Evaluating the management of diarrhoea in health centres in Mozambique

An evaluation of the health centre management of paediatric cases of diarrhoea, comprising observation of the consultation, interview of the guardian immediately afterwards and home follow-up was performed in one rural and three urban areas of Mozambique. Oral Rehydration Therapy was advised for 83% of patients, of whom 71% received ORS packets. Eighty-seven per cent of mothers followed up stated that they had given ORT, but only 37% had a solution present at the time of interview. The main weakness in case management was the lack of health education, especially about the quantity of fluid to give, which was reflected in the mothers' belief that ORT is a medicine to 'stop the diarrhoea' and their consequent administration of it like a syrup, one teaspoonful three times a day. The results of the evaluation have facilitated the design of more appropriate health education and health worker training materials and methods.

Surgical treatment of limb lymphedema

Among 286 patients suffering from limb lymphedema seen in the outpatient clinic in the period 1977-1983, 13 were operated upon. The indication for operation and its type were dictated mainly by the gravity of the clinical findings and the failure to respond to conservative measures. Various conservative and surgical regimes are briefly reviewed emphasizing the way they were incorporated into this series. Six patients who underwent excisional operative procedures and five of the seven patients who underwent lymphatic venous bypass procedures benefitted from the operation and the adjuvant therapy.

Familial fragile 8q22 involved as a cancer breakpoint in cells of a large bowel tumor

A familial fragile 8q22 and an interferon-induced fragile 16q22 were found in two sisters. Eight years previously, both sisters developed an endometrial adenocarcinoma and now one of them presented with an adenocarcinoma of the colon. An 8q22 deletion was found in all the cells of the colonic tumor and seemed to be the primary initiating change. Other nonrandom and possibly promoting aberrations were also present, among others, a 16q22 deletion. The possibility exists that a familial fragile 8q22 may predispose to cancer and a fragile 16q22 may have promoting capacities.

Biochemical tissue markers of human colorectal carcinoma

The potential therapeutic effects of differentiating agents on leukemic and solid tumor cells are being evaluated worldwide. These effects can be followed by morphologic as well as biochemical parameters. The enzymatic profile of four enzymes and the level of carcinoembryonic antigen were studied in 24 human colorectal carcinoma specimens and their adjacent uninvolved mucosa. The enzymes studied were thymidine kinase and 6-phosphogluconate dehydrogenase as markers of proliferation, and alkaline phosphatase and gamma-glutamyl transpeptidase as markers of differentiation. A consistent finding was a marked increase in the activities of thymidine kinase and 6-phosphogluconate dehydrogenase in the tumor cells as compared with the adjacent normal mucosa. The activity of gamma-glutamyl transpeptidase was not significantly different between tumor and uninvolved colon tissue. Alkaline phosphatase activity was markedly reduced in the tumor specimens. A relationship between the degree of differentiation and the degree of penetration and CEA expression was demonstrated in the tumor specimens as well as in their surrounding uninvolved mucosa.

Anal pressure measurements in the study of hemorrhoid etiology and their relation to treatment

The etiology of hemorrhoids has been explained in the past based on anatomic principles, but this study examines the relationship of resting anal pressures to hemorrhoid etiology in 38 patients with hemorrhoids and 29 controls with no perianal symptoms. Three months after treatment by elastic band ligation, anal pressures were again measured in the hemorrhoid group. Anal pressures were significantly higher in the hemorrhoid group before treatment (102 +/- 26.33 mmHg) as compared with the controls (76.75 +/- 19.56 mmHg) (P less than .001). Three months following elastic band ligation there was a small drop in anal pressure (100 +/- 26.84 mmHg) but it remained significantly higher than the control group. There was also a significant correlation between symptoms and level of anal pressures. The results indicate that persons with hemorrhoids have higher anal pressures than controls. Elastic band ligation relieves the symptoms but should not affect the anal sphincter pressure. The fact that the anal pressures remained high after treatment could imply that higher pressures are an etiologic component in the formation of hemorrhoids.

Assessment of surgical residents' competence based on postoperative complications

The aim of this prospective study was to evaluate surgical residents' operative skills on the assumption that differences in training might have a significant effect on postoperative complications, their type and incidence. This was accomplished using a departmental microcomputer and special non-commercial personally-developed software. There was no significant clinical difference found in the postoperative complication rate in matched groups of patients treated by senior staff and resident staff of the Department. It is suggested that the close supervision by the senior staff might play a role in this outcome. Although analysis of subgroups of patients sustaining moderate to severe postoperative complications showed a statistically significant difference between these surgeon categories, we may consider this difference attributable to the more complex operative problems handled by the senior staff in the same circumstances.

Inversion (16)(p13q22) in tumor cells of sigmoid colon

We report on the cytogenetic findings in direct preparations of two tumors of the sigmoid colon. Respectively, they had a near-triploid and a near-tetraploid constitution and relative numerical and other inconstant chromosomal imbalances. The only constant chromosomal structural anomaly apparently was inversion of chromosome #16, inv(16)(p13q22), which was found in all the cells examined. This rearrangement has been found to be associated with a type of acute myelomonocytic leukemia type M4. We suggest that an etiologic clastogenic (and oncogenic) agent responsible for this rearrangement may eventually be the cause of various kinds of malignancy.

Plasma and platelet norepinephrine in normal and preeclamptic pregnancy

Catecholamines accumulate in platelets, and platelet catecholamine concentrations may give a more stable index of sympathoadrenal activity than do random plasma values. We measured norepinephrine in plasma and platelets from normal, nonpregnant women and from normal and preeclamptic pregnant women with a radioenzymatic assay. Plasma and platelet norepinephrine was not markedly different in normal, pregnant women during the third trimester, intrapartum or postpartum when compared with those levels in nonpregnant women. Platelet norepinephrine was significantly elevated in women with mild preeclampsia, but plasma norepinephrine was not. A linear relationship existed between platelet count and platelet norepinephrine concentrations in women with preeclampsia. These findings are compatible with the hypothesis of increased sympathoadrenal activity in women with mild preeclampsia and normal platelet counts. The lower platelet norepinephrine in thrombocytopenic patients suggests that platelet activation and degranulation have occurred and indicate that platelet catecholamine concentration does not provide a stable index of sympathoadrenal activity when platelets are being consumed.

Primary hyperparathyroidism due to mediastinal parathyroid adenoma

Of the 90 cases of primary hyperparathyroidism surgically treated in our department over the last decade (1975-1985), ten cases had a mediastinal parathyroidal adenoma. In only two of these patients was a median sternotomy required for excision of the mediastinal adenoma. Three of the ten patients underwent the initial operation in other institutions, having undergone a previous neck exploration. There were seven males and three females, ages ranging from 41-68 years. Six patients had nephrolithiasis, four had both renal stones and bone disease and two had peptic ulcer disease. One of them was operated on as an emergency because of hyperparathyroidism crisis with calcium levels of 15/16 mg%. Four patients were asymptomatic and had hypercalcemia detected by SMA screening. The calcium level ranged from 11.5-16.2 mg%. The phosphorus ranged from 1.6-2.8 mg% with a mean of 2.0 mg%. All ten patients had plasma PTH determination by radioimmunoassay, the values ranged from 1.5-3 times normal. In seven of the ten cases, the mediastinal parathyroid adenoma was localized within the thymus, the other three were adjacent to the great vessels, two to the aortic arch and one to the pulmonary artery-size ranging from 1.2-5.4 cm. Preoperative localization techniques: venous sampling in four cases; technetium scanning in three cases. No preoperative localization techniques were used in the other three cases. There was no mortality nor other significant postoperative complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Sciatic pain: a diagnostic pitfall

Neurological signs such as lower spinal cord lesions and/or femoral neuritis may be the presenting symptoms of a dissecting abdominal aortic aneurysm (AAA). We describe a patient in whom a severe sciatic pain was the presenting symptom of a non-dissecting AAA. The resection of the vascular mass resulted in dramatic relief of sciatic pain, thus indicating that the neurological impairment was caused by the non-dissecting aneurysm.

Cohort comparison study of children whose mothers have acquired immunodeficiency syndrome and children of well inner city mothers

The virus or viruses (human immunodeficiency virus) associated with the acquired immunodeficiency syndrome may be transmitted in utero or perinatally from an infected mother to her baby. Infected adults may remain asymptomatic for months to years, during which time a mother could transmit the virus. It is not known to what degree a mother may transmit the virus perinatally or whether postnatal transmission is possible. We studied a cohort of children whose mothers had been reported to have acquired immunodeficiency syndrome, comparing human immunodeficiency virus-seropositive with seronegative children as well as a cohort of inner city children with similar socioeconomic characteristics whose mothers are well. Three (12%) of 25 children whose mothers have acquired immunodeficiency syndrome were seropositive compared with none of 44 children whose mothers were well. The seropositive children had lower T4A:T8 lymphocyte ratios than children in the other groups. Nine children of affected mothers were young enough to have been born within their mother's incubation period and were seronegative and well. When compared with seronegative children the seropositive children did not have greater contact with their ill mothers, either in types of physical interaction or in length of time lived together. Although this study cannot preclude the possibility of postnatal nonsexual transmission, it does present evidence against it.

Age profiles of benign gallbladder disease in 2,000 patients

Hospital charts and operative notes on 2,000 consecutive cholecystectomies performed between 1965-1984 for benign gallbladder disease were reviewed and computer analyzed. Patients were divided into five age categories (1-29, 30-49, 50-69, 70-79, 80 years and above). Fifteen variables were examined for each age category, including total number, sex, presenting symptoms (jaundice, acute cholecystitis, pancreatitis), intraoperative findings (presence of stones, common bile duct width and stones), operative procedures, bile cultures, histology, postoperative course and mortality. In addition to critically assessing performance and permitting comparison with other series, this age-related analysis suggests the following conclusions: The female predominance in age category 1 diminishes in categories 4 and 5. Acute cholecystitis and suppurative cholangitis occur in 44% of age category 5, compared to 14-24% in other age categories. Intraoperative fluorocholangiography is mandatory; common bile duct stones were found in 14% of age category 1. Age category 2 seems to be the group least susceptible to choledochal pathology. Acalculous cholecystitis is closely related to gangrenous changes, especially (almost selectively) in age categories 4 and 5. The frequency of infected bile rises with age, and is found in 90% of patients in age category 5. Mortality from operations for benign gallbladder disease is ten times higher in patients over 70 years of age compared to younger patients. An ultrasonographic study should be performed before any major laparotomy, especially in the aged, in order to diagnose silent stones, and prepare the patient for concomitant cholecystectomy. Elective cholecystectomy in age categories 4 and 5 is still accompanied by high mortality rates.

Macrophage migration inhibition factor test in breast tumors

Thirty women with breast lumps who attended our outpatient clinic were randomly chosen for this study. The breast tumors were benign in 8 and malignant in 22 patients. Ten healthy women constituted a control group. In 15 of the 22 patients (68%) with malignant lesions, the migration inhibition factor (MIF) test was positive. Only one of the patients with benign lumps had a positive reaction. The MIF test was negative in all women in the healthy control group. It seems reasonable to conclude that the human cell-mediated immunity system is affected by the presence of breast cancer, and that the MIF test aids in the differentiation between benign and malignant breast tumors and has a sensitivity of at least 70%. The test may be of value in the postoperative follow-up of patients with breast cancer.

Anastomosis of vascular grafts to the below knee vessels with the aid of Fogarty catheter

A simple method for constructing a distal anastomosis is reported with the aid of Fogarty catheter. By this method exposure of the artery at the distal end is improved. Possible trauma caused by clamps is avoided and construction of anastomosis is simplified.

Non-operative therapy combined with limited surgery in management of peripheral lymphedema

Vigorous intermittent pneumatic compression combined with limited surgery for huge lymphedema of the extremities is described. The goal of operation is primarily to restore the distorted lymphedematous limb to a more normal shape to facilitate continued non-operative treatment.

The Role of Ambulatory Surgery of Thrombosed Varicose Veins

Superificial thrombosis is among the most frequent complications of varicose veins. Miscellaneous treatments have been attempted for relief of patients' symptoms, most of them unsatisfactory. We advocate simple evacuation of the thrombosed varix followed by elastic bandaging and walking exercises, a regimen which gives relief in a short period. Treatment of varicose veins should follow; no drug therapy is necessary.

Inflammatory fibroid polyp of the jejunum causing intussusception

A case of inflammatory fibroid polyp of the jejunum is presented. This is the seventh case of this type of polyp in the jejunum and, to the best of our knowledge, the first one producing jejunojejunal intussusception. Symptoms of the inflammatory fibroid polyp in this part of the intestine are usually those of intermittent obstruction or intussusception, as in our patient. The treatment is surgical excision of the polyp.

Primary leiomyosarcoma of the right common iliac artery--a rare finding and a cause of occlusive vascular disorder

A case of primary intraluminal leiomyosarcoma of the right common iliac artery that presented itself by intermittent claudication is described. The diagnosis was established only postoperatively, based on examination of the endarterectomy specimen. No other primary tumor was found in the postoperative investigation and the patient received no further treatment. A review of the literature attests to the rarity of the diagnosis and the uncertainty regarding the mode of treatment.

Septum of the gallbladder, clinical implications and treatment

We report four patients with a congenital gallbladder septum whose symptoms resembled those of cholelithiasis, in one case giving rise to acute cholecystitis. Cholecystectomy relieved symptoms in all cases and examination of the operative specimen confirmed the clinical diagnosis and X-ray findings. Ultrasonography made a positive diagnosis in the last two cases and no stones were found in any of the cases described. Cholecystectomy is advocated in symptomatic patients with this condition, even when gallstones are not present.

The "Lympha-Press" intermittent sequential pneumatic device for the treatment of lymphoedema: five years of clinical experience

Five years of clinical experience with the "Lympha-Press" is presented. This intermittent sequential pneumatic device has proved to be very efficient as a conservative method of treatment in lymphoedema of the upper and lower limbs, and as an aid for surgery of lymphoedema.

Primary duodenal carcinoid with malignant carcinoid syndrome: a case report

Primary duodenal carcinoid causing a malignant carcinoid syndrome is rare. Herein a case is reported. In view of this case and a review of the literature, the carcinoid syndrome is almost pathognomonic of massive liver metastasis or involvement of organs whose venous drainage is not through the portal system. The right upper quadrant abdominal pains accompanied by symptoms that resemble even part of the carcinoid syndrome should initiate the investigational process including proximal gastrointestinal endoscopy to avoid delay in diagnosis of duodenal carcinoid.

TI-59 programmable calculator program for calculating predicted operative mortality in general surgery

A program for the TI-59 programmable calculator for calculating predicted postoperative mortality is presented. Input data are based on handy, clinical, non-invasive pre-operative and operative parameters retrieved mostly significant in this respect by former multivariate logistic regression analysis of a broad data-base; their relative weights are incorporated into the program data base as basic coefficients. Considerations employed in its usage are discussed, as well as possible future technical and/or environmental modifications.

The use of far distal arterial bypass for limb salvage

Thirty-four distal arterial reconstructions to the ankle and the foot for limb salvage were performed in 33 patients, 11 of whom underwent additional operative procedures. The follow-up period is up to 4 years. The operative mortality rate was 9.09%. The 6 month, 1 year and 2 year accumulated patency rates calculated by life table analysis were 85%, 86.7% and 77.3%, respectively. Limb salvage was achieved not only in patients with patent grafts but also in a considerable number of patients whose grafts were occluded between 3 and 24 months postoperatively.

Postoperative course and rehabilitation achievements of colostomates

Forty colostomates (mean age, 61.5 years) were examined and interviewed 3 to 174 months (mean, 47.5 months) after creation of their colostomies, to try to determine their rehabilitation achievements after leaving the hospital. All patients had permanent colostomies, most of them after Miles' operation for carcinoma of the rectum. Most patients leave the hospital distressed and unprepared for independent life. They lack confidence and urgently need the help of the community health services, which repeatedly disappoint them. Patients are not aware of the anticipated problems and available agencies that offer support. They have irregular bowel habits, discharge of gas and unpleasant odor, as well as diminished sexual and social life. Irregularity of bowel habits seems to be the most difficult unresolved problem and is the main cause for social handicap, a handicap which is exacerbated by various commonly occurring surgical complications.

Acquired immunodeficiency syndrome in New York City. Evaluation of an active surveillance system

In January 1983, the New York City Department of Health initiated an active surveillance program for acquired immunodeficiency syndrome (AIDS) in 19 hospitals and a modified-active surveillance program in the remaining 69 hospitals. We reviewed hospital laboratory and autopsy records in 12 active surveillance hospitals and three modified-active surveillance hospitals six months later. Patients who had opportunistic diseases characteristic of AIDS diagnosed in 1982 (before active surveillance) and 1983 (after implementation of active surveillance) were matched against health department AIDS surveillance reports. For the 16 months we evaluated, 96% of patients identified with AIDS in the 12 active surveillance hospitals and 100% of those in the three modified-active surveillance hospitals had been reported to the health department. The delay between diagnosing a case and reporting it to the health department significantly decreased between 1981 and the first six months of 1983 in all hospitals. The proportion of cases reported within one month of diagnosis increased from 45% to 69% during this period. We conclude that the current surveillance program for AIDS in New York City is effective and that case reporting is sufficiently complete for accurate analysis of disease trends.

The mobile pneumatic arm sleeve: a new device for treatment of arm lymphedema

A new simple and inexpensive device for treatment of upper limb lymphedema is described. Two days of application (approximately 12 hours) in 20 patients who otherwise maintained normal activities achieved a mean reduction of 21% of tissue swelling.

Clinical significance of choledochal diameter and hyperbilirubinemia in acute cholecystitis

Persistent choledochal stones as well as negative choledochal explorations lead to increased morbidity and expense in surgery for acute cholecystitis. In an attempt to establish more precise criteria for the presence of CBD stones, 300 consecutive emergency cholecystectomies were studied and computer analyzed. Precise determination of the choledochal diameter and preoperative bilirubin levels permit a very accurate estimation of the probable presence of choledochal stones. On the basis of this information, more than 50% of patients can be classified in the low risk group, in which operative cholangiography can be omitted with minimal risk when technical difficulties are encountered, and choledochotomy may be avoided when cholangiography is unclear.

Simultaneous local recurrence of retroperitoneal paraganglioma with liver metastases

A 68-year-old woman with a history of a nonfunctional paraganglioma resected 23 years previously presented with an abdominal mass. Tumor metastases to the liver were seen at the second operation. The tumor had a more pleomorphic appearance, but was otherwise similar to the original tumor. We discuss the difficulty of predicting the later malignant behavior of the tumor from the original biopsy specimen.

Emergency abdominal procedures in patients above 70

The tremendous increase of emergency abdominal operations in elderly adults is due to the growing geriatric population, many with abdominal pathology. There also seems to be a greater willingness of the surgeon to operate on these patients. This report deals with 200 consecutive abdominal emergency operations in patients above age 70. During a period of 8 years, 472 operations in this age group were performed; there was a total of 871 emergency operations in all ages. The number of men was higher than women. The commonest cause of surgery in this group was biliary disease, followed by intestinal obstruction. Appendicitis was responsible for only 15% of the geriatric emergencies. The results suggest that early surgery with definitive procedures offers the best chance of success.

Sonographic monitoring to guide the performance of postabortal uterine curettage

This communication describes a technique of sonographically monitored uterine curettage. This method is of particular value in the management of postabortal endomyometritis associated with retained products of conception or in any situation in which anatomic variation (for instance, retroversion) makes curette insertion difficult.