Significance of accessory ductal structures in hernia sacs

The finding of ductal structures resembling a vas deferens during pathological examination of a hernia sac specimen has significant medical and legal implications. A method of distinguishing these accessory structures from an inadvertently transected vas has been lacking and is needed. Between July 1989 and January 1990 we examined 147 hernia sacs from 105 consecutive prepubertal and adolescent boys to determine the incidence and salient histological features distinguishing these ductal structures from a true vas deferens. Luminal diameters of the ductal structures were compared with published normal age-related established vas deferens diameters and with those measured during hernia repair in 10 of our youngest patients. Among the 147 specimens 6 hernia sacs (4.1%) contained ductal structures. We found that the mean ductal diameter (0.263 mm.) was significantly smaller than that of a normal vas deferens (0.69 to 1.5 mm.). Furthermore, the surrounding mantle of tissue of these ductal structures lacked muscle tissue when studied with Masson trichrome stain. We conclude that duct diameter and trichrome staining are simple ways of differentiating these structures from a true vas deferens.

Electrical stimulation and multichannel EMG recording for identification of functional neural tissue during cauda equina surgery

Electrical stimulation of structures within the surgical field was used to identify functional neural elements during 25 cauda equina operations. EMG responses from anterior thigh, posterior thigh, and anal sphincter muscles were recorded simultaneously using a multichannel signal averager. During nine operations, stimulation of a presumed filum terminale or other tissue produced clear EMG responses, prompting modification of surgical procedures. In one patient, this resulted in preservation of a flattened spinal cord which resembled a band of scar tissue. Some EMG responses were restricted to a single muscle group; these neural structures would probably not have been identified if only a single-channel EMG recording was used. Visual examination alone was not adequate for identifying functional neural elements, or for determining whether atretic-appearing nerve roots were functional. Electrical stimulation with multichannel EMG recording facilitates the preservation of functional neural elements and the optimization of surgical results in cauda equina surgery.

Ethics and the allocation of health resources to the elderly

This paper examines some of the ethical issues confronting the allocation of scarce health resources in the context of an ageing society with increasing levels of chronic disease. The allocation of resources at both the micro and macro level is explored, utilising the ethical principles of patient-centred beneficence, autonomy, full beneficence and justice. The implications of the dominance of science and technology within health care are analysed along with the paternalistic and individualistic nature of traditional medical ethics. The possible variations in value systems between patients and health professionals are examined and a greater emphasis on patient autonomy is advocated. Such a change, it is argued, may well result in an actual decrease in demand for expensive high technology treatment.

Efficacy of orchiopexy by patient age 1 year for cryptorchidism

We evaluated 77 male patients with true cryptorchidism ranging from 2 to 46 months old to determine whether orchiopexy could be performed safely and efficiently, and whether treatment was helpful in patients less than 1 year old. Our results indicate that orchiopexy in patients younger than 1 year is safe, effective and beneficial, and optimizes treatment of this condition.

Significance of intraoperative venographic patterns on the postoperative recurrence and surgical incision placement of pediatric varicoceles

Intraoperative post-ligation spermatic venography has proved to be a reliable adjunct in pediatric varicocele surgery. In a previous study we described the technique and initial results. In this series of 60 consecutive patients with pediatric varicoceles having intraoperative venography, we specifically studied the collateral venous circulation and crossover veins to characterize the venographic patterns associated with varicocelectomy failure. The relationship of incision site and number of venograms necessary to ensure complete interruption of the internal spermatic system was evaluated to determine if an optimum incision placement exists, minimizing the number of venograms necessary. Our data indicate that the most common etiology of recurrent varicocele in children seems to be residual proximal (central) collateral veins, pelvic collateral veins (that is cremasteric, deferential and crossover veins) rarely seem to contribute to varicocelectomy failure and there is an inherent but low risk of varicocelectomy failure despite radiological evidence of complete internal spermatic vein interruption.

Significance of epididymal and ductal anomalies associated with testicular maldescent

Epididymal abnormalities have long been found in conjunction with cryptorchid testicles. The aim of this study was to document the different types of epididymal and ductal anomalies in relation to the position of the cryptorchid testis and to determine their clinical significance. Exploration was performed on 187 cryptorchid testes in 174 boys. The position of the testis and the epididymal and ductal anomalies were documented at operation. A biopsy was taken from the testis or atretic spermatic cord structures for light microscopy. Epididymal, ductal and/or testicular anomalies were detected in 43 per cent of the 187 testes, including anomalies of ductal fusion, anomalies of ductal suspension and anomalies associated with absent or vanishing testes. Biopsy of the testes with severe anomalies of ductal fusion showed preservation of germ cells in 69 per cent and diminished germ cells in 31 per cent. The higher the arrest of testicular descent, the more grossly abnormal was the associated ductal system. Early successful orchiopexy alone may not ensure subsequent fertility despite the presence of normal germ cells.

Needle biopsy in the diagnosis of testicular leukemia in children

Aggressive chemotherapy in patients with acute lymphoblastic leukemia has resulted in a marked upsurge in patient survival. In the course of their management, testicular biopsy and rebiopsy have an important role. We evaluated the histological findings in 50 sets of open wedge and simultaneous needle core biopsy specimens from 44 testes of children with acute lymphoblastic leukemia to determine the accuracy of the needle biopsy technique in the evaluation of testis involvement in acute lymphoblastic leukemia. We conclude that needle biopsy of the testis in acute lymphoblastic leukemia is highly accurate and correlates well with the conventional open wedge biopsy, and it may have a role in the management of children with acute lymphoblastic leukemia.

The dilated urinary tract in children. Prospective analysis with correlation of radiological, isotope, pressure perfusion and surgical findings

Moderate and even severe dilatation of the urinary tract in the absence of vesicoureteric reflux may remain stable or show spontaneous resolution. Two such cases are described. Twenty-five children with dilated urinary systems were studied to correlate the radiological, isotope, pressure perfusion and surgical findings. A positive Whitaker test correlated well with the surgical findings and post-operative improvement in renal function in all patients with pelviureteric junction (PUJ) and vesicoureteric junction (VUJ) obstruction. High flow rates of 8.6 and 12 ml are required even in neonates and infants in order to demonstrate obstruction by Whitaker testing.

Fibroepithelial polyp in a child

Only 15 cases of fibroepithelial polyp in children have been reported in the world medical literature. Clinical differentiation between this tumor and a malignant ureteral tumor is difficult and often results in unnecessary nephrectomy. We report the sixteenth case of a child with fibroepithelial polyp of the ureter. The lesion was resected, and the kidney was preserved. Optimum treatment of this lesion mandates renal preservation in children. The rationale for this recommendation is explored.

Xanthogranulomatous pyelonephritis in children

We report on a child with xanthogranulomatous pyelonephritis--an uncommon entity in children. A review of the literature revealed that in only 18 per cent was the diagnosis made correctly preoperatively. In children the disease is of a focal nature rather than a diffuse one, suggesting that possibly radical surgery would be less necessary for adequate treatment.

Routine intraoperative post-ligation venography in the treatment of the pediatric varicocele

Varicocelectomy in the adult is followed by a relatively low recurrence rate but children treated by conventional techniques seem prone to have more frequent recurrences. We believe that the higher recurrence rate observed in children after routine varicocelectomy actually represents residual varicose communications that had been missed at the primary operation. Routine post-ligation intraoperative venography has been used to detect these occult communications in 26 children undergoing varicocelectomy. Our results indicate a low recurrence rate (3.6 per cent), suggesting that routine use of this procedure with childhood varicocelectomy is beneficial.

Role of urodynamics in management of urethral diverticulum in females

This report deals with 10 female patients with urethral diverticula, 8 of whom were also found to have findings of stress incontinence. This association was proved by urodynamic studies. Three patients were seen with incontinence postdiverticulectomy. Seven patients were evaluated prior to diverticulectomy, and of these 5 had anatomic changes of stress urinary incontinence. Those patients in whom the preoperative evaluation considered them to be at risk for development of stress incontinence postdiverticulectomy were treated with a prophylactic urethropexy. Patients so treated were continent and voided well and were probably spared having a postoperative problem with incontinence. The role of urodynamic techniques in the detection of any association between the diverticulum and a possible risk of postdiverticulectomy incontinence, and how to recognize the problem and its correction before it becomes clinically manifest are the stated purposes of this report.

Human monorchism: a clinicopathological study of unilateral absent testes in 65 boys

We reviewed the medical records of 65 boys with surgically and pathologically proved monorchism. A striking laterality to the left side was identified. In 83 per cent of the patients wolffian structures were present and in 20 per cent microscopic evidence of a terminal nubbin of hyalinized, calcified or hemosiderin-containing tissue was noted. These findings strongly suggest that in most instances of monorchism a testis had been present and had undergone subsequent in utero degeneration. Characterization of the hormonal changes associated with unilateral absent testes was done by determining fasting morning levels of luteinizing hormone and follicle-stimulating hormone. In a subgroup of monorchid boys and age-matched prepubertal unilateral cryptorchid boys luteinizing hormone release factor stimulation also was performed to determine if endocrine analysis could predict the absence of 1 testis.

Cutaneous complications of heart transplantation

Since July 1984, 12 heart transplants have been performed at the University of Kansas Medical Center During this period, all recipients were screened for any dermatologic problems that may have been present, either before surgery or that may have resulted postoperatively as a consequence of immunotherapy used to suppress heart rejection. This report describes the most common cutaneous findings that in our experience include hypertrichosis, herpes simplex, warts, tinea, and steroid acne. Although these are usually not life-threatening problems, careful attention to the skin and mucous membranes may prevent serious infectious complications, improve personal hygiene, and bolster the patient's self-image.

Propranolol in cardiac arrhythmias: a comparative study of the conventional and long-acting formulations

The comparative anti-arrhythmic effect of equivalent daily doses of conventional propranolol ('Inderal') and long-acting propranolol ('Inderal' LA) was assessed in a double-blind, crossover study lasting 6 weeks in 13 patients with cardiac arrhythmias. Patients were investigated using 24-hour ambulatory monitoring. Both formulations of propranolol significantly reduced the heart rate, together with the number of ventricular premature beats and ventricular couplets, with no significant difference between treatments. The two formulations also produced similar plasma concentrations of propranolol. The long-acting formulation of propranolol proved an effective anti-arrhythmic treatment which, with once-daily dosage, may improve patient compliance with treatment.

Deep hypothermic arrest in children undergoing heart surgery

Deep hypothermia with cold cardioplegia is a technique that increases the chances for successful palliative or reparative cardiac surgery for the critically ill infant or child with complex or severe cardiac anomalies. Perioperative nursing care is of vital importance to the child, family, and operative team. Nursing care measures include perioperative teaching as well as preoperative and postoperative physical assessment of the child and psychosocial assessment of the child and family unit. An understanding of the advantages and the potential complications of hypothermic techniques enhances the nurse's ability to carry out these nursing interventions.

Mechanisms of injury in unilateral testis torsion

We investigated the mechanisms of injury involved in unilateral testis torsion as well as the interventional effects of orchiectomy at 48 h and immunosuppression with corticosteroids in rats. Torsion was associated with abnormal contralateral testis histology and raised antilymphocytes and antisperm antibody titers. Both orchiectomy and steroid administration lessened these findings, suggesting that an immunological process underlies the abnormality seen in this experiment model.

Mixtures of whole blood and hydroxyethyl starch--hemoglobin polymers

This study examines some of the biophysical properties of mixtures of whole blood with 3 different hydroxyethyl starch-hemoglobin (HES-Hgb) polymer blood substitutes. The polymers have about a 3-fold range of number average molecular weight and intrinsic viscosity range. The range dependent rheologic studies with a 60 g/L of polymer solution showed that all 3 blood substitutes were very effective hemodiluents paralleling the hemorheologic properties of the starting HES polymers. The 2 higher molecular weight polymers enhanced the erythrocyte sedimentation rates (ESR) at an 8:1 blood to polymer dilution; however, the lowest molecular weight sample actually retarded the settling. The kinetics of malonamide-induced hemolysis indicated that these new polymers do not increase the rate of hemolysis but rather, offer some protection in a manner similar to stroma-free Hgb (SFH) solutions. The oxygen transport properties determined by biotonometry during an exchange transfusion showed that the P50 values decreased and were dependent upon the Hct. However, these samples were able to maintain rats at an Hct level of 10%.