Medical management of congenital portosystemic shunts in 27 dogs--a retrospective study

Case records of 27 dogs with medically managed congenital portosystemic shunts were reviewed. Fourteen were followed up by telephone questionnaires to the owners. Age, breed, sex, clinical signs and blood results were similar to previous studies. Weight and quality of life were stable or improved on treatment in all cases. Total serum protein concentration and alanine aminotransferase and alkaline phosphatase activities fell significantly during treatment. Fourteen dogs were euthanased, four were lost to follow-up and nine remained alive. Mean survival time for the dogs euthanased was 9.9 months. Mean follow-up period for the dogs still alive was 56.9 months and all had survived more than 36 months from diagnosis. Surviving dogs with intrahepatic shunts had a significantly shorter follow-up period than dogs with extrahepatic shunts. Two prognostic indicators were identified, age at initial signs and blood urea concentration on presentation, both correlating with survival time. It was demonstrated that a significant proportion of dogs with portosystemic shunts managed medically have a good prognosis.

Quality of life decisions at the beginning of life: ethical considerations

The burdens of life with treatment may outweigh the benefits. Under which set of circumstances and to what extent a neonate should receive medical intervention is a difficult ethical issue involving principles and cultural aspects which may be in conflict. The nature of the disease, the risks involved in treatment or non-treatment, the degree to which therapy will extend life, the discomfort associated with therapy, the anticipated quality of life, the wishes of surrogates, and national cultural mores are the important considerations in determination of the neonate's best interest in order to arrive at ethically defensible decisions. These decisions are not necessarily cross-culturally uniform.

Ethical practice in the management of impaired neonates--a Chinese viewpoint

In recent years, the issue of whether medical care should be given to impaired neonates has given rise to widely divergent views among practitioners of medicine, law and ethics. The general public also holds wide-ranging opinions on this subject. The divergence centres on whether medical care should be given to seriously impaired neonates, on whom should make decisions in these matters, and who should perform acts of euthanasia, in accordance with the current climate of opinion in China. This opinion has been focused both on ethical principles and on relevant precepts relevant to the "value of life." The author presents his opinions and explanations on the rights of impaired neonates, the rights and duties of parents and medical staff, and his views on the application of beneficence relative to this subject.

[Current status of antenatal diagnosis & perinatal medical network]

Antenatal diagnosis has undergone an explosion of growth in the last decade. This has revolutionized the practice of fetal medicine. Ideally, the antenatal diagnosis of congenital anomalies should improve antenatal counseling, it may also affect the timing, site, and method of delivery and potentially allow for intrauterine surgical correction. Paradoxically worse outcomes, however, have been observed in cases of some anomalies such as diaphragmatic hernia and omphalocele. Most of them combined premature birth and/or low birth weight with associated lethal anomalies: the combination almost inevitably led to mortality. In order to reduce the mortality, new approaches will be required for such anomalies in the future. Perinatal medical network will also be important to promote a closer association between perinatal medicine and perinatal surgery.

Treatment of venous malformations by direct injection with ethanol

PURPOSE

Venous malformations (VMs) may be discrete or extensive, and larger lesions may be difficult to remove with surgery. Incompletely removed lesions have a tendency to recur. We report our experience with ethanol ablation of VMs.

METHODS

All 12 patients (seven women; mean age, 37 years) were evaluated with magnetic resonance imaging before treatment. A total of 19 prior surgical excisions had been performed for seven of the patients. Symptoms were present in all 12 patients and included bleeding, pain, swelling, and limitation of exercise. The VMs were present in the lower extremities of seven patients, in the upper extremities of three patients, and in the flank and buttocks in two patients.

RESULTS

The 12 patients have undergone 30 injection procedures, with six patients requiring one, three patients requiring two, two patients requiring three, and one patient having undergone 12 treatments. General anesthesia was used in 11 patients. Blood loss was minimal for all procedures, and 28 of the 30 procedures were technically successful. Skin ulceration was seen in approximately half of the treated VMs, all of which healed with local wound care. Focal VMs were injected in six patients and resolved with a single treatment in five patients. Patients were free of symptoms at a mean follow-up of 10 months. Extensive VMs were injected for discrete, symptomatic areas in five patients. These lesions all regressed and were asymptomatic at a mean follow-up of 23 months in all but one patient. However, these lesions required multiple treatments as additional areas became problematic.

CONCLUSIONS

Ethanol sclerosis is a well-tolerated, safe, and effective adjunct to the management of VMs. Advantages of ethanol injection include the ability to treat a very localized area without an incision. Conversely, extensive lesions may be palliated as symptoms occur.

Floating kidneys: a century of nephroptosis and nephropexy

PURPOSE

Recently trained physicians are often unfamiliar with nephroptosis. Nephropexy, once a routine operation, almost disappeared from American practice more than 2 decades ago. In view of a recent revival of interest in nephroptosis and nephropexy in the American urological literature, a historical overview of nephroptosis and the evolution of surgical nephropexy is timely.

MATERIALS AND METHODS

A National Library of Medicine data base (1966 to 1996) search of "nephroptosis," "nephropexy" and "Dietl's crisis" was performed. Textbooks and monographs from the last 100 years were consulted. Original clinical descriptions and surgical accounts dating back more than 130 years were traced and reviewed.

RESULTS

Nephroptosis and nephropexy have been subjects of controversy since Edebohls in New York popularized nephropexy in 1893. A close association with "neurasthenia" clouded objectivity prior to 1920. Nearly 200 surgical procedures were described. Urological opinion was often sharply polarized. In the last 2 to 3 decades the subject was largely eclipsed in the United States. Recently, however, new laparoscopic surgical techniques have been applied to the treatment of symptomatic nephroptosis.

CONCLUSIONS

Few diagnoses and surgical procedures have had such a contentious and colorful history. It seems likely that new criteria for diagnosis of symptomatic nephroptosis and the introduction of laparoscopic nephropexy will lead to renewed interest in the subject among generalists and specialists. Knowledge of the current literature can be enriched by an overview of the events of the last century.

An algorithm for the management of anterior urethral valves

PURPOSE

We present our management algorithm for patients with anterior urethral valves seen in the last 2 decades with and without the benefit of prenatal sonography.

MATERIALS AND METHODS

A case series design was used to study 17 cases of anterior urethral valves. Five patients presented with prenatal hydronephrosis from 1984 to 1993 and 12 presented with predominant voiding symptoms between 1975 and 1996 at a mean age of 6 years.

RESULTS

Treatment included supravesical diversion in 1 case, vesicostomy in 5, urethroplasty in 5 and transurethral fulguration in 6. Four of the 5 patients with a prenatal diagnosis of hydronephrosis had moderate to severe hydronephrosis compared to 3 of the 12 who did not undergo prenatal sonography. All 17 patients were continent and infection-free, and had little or no hydronephrosis at a mean followup of 5 years.

CONCLUSIONS

We recommend vesicostomy in infants with high grade bilateral vesicoureteral reflux and poor emptying of the urinary tract, transurethral fulguration if the urethra has sufficient caliber and support, and urethroplasty in other patients. Based on our management algorithm patients with anterior urethral valves do not have sequelae due to distal obstruction of the urinary tract.

Müllerian agenesis: an update

Recently, many advances have been made in the study of sexual differentiation, including the discoveries of the gene for antimüllerian hormone as well as the gene for its receptor. However, the etiology of the clinical syndrome of müllerian agenesis remains elusive. We hypothesize that activating mutations of either the antimüllerian hormone gene or its receptor gene may cause müllerian duct regression in a genetic female during embryogenesis. This clinical commentary discusses the current management of the syndrome including the Abbe-McIndoe procedure, the most commonly used method of surgical correction, and the Frank vaginal dilation method, the most common nonsurgical method of correction.

Venous malformations: sclerotherapy with a mixture of ethanol and lipiodol

PURPOSE

To evaluate the usefulness of a mixture of absolute ethanol and lipiodol in the management of venous malformations.

METHODS

Percutaneous sclerotherapy was performed with a mixture of absolute ethanol and lipiodol (9:1) in 17 patients with venous malformations, once in 12 patients, twice in 5. The therapeutic efficacy was evaluated by pain reduction. Conventional radiographs (n = 15) and posttreatment magnetic resonance imaging (n = 5) were obtained for the follow-up evaluation.

RESULTS

Sclerotherapy was successful in all but two patients. The therapeutic effect was excellent in two patients, good in seven, fair in five, and poor in one. Radiopacity of lipiodol was beneficial for monitoring the procedure rather than for follow-up evaluations. Areas with low signal-intensity strands were increased on T2-weighted images obtained after the sclerotherapy.

CONCLUSION

Sclerotherapy with a mixture of ethanol and lipiodol is effective in treating venous malformations.

Management of the fetus with a correctable malformation in Paris maternity units: evolution 1985-1994

OBJECTIVE

To analyze the evolution of the management of delivery and neonatal care in a population of children with correctable malformations born in Parisian maternity hospitals during the period 1985-1994.

METHODS

Data were collected by the Paris Registry of Congenital Anomalies from 400,000 births recorded in Parisian maternity hospitals over a 10-year period. Chromosomal anomalies were excluded. The evolution between the first period (1985-1989) and the second (1990-1994) was analyzed for the following indicators in the management of liveborn children: place of delivery; frequency of prenatal diagnosis; transfer to intensive care units, and mortality.

RESULTS

More than 60% of the births of malformed children took place in public maternity hospitals where better management is offered. Most of them were prenatally diagnosed, except for esophageal and anorectal atresia for which the rate of prenatal diagnosis was low. For malformations with poor prognoses (diaphragmatic and abdominal wall anomalies), the rate of deliveries in public maternity hospitals reached about 90%, mostly in those with intensive care units. The evolution between the two periods was characterized by a quicker transfer to intensive care units, during the first day of life for most cases. Lethality during the first day, which was already low during the first period, decreased further. The early neonatal mortality rate decreased for cardiac anomalies, but not significantly. The prognosis remained poor for diaphragmatic anomalies: 49% of liveborn children died during the first week of life.

Decision-making in the critically ill neonate: cultural background v individual life experiences

OBJECTIVES

In treating critically ill neonates, situations occasionally arise in which aggressive medical treatment prolongs the inevitable death rather than prolonging life. Decisions as to limitation of neonatal medical intervention remain controversial and the primary responsibility of the generally unprepared family. This research was designed to study response patterns of expectant mothers towards treatment of critically ill and/or malformed infants.

DESIGN/SETTING

Attitudes were studied via comprehensive questionnaires divided into three sections: 1-Sociodemographic data and prior personal experience with perinatal problems; 2-Theoretical philosophical principles used in making medical ethical decisions; and 3-Hypothetical case scenarios with choices of treatment options.

SUBJECTS AND RESULTS

Six hundred and fifty pregnant women were studied. Maternal birthplace (p = 0.005) and level of religious observance (p = 0.02) were strongly associated with the desire for maximally aggressive medical intervention in the hypothetical case scenario. Specific personal experiences such as infertility problems, previous children with serious mental or physical problems were not correlated with the selection of different treatment choices. Of the theoretical principles studied, only the desire to preserve life at all costs was significantly associated with the choice for maximal medical treatment (p = 0.003).

CONCLUSIONS

Maternal ethnocultural background and philosophical principles more profoundly influenced medical ethical decision-making than did specific personal life experiences.

Hysteroscopic correction of a complete septate uterus using a balloon technique

Hysteroscopic dissection of the corporal part of a complete uterine septum, sparing the cervical portion, was performed using a balloon introduced into the second cavity.

[Malformations of male internal genitalia originating from the Wolffian duct]

This review includes the description and treatment of the various malformations of the male internal genitalia of Wolffian origin. Congenital epididymal cyst is the most frequent anomaly; it is usually asymptomatic so that surgery is seldom necessary. Agenesis of the deferent is usually discovered during surgery for undescended testis and is frequently associated with a homolateral renal agenesis. Ectopia and duplication are other possible anomalies affecting the deferent. Seminal vesicle cysts is mainly discovered after puberty; pelvic pain and/or urinary symptoms are the main revealing signs. It is frequently associated with other uro-genital anomalies, mainly renal agenesis.

Rotational deformities in the lower extremities

Rotational abnormalities of the lower extremities remain a significant complaint among parents of pediatric patients. Intoeing can result from metatarsus adductus, internal tibial torsion, or femoral anteversion. Rarely is orthopedic treatment necessary. Current recommendations regarding the treatment of intoeing are given.

Late selective termination of fetal abnormalities in twin pregnancies: a multicentre report

OBJECTIVE

To evaluate the outcome of late selective fetal termination based on combined data from eight tertiary perinatal centres.

DESIGN

Israeli law requires institutional committee approval for pregnancy termination. Moreover, after 24 weeks only a district superior committee can approve the termination. A total of 36 bichorionic twin pregnancies who underwent selective fetal termination after 24 complete gestational weeks were identified in eight Israeli centres.

RESULTS

In 23 women (63.9%) the indication for selective termination was structural anomaly, and in 13 (36.1%) the indication was chromosomal abnormality. The mean gestational age at the time of diagnosis was 24.1 +/- 1.9 weeks. The termination procedure was performed at a mean gestational age of 25.5 +/- 2.0 weeks (median 25, range 24-33 weeks). There was one case of immediate procedure-related complication (i.e. amnionitis) and the unaffected infant died, which was the only perinatal death in this series. No evidence of coagulopathy was reported. Only five women (13.8%) delivered before 34 completed weeks. The mean gestational age at delivery was 36.9 +/- 2.9 weeks (28-41 weeks), and the mean procedure-to-delivery interval was 11.8 +/- 3.2 weeks (median 13, range 3-17 weeks).

CONCLUSIONS

Late (> 24 weeks) selective termination in twin pregnancies is associated with favourable perinatal outcome of the healthy twin. In countries where the law permits late pregnancy termination, the parents should be informed of that possibility.

Neural grafting as a tool for the study and reversal of neurobehavioral birth defects

The transplantation of fetal neurons has gained notoriety in recent years for its perceived potential to reverse neurological deficits caused by loss of one or another neuronal population. The present paper describes a neural grafting approach employed by our laboratory to gain more insight into the drug-induced neurobehavioral teratogenicity. Mice were exposed prenatally to phenobarbital by feeding the barbiturate to the pregnant dam on gestation days 9-18. Heroin exposure was accomplished by injecting dams during the same gestational period. At maturity, the drug-exposed offspring displayed profound deficits in specific behavioral tasks, suggesting alterations in the septohippocampal cholinergic pathway. Biochemically, we observed increased presynaptic activity in the pathway, which was not accompanied by a corresponding reduction in postsynaptic activity. Rather, there was a general hyperactivation along the different postsynaptic phases. In contrast, we noted a desensitization of protein kinase C activity in response to the exposure of a cholinergic agonist to the drug-exposed offspring. Subsequent transplantation of embryonic cholinergic cells from normal mice to the impaired hippocampus reversed the behavioral deficits, whereas sham-operated controls exhibited no improvement. Concomitantly, all the biochemical alterations studied, both presynaptic and postsynaptic, were either partially or completely reversed following grafting.

Busulphan kinetics and limited sampling model in children with leukemia and inherited disorders

Busulphan pharmacokinetics were investigated in 20 children, who underwent bone marrow transplantation for either leukemia or inherited disorders. Busulphan (1.90-6.02 mg/kg/day) was administered orally as a single dose or twice daily. Busulphan kinetics were found to be linear within the studied range. Children with inherited disorders eliminated busulphan significantly faster after the first and the last dose with half-lives (t1/2) of 1.93 and 1.71 h, respectively compared to children with leukemia (3.16 and 2.70 h, respectively). The area under plasma concentration curves (AUCs, corrected for mg/kg) as an expression for the systemic exposure of busulphan were significantly higher in children with leukemia, 22.4 and 19.04 mumol/l.h (5527 and 4690 ng.h.ml-1) after the first and the last dose, respectively, compared to 11.2 and 8.2 mumol/l.h (2768 and 2029 ng.h.ml-1) found in children with inherited disorders. The present results confirm those reported by others, ie busulphan pharmacokinetics can be influenced by the underlying disease and its status. Our population pharmacokinetic analysis showed a negative correlation between the weight corrected clearance and the age in both groups of children. However, clearance was about 42% higher in children with inherited disorders compared to those with leukemia. To estimate AUC for the first dose, we evaluated a limited sampling model based on three concentrations (1, 3 and 6 h). A high correlation (r = 0.998, P < 0.0001, n = 40) between the estimated and the determined AUC was found. The present model is reliable and adequate for studying more patients, with a long-term follow-up combined with drug monitoring in correlation with drug efficacy and toxicity to define the optimal busulphan dosage required.

Use of the Wagner apparatus to lengthen the antebrachium of a growing dog

A six-month-old male golden retriever was presented with a shortened radius and ulna and valgus deformity of the carpus secondary to premature closure of the distal radial and ulnar physes. Osteotomies of the radius and ulna were performed and the antebrachium was lengthened over eight weeks using a Wagner apparatus. This external fixation distractor is used in humans for limb-lengthening procedures. In this case, it was used to correct the angular deformity and to lengthen the limb.