Infantile hypertrophic pyloric stenosis in a Third-World environment.

Sixty-two consecutive patients with hypertrophic pyloric stenosis, presenting over a 6-year period, are reported. The sequelae of late presentation and diagnostic delay are outlined. Clinical diagnosis may be difficult. Barium meal examination has proved a more useful single investigation than ultrasonography, although these methods of investigation are complementary. Management difficulties include severe biochemical derangement, correction of which delays surgery. In black communities pyloric stenosis remains a rare condition and heightened clinical awareness remains the most important means of achieving earlier diagnosis.     

Oesophageal atresia: caudo-thoracic epidural anaesthesia reduces the need for post-operative ventilatory support

The mortality of neonates with oesophageal atresia in the Third World remains high because of delays in presentation and diagnosis. Lack of appropriate intensive care facilities is a further contributing factor. Caudothoracic epidural anaesthesia was used during surgical repair of oesophageal atresia in 35 patients in an attempt to minimise the need for post-operative ventionally support. This group was compared with 36 patients whose surgery was performed under general anaesthesia. The age at the time of referral, sex ratio, and weight were comparable in both groups. Using the Waterson classification, a greater number of poorer prognostic patients were seen in the epidural group (P <0.02). In all Waterson risk categories fewer patients required ventionally support post-operatively, which was statistically significant (P <0.01) when all categories were combined. We are encouraged by our results and believe this technique has a rôle in the management of neonates undergoing major surgery, both where neonatal intensive care exist or is deficient as in many parts of the Third World.     

Corticotropin-Releasing Hormone Modulation of a Conditioned Stress Response in the Central Amygdala of Roman High (RHA/Verh)-Avoidance and Low (RLA/Verh)-Avoidance Rats

Roman high (RHA/Verh)- and low (RLA/Verh)-avoidance rats are selected and bred for rapid versus nonacquisition of two-way, active avoidance behavior in the shuttle box. RHA/Verh rats generally show a more active coping style than do their RLA/Verh counterparts when exposed to various environmental challenges. The central nucleus of the amygdala (CeA) is known to be involved in the regulation of autonomic, neuroendocrine, and behavioral responses to stress. Its involvement in the selection of coping strategies has also been suggested. Corticotropin-releasing hormone (CRH) seems to be one of the key neurohormones in the control of CeA output. Neuroanatomical studies have revealed that the majority of CRH fibers from the CeA have direct connections with autonomic regulatory nuclei in the brain-stem, e.g. lateral parabrachial nucleus (lPB). The effects of CRH (30 ng) on modulating CeA activity were studied by infusion of CRH into the CeA during conditioned stress (inescapable foot-shocks) in RHA/Verh and RLA/Verh male rats. Heart-rate responses after CRH treatment were not changed in either line. However, distinctly different behavioral responses were seen after CRH infusion into the CeA of both rat lines. A decrease in immobility responses was seen in both RHA/Verh and RLA/Verh rats, while an increase in exploration was observed in RHA/Verh rats only in the conditioned stress situation. Rearing levels were increased in the RHA/Verh rats, whereas they were decreased in the RLA/Verh animals. As a result of CRH infusion, the number of FOS immunoreactive cells in the lPB of RLA/Verh rats was decreased, whereas an opposite response was found in RHA/Verh rats. These results indicate that the CRH system of the CeA connected with output brain-stem areas is differentially involved in the cardiovascular and behavioral responses of these rats having different coping styles.     

Measuring social disabilities in mental health

Social functioning is important in relation to mental illness as it can limit the ability to function independently and because it may vary separately from symptoms. This paper summarises and critically reviews the development of the WHO Classification of Impairments, Disabilities and Handicaps. The value of social role theory is described followed by a classification of the relevant assessment scales in this field. Mental disorders are in general strongly associated with social dysfunctioning, particularly in schizophrenia and the major affective disorders. For a long time social dysfunctioning was considered an epiphenomenon and just a part of the disease process. Criteria for the diagnosis of a mental disorder were and still are often derived from the domains of work and social relationships. There are at least two related reasons why social functioning deserves a closer look:

1. There is an increasing trend to treat patients in the community instead of in the hospital: the changing orientation on community care needs careful evaluation with respect to its consequences. To what extent is survival in the community possible and what is the quality of life like there? Are community programs better than hospital treatment, and for whom? Therefore, separate measurement is justified for evaluation of outcome and costs and benefits.
2. There is growing evidence that the courses of symptomatology and social dysfunctioning may vary relatively independently: social disablement of a patient may be characterized much more by social disabilities than by persistent psychiatric symptoms; the former may call for another kind of action than usually available. For example, psychosocial rehabilitation focuses on cognitive and social abilities of the patient which are crucial for a more or less independent life. Therefore, seperate measurement is justified for the sake of the right choice of treatment.

The usual diagnostic systems such as the ICD and the DSM offer no adequate solution to the problem of classification and assessment of social dysfunctioning as a consequence of mental disorder. We have to look for other classification systems such as the International Classification Impairments, Disabilities and Handicaps (ICIDH) of the WHO (1980, 1993) which offers a conceptual model to study the long-term consequences in terms of functional disabilities and experienced social handicaps, and the effectiveness of health care to handle these kind of problems.     

Lymph node biopsies in HIV-infected and non-infected children with persistent lung disease.

OBJECTIVE: The diagnosis of opportunistic infections in children with persistent lung disease (PLD) who are infected with the human immunodeficiency virus (HIV) is difficult to establish, especially in resource-poor countries. Lymphadenopathy is a frequent associated clinical finding among these children. We evaluated the usefulness of excision lymph node biopsies in determining an aetiological diagnosis in HIV-infected and non-infected children with PLD. METHOD: Forty-five children with PLD and significant lymphadenopathy were subjected to lymph node biopsy. Of these, 27 were HIV-infected. All subjects had excision biopsies; 39 (86.7%) of these cases also underwent fine needle aspiration cytodiagnosis (FNAC) and trucut needle biopsies. RESULTS: Tuberculosis was identified as the final diagnosis in 11 (40.7%) and 12 (66.7%) HIV-infected and noninfected children, respectively. Ancillary investigations (Mantoux, gastric washings) suggested a diagnosis of tuberculosis in eight (72.7%) and eight (66.7%) of the final diagnoses of tuberculosis among HIV-infected and non-infected children, respectively. Lymph node biopsies identified a further three (27.3%) and four (33.3%) more cases of tuberculosis as compared to ancillary investigations among HIV-infected and non-infected groups, respectively. Results of FNAC and trucut biopsy showed good correlation with excision biopsy: 96.4% and 97.4%, respectively. However, adequate samples were obtained in only 23 of 39 FNAC and 33 of 39 trucut biopsies. CONCLUSION: Excision lymph node biopsies form a useful adjunct investigation in children with PLD and generalised lymphadenopathy. The most common disease identified among HIV-infected and non-infected children in Durban, South Africa, is tuberculosis. FNAC and trucut biopsies may also be useful in the evaluation of lymphadenopathy when appropriate specimens are obtained.     

Transvaginal mesh,gender and the ethics of clinical innovation

On 10 October 2018, Australian Health Minister Greg Hunt issued a national apology to the Australian women who experienced ‘horrific outcomes’ following surgery using transvaginal mesh—acknowledging the ‘historic agony and pain that has come from mesh implantation’. This apology followed many decades of ‘innovative’ use of transvaginal mesh for the treatment of pelvic organ prolapse. We use the case of transvaginal mesh to explore how clinical innovation may not only harm patients, but also entrench vulnerability and exacerbate existing inequities—in this case, those relating to gender.     

Rehabilitation: New term for or further development of social psychiatry? A Dutch perspective

Social psychiatry as an academic discipline and field of clinical practice seems to have lost its prominence and is being incorporated in regular clinical services of mental healthcare and also in various branches of social, genetic, psychiatric or clinical epidemiology. However, the central debate in social psychiatry from its very beginning on how to care best for patients with severe mental illness (SMI) in the community, what to do with mental hospitals as potentially harmful pernicious institutions or with the hospitalization process, has never lost its momentum even in scientific meetings today. Social psychiatry and rehabilitation share a common focus on these issues, e.g. on independent living and working, on participation in society, and on prevention of hospitalization. Rehabilitation as an ideological and somewhat revolutionary movement of users and professionals in wanting to produce a fundamental change of mental healthcare (e.g. no compulsory treatment) and of society (e.g. elimination of stigma) developed its methods away from medicine and psychiatry and also away from testing these methods. Nowadays we observe growing scientific evidence for various psychosocial rehabilitative interventions which could substantiate the original mission of social psychiatry.