltopectoral flap donor site. All 9 patients were successfully decannulated without shortness of breath, stridor, or recurrent stenosis at the time of follow-up. CONCLUSIONS: Allograft tracheoplasty is a new technique for the reconstruction of recurrent tracheal stenosis. It appears to be reliable for extensive airway defects that are refractory to conventional tracheoplasty techniques.     

Redo mitral valve surgery using the port-access system

Redo mitral valve surgery is hazardous, hence we explored an alternative approach using a port-access system that avoids reentry. Between October 1997 and December 2000, 32 patients underwent mitral reoperation using the system. All patients had previous cardiac operations. This procedure consisted of a right anterolateral minithoracotomy and femorofemoral cannulation using special port-access instruments and endoaortic clamping in 24 patients or direct transthoracic sliding-rod aortic clamping in 8. The valve disease was of rheumatic etiology in 28 patients and degenerative in 4. The valve was replaced in 31 cases and a paravalvular leak after mitral valve replacement was closed in 1. In 2 cases, the tricuspid valve was repaired along with mitral valve replacement. Mean total operating time was 4.5 +/- 1.2 hours, cardiopulmonary bypass time 162 +/- 72 minutes, and aortic crossclamp time 62 +/- 21 minutes. There was no mortality, and mean stay in the intensive care unit was 22 +/- 7 hours and hospital stay 6.4 +/- 1.2 days. Postoperative blood transfusion was required in 12 patients. In view of the favorable results, we recommend using the port-access system as a standard approach for mitral reoperation.