[Anatomy as theatre. From the library of the Society of the Dutch Journal of Medicine. Govard Bidloo: Ontleding des Menschelijken Lichaams (Dissection of the Human Body); 1689; and William Cowper: The Anatomy of Humane Bodies; 1698]

Opinions differ regarding the scientific quality of the atlas by Govard Bidloo, Ontleding des Menschelijken Lichaams (Dissection of the Human Body) (1689) and the plagiarism made thereof by William Cowper, The Anatomy of Humane Bodies (1698). Both books were also published in Latin; the Society of the Dutch Journal of Medicine has acquired a copy of all 4 atlases. The anatomical plates were made by the artist Gerard de Lairesse (Liège 1640-Amsterdam 1711) and their great artistic value is beyond all doubt. De Lairesse settled in Amsterdam in 1665, a few months after the reopening of the city theatre, and subsequently achieved fame as an innovative creator of theatre sets. He also became one of the favourite artists of prince William III and many other well-to-do citizens of Amsterdam. The great artistic value of his anatomical plates justifies more attention for his importance as a medical illustrator in medical history.

[The library of the Society of the Dutch Journal of Medicine]

This year the library of the Vereniging Nederlands Tijdschrift voor Geneeskunde (Society of the Dutch Journal of Medicine) has reached the age of go. The idea was born in 1900 when the editor-in-chief M.Straub proposed starting a library for the Journal. This was rejected by the members of the Society, but fourteen years later, in 1914, when the new editor-in-chief G.A. van Rijnberk made a similar proposal, it was accepted. His long-term as editor (1913-1946) would prove to be a guarantee for the acquisition of a large collection of books, both antique and contemporary. The collection reflects the history of medicine, notably in The Netherlands, but also in a wider sense. Over the years, several catalogues of the collection have been published, and this year has seen the completion of an electronic catalogue which is available on the Internet (www.ntvg.nl). The acquisition and restoration of books have been re-started in the past five years and a fellowship for the study of the existing collection of books has been instituted.

Short term and long term health related quality of life after congenital anorectal malformations and congenital diaphragmatic hernia

AIMS

To examine short term and long term health related quality of life (HRQoL) of survivors of congenital anorectal malformations (ARM) and congenital diaphragmatic hernia (CDH), and to compare these patients' HRQoL with that of the general population.

METHODS

HRQoL was measured in 286 ARM patients and 111 CDH patients. All patients were administered a symptom checklist and a generic HRQoL measure. For the youngest children (aged 1-4) the TAIQOL (a preliminary version of the TAPQOL) was used, for the other children (aged 5-15) the TACQOL questionnaire, and for adults (aged >16) the SF-36.

RESULTS

As appeared from the symptom checklists, many patients remained symptomatic into adulthood. In the youngest ARM patients (aged 1-4 years), generic HRQoL was severely affected, but the older ARM patients showed better HRQoL. In the CDH patients, the influence of symptoms on HRQoL seemed less profound. The instruments we used revealed little difference between adults treated for ARM or CDH and the general population.

CONCLUSIONS

These results show that for two neonatal surgical procedures, improved survival does not come at the expense of poor HRQoL in adults. Even though there is considerable suffering in terms of both morbidity and mortality in the youngest group, the ultimate prognosis of survivors of the two studied congenital malformations is favourable. This finding can be used to reassure parents of patients in need of neonatal surgery for one of these conditions about the prospects for their child.

[DNA damage and aging]

At present the mouse is the ideal experimental animal for studying molecular biological processes in human diseases. Premature aging occurred in mice with an induced mutation that resulted in a defective DNA repair mechanism. Compared to normal unmanipulated mice they exhibited characteristic symptoms of premature aging, such as premature greying, aging of the skin, osteoporosis, kyphosis, early menopause and a reduced longevity. Although these experiments only cover a small number of the many aging symptoms present in humans, it is nevertheless clear that DNA damaged by free oxygen radicals but which is not repaired, is an important cause of the onset of aging.

[From the library of the Netherlands Journal of Medicine. Rudolf Virchow: Die Cellularpathologie in ihrer Begründung auf physiologische und pathologische Gewebelehre; 1858]

With the publication of Die Cellularpathologie in ihrer Begründung auf physiologische und pathologische Gewebelehre in 1858, the author Rudolf Virchow (1821-1902) originated the idea that each cell in each living organism, both plant and animal, originates from another cell and that the origin of disease can only be located in the cell. The book laid the foundations for cell pathology as a scientific discipline and was the most important publication by Virchow, who as doctor and statesman gathered so much fame that he became almost a mythical figure in his own time. The finding that every cell originates from another cell and does not develop from amorphous interstitium is actually attributable to Robert Remak.

[One hundred years of the Association of Surgeons in the Netherlands. IX. Pediatric surgery]

The Working Group 'Surgrey in Children and Newborns', founded in 1974, was the precursor of the first subsection of the Association of Surgeons in the Netherlands, founded in 1981: the Netherlands Association for Paediatric Surgrey. Around 1900, paediatric surgery acquired an identity on the basis of what took place in children's hospitals. All the admissions were then on social indications with a surgeon being called in as a consultant if necessary. Following the Second World War, the development in anaesthesia and analgesia and an increasing understanding of metabolic processes made ever larger operations possible. The required specific expertise and the need to bring it together were decisive arguments for the foundation of the subsection. Since then, the developmental biological and genetic aspects of severe congenital malformations have, inter alia, become new topics for investigation; the consequences for medical ethics continue to be a point for attention.

[From the library of the Dutch Journal of Medicine. Giovanni Battista Morgagni: De sedibus, et causis morborum per anatomen indagatis, 1761]

The library of the Vereniging Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine Association) is a treasure-trove of information for those who wish to study the roots of the identity of the modern doctor. Recently, a book published in 1761 was purchased: De sedibus, et causis morborum per anatomen indagatis was written by Giovanni Battista Morgagni (1682-1771) when he was almost eighty years old. This book, in which Morgagni recorded the findings of 700 autopsies and linked them to the complaints of the patients and the symptoms of their diseases, marked the advent of anatomic pathology as a separate medical discipline.

The cost-effectiveness of neonatal surgery and subsequent treatment for congenital anorectal malformations

BACKGROUND/PURPOSE

The progress made in all fields of medicine, including neonatal surgery, has contributed to the rise in healthcare costs. Although neonatal surgery may provide survival gains, these could be at the expense of worse quality of life caused by impairment after surgery. For example, congenital anorectal malformations (CAM) are complex anomalies, and the surgical techniques available have their limitations in achieving continence. It therefore seems justifiable to consider what the effects of treatment are in relation to the costs. Evidence of the cost-effectiveness of neonatal surgery, however, is lacking.

METHODS

The authors analyzed both direct and indirect, medical and nonmedical costs in patients who had undergone treatment for CAM. Quality-adjusted life years (QALYs) were measured using the EuroQol EQ-5D questionnaire. Descriptive quality-of-life data were collected using a disease-specific questionnaire and a medical consumption questionnaire.

RESULTS

Mean costs of treatment are calculated at Euro 31,593. Treated CAM patients suffer stool difficulties and their medical consumption is relatively high. The EQ-5D, however, shows that the quality of life of CAM patients is only slightly lower than that of the general population (0.88 v 0.93). Treatment results in a gain of 12.7 QALYs. Costs per QALY of treatment for CAM amount to Euro 2,482.

CONCLUSIONS

Treatment for CAM has a favorable cost-effectiveness ratio compared with other evaluated healthcare programs. Bearing in mind the increasing political interest in evidence-based and cost-effective medicine, the results are encouraging.

Cost-effectiveness of neonatal surgery: a review

BACKGROUND/PURPOSE

Technological developments have revolutionized both diagnosis and treatment in neonatal surgery. However, it has been increasingly recognized that financial resources might become insufficient to provide all the medical care that is technically feasible or that patients and families might desire. The purpose of this study is to apply the theory of health economics to neonatal surgery and to explore the extent and the kind of economic evaluation done in neonatal surgery.

METHODS

To explore the work done so far, the authors undertook a literature search aimed at costs and effects of surgical interventions in newborns with Ravitch' surgical index diagnoses of congenital anomalies. Common keywords in cost-effectiveness analysis were used to search Medline.

RESULTS

Evidence about the cost effectiveness of neonatal surgery is largely lacking. This is probably because of difficulties in long-term tracking of the patients and to the problem that most generic quality-of-life measures are not applicable in children yet.

CONCLUSIONS

Further cost-effectiveness research in neonatal surgery is warranted to settle priority discussions in health care when neonatal surgery is part of such discussions. Methodology for generic quality-of-life measurement in children is badly needed.

Intussusception in a tropical country: comparison among patient populations in Jakarta, Jogyakarta, and Amsterdam

BACKGROUND

Intussusception is the most common cause of intestinal obstruction in young children, and high mortality rates remain a problem in developing countries. The purpose of this study was to describe and elucidate the differences in outcome between groups of children with intussusception in Indonesia, a developing country, and The Netherlands, a developed country.

METHODS

In this retrospective review, 176 patients were studied in three types of hospitals. A comparison was made among children treated at a primary care rural hospital in Indonesia, at a secondary care urban hospital in Indonesia, and at a tertiary care urban hospital in The Netherlands.

RESULTS

Children in the rural community hospital in Indonesia were more severely ill at arrival and had a significantly longer duration of symptoms, an increased incidence of nonviable bowel, and a mortality rate of 20%, in contrast to a mortality rate of 3% in the urban hospital in Indonesia and no deaths in the Dutch hospital.

CONCLUSIONS

The mortality of children with intussusception in rural Indonesia is much higher than in urban Indonesia or in The Netherlands, probably because of delayed treatment, which results in more patients undergoing surgery in worse physical condition.

Directing portal flow is essential for graft survival in auxiliary partial heterotopic liver transplantation in the dog

BACKGROUND/PURPOSE

Auxiliary liver transplantation is an attractive alternative for orthotopic liver transplantation in patients with certain inborn errors of metabolism of the liver in which complete resection of the liver is unnecessary or even contraindicated. Because in these diseases portal hypertension is mostly absent, finding a balance in portal blood distribution between native liver and graft is complicated. The objective of this study was to investigate requirements for long-term (180 days) graft survival in auxiliary partial heterotopic liver transplantation (APHLT) in a dog model.

METHODS

A metabolic defect was corrected in 26 dalmation dogs with a 60% beagle heterotopic auxiliary liver graft. Four groups of different portal inflow were studied. In the ligation group the portal vein to the host liver was ligated. In the split-flow group graft and host liver received separate portal inflow. In the banding group the distribution of the portal flow was regulated with an adjustable strapband and in the free-flow group the portal blood was allowed to flow randomly to host or graft liver.

RESULTS

Metabolic correction increased in all groups after transplantation from 0.19 +/- 0.02 to 0.70 +/- 0.05 (P< .0001) but remained significantly better in the ligation and split-flow groups (graft survival, 135 +/- 27 and 144 +/- 31 days). In the banding group metabolic correction decreased significantly after 70 days, and although the grafts kept some function for 155 +/- 14 days, in 4 of 6 dogs portal thrombosis was found. In the free-flow group, competition for the portal blood led to reduced correction within 12 days and total loss of function in 96 +/- 14 days. Graft function also was assessed with technetium (Tc) 99m dimethyl-iminodiacetic acid uptake. A good linear association between HIDA uptake and metabolic correction was observed (r = 0.74; P < .0005). Grafts that contributed more than 15% to the total uptake of HIDA showed biochemical correction. This indicates a critical graft mass of about 15% to 20% of the hepatocyte volume to correct this metabolic defect.

CONCLUSION

Auxiliary partial heterotopic liver transplantation can be a valuable alternative treatment for inborn errors of hepatic metabolism if the native liver and the graft receive separate portal blood inflow.

[The profile of a good doctor]

What is a good doctor? From the 12th to the 19th century the doctor was mostly an intellectual largely restricted to observing and describing symptoms and diseases. The 19th century saw the beginning of scientific insight into the causes of diseases. However, the primary objective of medical science is not to collect knowledge but to promote health. This involves both knowledge and art. Both arise from talent and education and are best achieved by early practical introduction to the basic subjects and scientific research, and during contacts with prominent teachers.

Long-term psychological evaluation of intersex children

Treatment of psychological problems of 59 children with a physical intersex condition is described. The group consisted of 18 female pseudohermaphrodites with congenital adrenal hyperplasia (CAH), 20 male pseudohermaphrodites and 2 true hermaphrodites born with ambiguous external genitalia assigned the female sex (ambiguous girls), 14 male pseudohermaphrodites born with completely female external genitalia and assigned the female sex (completely female group), and 5 male pseudohermaphrodites born with ambiguous external genitalia and assigned the male sex. Despite the sex assignment, genital organ correction soon after birth, psychological counseling of parents and intensive psychotherapy of the children, general psychopathology developed equally in all 4 groups (39% of total group). Although 87% of the girls with a physical intersex condition developed in line with the assigned sex, 13% developed a gender identity disorder though only 1 girl (2%) failed to accept the assigned sex. Gender identity disorder and deviant gender role were in evidence only in girls with CAH and girls of the ambiguous group. Biological and social factors seem responsible for the development of gender identity disorder, such as pre- and postnatal hormonal influences on the brain enabling deviant gender role behavior to develop, and an inability on the part of parents to accept the sex assignment. A reconsideration of the sex assignment in male pseudohermaphrodites and true hermaphrodites born with ambiguous external genitalia is discussed.

Function of pediatric Nissen-Rossetti fundoplication followed up into adolescence and adulthood

BACKGROUND

We analyzed the very long-term results of the Nissen-Rossetti fundoplication performed in young children. Little has been reported about follow-up longer than 5 years in homogeneous populations. This study concerns a homogeneous group with a minimum follow-up of 10 years; these former patients, therefore, are now adolescents or adults.

STUDY DESIGN

In 24 consecutive patients without other congenital or acquired anomalies of the esophagus or stomach, we evaluated the primary postoperative diagnoses, symptoms of recurrent reflux, and their state of health in 1994.

RESULTS

After a median follow-up of 16 years, the result was excellent in 18 patients, good in 5, and poor in I (graded according to Visick). Patients with recurring reflux symptoms had evidence of failure of the fundoplication. All but 1 had been given a diagnosis of recurrent reflux within 2 years after the operation. The situation after 2 years seems predictive for the later outcome.

CONCLUSIONS

In almost all cases, the Nissen-Rossetti fundoplication is a long-lasting, effective treatment for young children with symptomatic gastroesophageal reflux.

Long-term pulmonary sequelae in children with congenital diaphragmatic hernia

Neonates with congenital diaphragmatic hernia (CDH) often suffer from respiratory insufficiency due to lung hypoplasia and pulmonary hypertension. Artificial ventilation is frequently required, and this leads to a high incidence of bronchopulmonary dysplasia. Long-term follow-up studies have shown persisting airway obstruction. To evaluate the long-term pulmonary sequelae in CDH, we studied 40 CDH patients of age 7 to 18 yr (median 11.7 yr) and 65 age-matched controls without CDH and lung hypoplasia who underwent similar neonatal treatment. Mild airway obstruction was found in both groups with more peripheral airway obstruction in CDH patients than in control subjects. Both groups had normal TLC and single-breath carbon monoxide diffusion capacity (DLCO). CDH patients had increased residual volume (RV) and RV/TLC compared with controls. Increased airway responsiveness to methacholine (MCH) was common but bronchoconstriction to inhaled metabisulfite (MBS) was rare both in CDH and control subjects. We conclude that this group of CDH patients has minor residual lung function impairment. Mild airway obstruction and increased airway responsiveness to inhaled MCH but not to MBS suggest that structural changes in distal airways are involved and not autonomic nerve dysfunction. Both artificial ventilation in the neonatal period and residual lung hypoplasia seem important determinants of persistent lung function abnormalities in CDH patients.

Staff attitudes towards continuation of life-support in newborns with major congenital anomalies

This study was conducted to gain insight into the attitudes of medical staff towards life-support of newborns with life-threatening problems, seen against the background of these children's expected morbidity and quality of life. The opinions about the mode of life-support were determined by questionnaires and the demographic characteristics of the respondents were noted. Each patient's risk of mortality was scored by means of the standardized Paediatric Risk of Mortality Score (PRISM). Attitudes towards support were unanimous for 39 of the 46 patients. For the other 7 patients at least one of the respondents preferred a different support mode than that given at the time. The attitudes were influenced by the patient's risk of mortality.

CONCLUSION

Decisions about life-support of newborns with life-threatening problems should include all the disciplines involved in patient care and should be made at an early stage.

Prospective evaluation of faecal fatty acid excretion in short bowel syndrome in newborns

Short bowel syndrome (SBS) in the newborn results in limited intestinal absorptive capacity, leading especially to fatty acid (FA) malabsorption. It is unknown whether adaptation occurs in time in FA absorption, and whether this adaptation is chain-length dependent. The aid of the present study was to prospectively evaluate FA absorption and excretion during SBS in the newborn. Twenty-one neonates who underwent small bowel resection (of variable length) for various reasons (necrotizing enterocolitis, intestinal atresia, meconium peritonitis, cloacal extrophy, etc) were studied. Eight neonates had SBS, defined as a small bowel remnant of less than 50% of the original small bowel length related to gestational age. The mean remaining small bowel length in the SBS group was 34% (24% to 42%). The non-SBS control group consisted of 13 neonates who had only minor small bowel resections. The mean remaining bowel length for the non-SBS group was 95% (70% to 100%). The results show that the total fractional excretion of FA (FE-FA) at 2 weeks and 1, 2, 3, and 4 months postsurgery was 51% +/- 37%, 33% +/- 24%, 51% +/- 65%, 53% +/- 27%, and 7% +/- 2% in patients with SBS, versus 12% +/- 8%, 24% +/- 10%, 9% +/- 3%, 8% +/- 3% and 17% +/- 14% in the non-SBS controls, respectively (P < .05 by ANOVA). There appeared to be an amelioration in time in FA absorption, especially in the SBS group, after 3 months. FE-FA was chain-length related, being considerably less for C10 and C12 than for C14 and longer amounts. An amelioration of absorption occurred in the SBS patients, especially with the longer-chain FA. On the basis of the study data, the authors conclude that in the initial adaptation phase shorter chain lengths are better absorbed than longer chain lengths; however, in the latter FA group, substantial adaptation occurs with time.

Hepatic artery ligation for hepatic vascular tumors with arteriovenous and arterioportal venous shunts in the newborn: successful management of two cases and review of the literature

The authors report their experience with hepatic artery ligation in two newborns, as well as relevant findings from a literature review. A 2-day-old boy had progressive cardiac and respiratory difficulty. A firm liver was palpable, with an overlying thrill. Sonography and arteriography showed diffuse arteriovenous shunting in both liver lobes. Hepatic artery ligation provided remarkable hemodynamic and clinical improvement. Another boy was admitted 3 weeks after birth because of bilious vomiting with abdominal distension and bloody stools. Abdominal examination showed a large liver with a systolic bruit and thrill. X-rays showed cardiac enlargement and dilated bowel loops with air-fluid levels. Arteriography and sonography showed arteriovenous and arterioportal venous shunting. Laparotomy was performed, and a large vascular malformation was palpated in both liver lobes. The entire bowel was congested and cyanotic, but there were no signs of obstruction. This patient had acute portal hypertension imitating intestinal obstruction. Ligation of the hepatic artery improved the color of the bowel, and the thrill disappeared. Five and nearly 4 years after the operation, both boys are growing normally without medication or diet. Sonography showed almost complete resolution of the hemangiomas.

Prospective evaluation of the absorptive capacity of the bowel after major and minor resections in the neonate

The outcome after major bowel resection in the neonatal period depends primarily on the time needed for bowel adaptation. A prospective study was begun in neonates after small bowel resection to evaluate the absorptive capacity of the bowel and growth parameters as a result of adaptation of the bowel. Twenty-four neonates who underwent bowel resection were included. The underlying diagnoses were necrotising enterocolitis (12), jejunal atresia (3), meconium peritonitis (3), and other (6). During the study, a standardized treatment with respect to nutrition was followed. At predetermined times, enterostomy fluid or faeces were collected for analysis of carbohydrate content, fat content, and fatty acids, together with a xylose test and a hydrogen breath test. Growth parameters included weight and height. The 24 patients were divided into two groups. Group A consisted of eight patients with short bowel syndrome (defined as loss of more than 50% of the original small bowel length related to gestational age). The mean remaining small bowel length in this group was 34.0% (24% to 42%). Group B consisted of 16 patients who had only minor bowel resections. Retarded growth was observed in four group A patients. Low levels of carbohydrate absorption were found 2 and 4 weeks after the initial operation in group A, and 2 weeks after the initial operation in group B. Low levels of fat absorption were found 4 and 8 weeks after the initial operation in group A. The coefficient of absorption of the different fatty acids showed complete absorption of caprylic acid.(ABSTRACT TRUNCATED AT 250 WORDS)

Segmental intestinal transplantation can be an adequate therapy for short bowel syndrome in growing dogs

This study was undertaken to investigate whether two-stage segmental small bowel allotransplantation can maintain growth and development of young dogs (16 weeks, 5 to 6 kg) with surgically created short bowel syndrome (SBS). After near-total small bowel resection (group 1; n = 3), irreversible weight loss was noted. After a sham operation (group 2; n = 3), no growth disturbances were found. Major histocompatibility matched small bowel transplantation (SBT) with cyclosporine A as immunosuppressant, was performed in two stages (group 3; n = 7). During the first stage, one meter of jejunoileum from an adult donor was placed as a Roux loop. Four weeks later, the native small bowel was removed and replaced by the graft. Only one dog survived long-term; the dogs died from infectious complications. The addition of selective decontamination of the digestive tract and early gastrostomy feeding (group 4; n = 10) resulted in long-term survival in 60%. Follow-up at 4 months showed that their growth was about 20% compromised compared with that of the sham-operated animals. Functional analysis showed that electrolytes, urea, and D-xylose were normal, but there was an increase in the lactulose:mannitol ratio, fecal fat excretion, and postheparin diamine oxidase release. These results show that under the conditions described, segmental SBT functions sufficiently to treat SBS but does not maintain normal growth.

Alveolar epithelial composition and architecture of the late fetal pulmonary acinus: an immunocytochemical and morphometric study in a rat model of pulmonary hypoplasia and congenital diaphragmatic hernia

The aim of the present study was to compare the architecture and alveolar epithelial cell composition of the pulmonary acinus in hypoplastic and normal fetal rat lungs. For this purpose, a rat model of pulmonary hypoplasia in association with congenital diaphragmatic hernia (CDH) induced by Nitrofen (100 mg on day 10 of pregnancy) was studied. Sections (5 microns) from lungs of control and Nitrofen-exposed fetal Sprague Dawley rats with or without CDH aged 18-22 days (vaginal plug on day 1, birth on day 23) were stained with hematoxylin and eosin. To identify developing alveolar epithelial cells, sections were incubated with anti-surfactant protein A (SP-A; rabbit anti-mouse) or preimmunization serum (indirect immunofluorescence). On days 18 and 19, control lungs and exposed lungs from fetuses with and without CDH looked similar (pseudoglandular stage of lung development). The prospective pulmonary acinus consisted of acinar tubules with small round lumens, lined by cuboid, fluorescent type II cells. Morphometric analysis on day 19 showed significantly smaller lung volumes and lung tissue volumes after Nitrofen exposure. On day 20 (canalicular stage), some tubules were slightly dilated and lined by cuboid and thinner fluorescent cells; these dilated tubules were less numerous in lungs from exposed fetuses with CDH. On days 21 and 22 (saccular stage), the saccular lining consisted of cuboid to thin fluorescent cells in exposed lungs from fetuses with and without CDH, and fluorescent (low) cuboid cells interspersed with dark zones (type I cell areas) in control lungs. In the exposed lungs from fetuses with CDH, the lumens of all airspaces were frequently slit-like, and the septa were thicker. These phenomena gave the lungs a primitive, compact aspect. Morphometric analysis on day 22 showed smaller lung volumes and lung tissue volumes, smaller airspace/tissue ratios, smaller epithelial surface areas, and more type II cells per surface area in Nitrofen-exposed lungs than in normal control lungs. The results suggest that Nitrofen-exposed, and thus hypoplastic, fetal rat lungs are retarded with respect to the differentiation of cuboid type II cells into squamous type I cells whether or not CDH is present, and with respect to the development of the future airspaces between days 20 and 22 if CDH is present.

Etiological aspects of congenital diaphragmatic hernia: results of a case comparison study

We report the results of a parental questionnaire concerning possible etiological and teratological factors, such as exposure to herbicides, in the development of congenital diaphragmatic hernia (CDH). The herbicide Nitrofen interferes with lung development in rats, can induce diaphragmatic hernia and greatly resembles thyroid hormone. No association with the studied teratogens nor with maternal thyroid dysfunction was found. The questionnaire was completed by 33 parents whose baby had CDH, and by 43 couples whose baby had oesophageal atresia. The resemblance of Nitrofen to thyroid hormone, a well-known growth factor for the developing lung, is of particular interest from a pathogenetic point of view in the development of CDH.

Gas exchange across native lungs and extracorporeal membrane in neonates and pigs during extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is a commonly used treatment modality for severe neonatal respiratory failure. The aim of the present study was to evaluate the relationship between ECMO blood flow and gas exchange across the native lungs and the extracorporeal membrane. In three healthy pigs, the ECMO flow correlated significantly with oxygen transfer (VO2) across the membrane (n = 12, r = .90, P < .001) and inversely with VO2 across the lungs (n = 12, r = -.75, p < .005). In three pigs with acute respiratory distress syndrome induced by repeated bronchoalveolar lavage, flow also significantly correlated with VO2 across the membrane (n = 9, r = .93, P < .001) and inversely with VO2 across the lungs (n = 9, r = -.97, P < .001). Eight neonates had measurements taken at different time intervals and different flow rates during ECMO. The ECMO flow correlated significantly with VO2 across the membrane (n = 45, r = .61, P < .001) and inversely with VO2 across the lungs (n = 15, r = -.54, P < .05). The relationship between carbon dioxide transfer (VCO2) and ECMO flow rates had the same trend as VO2 on all occasions. It is concluded that the ECMO flow rate is one of the main determinants of gas exchange across the lungs and the membrane.

Evaluation of lung function changes before and after surfactant application during artificial ventilation in newborn rats with congenital diaphragmatic hernia

Patients with congenital diaphragmatic hernia (CDH) have unilateral or bilateral hypoplasia of the lungs including delayed maturation of the terminal air sacs. Because these lungs are highly susceptible to barotrauma and oxygen toxicity, even in full-term newborns, continued research into optimal ventilatory regimen is essential to improve survival rate and to prevent ongoing lung damage. Against this background, the effect of exogenous surfactant application is evaluated. In newborn rats, CDH was induced after a single dose of 2,4 dichloro-4'-nitrophenyl (Nitrofen) (400 mg/kg) on day 10 of gestation. The newborn rats were intubated immediately after hysterotomy, transferred to a heated multichambered body plethysmograph, and artificially ventilated. Inspiratory peak pressures were initially set at 17 cm H2O, with positive end-expiratory pressure at 0 cm H2O and FIO2 at 1.0. The pressure was raised in steps of 5 cm H2O, from 5 to 30 cm H2O, to obtain pressure-volume diagrams at 0, 1, and 6 hours of artificial ventilation. These measurements were obtained in controls and in CDH rats with and without endotracheal installation of bovine surfactant (n = 4 to 10 in each group). Significant differences in lung volume between CDH and control rats were observed at all time-points. Surfactant application had a positive effect on lung volume, especially in control rats at t = 1 hour. No significant differences were observed between the CDH groups at t = 1 or t = 6 hours. In this animal model, the effect of artificial ventilation as well as the beneficial short-term effect of exogenous surfactant application have been evaluated. A continued positive effect on lung volume in CDH lungs could not be determined. Routine administration of exogenous surfactant in human CDH patients is not supported by these experimental results.

[3-week traction with 3-week spica-cast immobilization is as good as 6-week traction, and much cheaper]

OBJECTIVE

To gain insight into the clinical en economic results of the treatment of femoral shaft fractures in children by means of traction for 3 weeks and spica immobilization for 3 weeks as an outpatient in comparison with traction for 6 weeks.

DESIGN

Retrospective.

SETTING

Sophia children's hospital in Rotterdam.

METHOD

Between 1981 and 1989, 278 children were admitted because of a femoral shaft fracture. This follow-up study concerned 229 children of whom 139 were treated by means of 6 weeks' traction (group 1) and 90 received the combination treatment (group 2). The two groups were comparable with regard to age, sex, cause, type and site of the fracture.

RESULTS

All fractures healed, complications were rare and equally divided between the two groups. There was no significant difference between the two groups with regard to shortening and angulation of bone fragments. The mean duration of hospital stay was almost 47 days in group 1 as against 22 days in group 2, leading to a reduction of Dfl. 19,500.--in hospitalization costs per child.

CONCLUSION

The results of treatment of femoral shaft fractures by means of traction in combination with spica immobilization equal those of 6 weeks' traction. The shortened duration of hospital stay leads to a considerable reduction in costs.

[Limitations to care; evaluation of decision making concerning the death of 104 children in a surgical intensive care unit]

OBJECTIVE

To analyse the decision-making process concerning withholding and withdrawal of life-sustaining treatment in children who died in a paediatric surgical intensive care unit.

DESIGN

Retrospective evaluation of medical and nursing records from the period 1988-1992.

SETTING

Sophia Children's Hospital-University Hospital Rotterdam.

METHOD

The evaluation concerned 104 children who died in the paediatric surgical intensive care unit during the study period. The causes of death were classified according to the classification proposed in a recent report issued by the Dutch Association of Paediatricians. A distinction was made between newborns and older children.

RESULTS

In both newborns and older children, about half of the children had died because treatment was either withheld (4/104) or withdrawn (53/104). There were no cases of 'intentional termination of life in emergencies'. The remaining children had died in spite of medical treatment that had been considered worthwhile.

CONCLUSION

The problems and guidelines suggested from the field of neonatology are applicable not only to newborns with severe congenital anomalies, but also to older children. Evaluation of the decision-making process should not be limited to medical-technical and nursing aspects, but should also include the experiences of the parents and the treatment team.

[Care and experiences of 20 set of parents concerning the death of children in a surgical intensive care unit]

OBJECTIVE

To gain insight into the attitude and experiences of parents concerning the death of children in a paediatric surgical intensive care unit of a University Children's hospital.

DESIGN

Retrospective evaluation of records from 1988-1992, supplemented with semistructured interviews in the second half of 1992.

SETTING

Sophia Children's Hospital-University Hospital Rotterdam.

PATIENTS AND METHODS

The evaluation concerned 104 children. In 36 children death was a direct consequence of their illness, 11 died unexpectedly after an unsuccessful attempt at resuscitation, and in the remaining 57 treatment had not been initiated or had been withdrawn. Six months after the death of their child, twenty couples of parents of 20 children were asked after their experiences before, during, and after this death; in addition they were asked whether they would appreciate a longer contact with the hospital.

RESULTS

Most parents chose to be present at the moment of dying. The parents generally highly appreciated the talks about the decision-making process and about coming to terms with the loss of their child, both with doctors and nurses. Most also appreciated a talk at some later time.

CONCLUSION

The results from this study indicate that structured guidance of parents concerning their child's death in the form of a counselling programme, is advisable.

Rectoperineal fistula in newborn boys

Three newborn boys presented with features suggestive of classic low anorectal abnormality. However, during surgery they were found to have an intermediate anorectal abnormality and a rectoperineal fistula rather than an anocutaneous fistula. The surgical treatment of these infants is discussed.

Short bowel syndrome: metabolic and surgical management

The management of short bowel syndrome requires long-term nutritional support and monitoring, medication, and occasionally additional surgical procedures. Constant attention is required to ensure adequate adaptation of the gut. This article reviews the normal function of the small bowel, adaptation following resection, total parenteral and enteral nutrition, and the role of adjunctive surgical procedures in the management of short bowel syndrome.