Consent for functional endoscopic sinus surgery: are we complying with the law?

OBJECTIVE: To assess the current standard of consent for functional endoscopic sinus surgery and determine whether it complies with the law following the Montgomery ruling. METHODS: Ten complications following functional endoscopic sinus surgery were identified as common or serious from a literature search. Using questionnaires, ENT surgeons were asked which of these complications they discussed with patients, and patients were asked how seriously they regarded those risks using a five-point Likert scale. RESULTS: Consent practice from 21 ENT surgeons and data from 103 patients were analysed. The 'reasonable patient' would expect to be consented for all risks, except for pain, and scarring or adhesions. Most ENT surgeons would routinely discuss all risks that were considered significant, except for facial paraesthesia (29 per cent) and damage to the nasolacrimal duct (24 per cent). A negative change in sense of smell was not mentioned by 29 per cent of surgeons. CONCLUSION: This paper demonstrates that the current consent process for functional endoscopic sinus surgery is likely to be substandard medicolegally.

Ipsilateral ureteroureterostomy: does function of the obstructed moiety matter?

PURPOSE: Upper pole nephrectomy has been the traditional surgical management of children with poorly functioning upper pole moieties in duplex renal collecting systems having ureteral ectopia and ureterocele. However, ablative surgery confers a risk of functional loss to the remnant moiety due to vasospasm or vascular injury. It was hypothesized that ipsilateral ureteroureterostomy (IUU) is a safe and feasible approach for the management of these patients and that residual function in the obstructed upper pole does not affect surgical outcomes. MATERIALS AND METHODS: All patients with duplex systems who underwent IUU between 2010 and 2016 were retrospectively reviewed. Patients were sorted into two groups based on pre-operative imaging: those having <10% upper pole moiety function (UPMF) and those having ≥ 10% UPMF. Outcomes assessed were postoperative complications (Clavien-Dindo classification), need for secondary surgery, and radiological outcomes. RESULTS: The study cohort comprised 53 children with ectopia or ureterocele affecting the upper pole in a duplex system, 21 with UPMF <10% (median function 0% and median age 1.49 years) and 32 with UPMF ≥ 10% (median function 15% and median age 0.91 years). Median follow-up was 27.4 months and 27.6 months. In both the groups, prenatal hydronephrosis was the most common presentation (57% and 56%, respectively; p = 0.18) followed by urinary tract infection. Mann-Whitney U test comparing the two groups revealed no significant differences in any of the outcomes assessed. No patient required secondary surgery. CONCLUSION: Ipsilateral ureteroureterostomy is a safe, definitive surgical intervention that preserves the renal architecture in children with duplex collecting systems regardless of upper pole function.

Superallowed α Decay to Doubly Magic

We report the first observation of the ^{108}Xe→^{104}Te→^{100}Sn α-decay chain. The α emitters, ^{108}Xe [E_{α}=4.4(2) MeV, T_{1/2}=58_{-23}^{+106} µs] and ^{104}Te [E_{α}=4.9(2) MeV, T_{1/2}<18 ns], decaying into doubly magic ^{100}Sn were produced using a fusion-evaporation reaction ^{54}Fe(^{58}Ni,4n)^{108}Xe, and identified with a recoil mass separator and an implantation-decay correlation technique. This is the first time α radioactivity has been observed to a heavy self-conjugate nucleus. A previous benchmark for study of this fundamental decay mode has been the decay of ^{212}Po into doubly magic ^{208}Pb. Enhanced proton-neutron interactions in the N=Z parent nuclei may result in superallowed α decays with reduced α-decay widths significantly greater than that for ^{212}Po. From the decay chain, we deduce that the α-reduced width for ^{108}Xe or ^{104}Te is more than a factor of 5 larger than that for ^{212}Po.

Stellar

The ^{36}Ar(n,γ)^{37}Ar (t_{1/2}=35 d) and ^{38}Ar(n,γ)^{39}Ar (269 yr) reactions were studied for the first time with a quasi-Maxwellian (kT∼47 keV) neutron flux for Maxwellian average cross section (MACS) measurements at stellar energies. Gas samples were irradiated at the high-intensity Soreq applied research accelerator facility-liquid-lithium target neutron source and the ^{37}Ar/^{36}Ar and ^{39}Ar/^{38}Ar ratios in the activated samples were determined by accelerator mass spectrometry at the ATLAS facility (Argonne National Laboratory). The ^{37}Ar activity was also measured by low-level counting at the University of Bern. Experimental MACS of ^{36}Ar and ^{38}Ar, corrected to the standard 30 keV thermal energy, are 1.9(3) and 1.3(2) mb, respectively, differing from the theoretical and evaluated values published to date by up to an order of magnitude. The neutron-capture cross sections of ^{36,38}Ar are relevant to the stellar nucleosynthesis of light neutron-rich nuclides; the two experimental values are shown to affect the calculated mass fraction of nuclides in the region A=36-48 during the weak s process. The new production cross sections have implications also for the use of ^{37}Ar and ^{39}Ar as environmental tracers in the atmosphere and hydrosphere.

Probing the Single-Particle Character of Rotational States in

A beam containing a substantial component of both the J^{π}=5^{+}, T_{1/2}=162 ns isomeric state of ^{18}F and its 1^{+}, 109.77-min ground state is utilized to study members of the ground-state rotational band in ^{19}F through the neutron transfer reaction (d,p) in inverse kinematics. The resulting spectroscopic strengths confirm the single-particle nature of the 13/2^{+} band-terminating state. The agreement between shell-model calculations using an interaction constructed within the sd shell, and our experimental results reinforces the idea of a single-particle-collective duality in the descriptions of the structure of atomic nuclei.

Study of the

The existence of ^{26}Al (t_{1/2}=7.17×10^{5} yr) in the interstellar medium provides a direct confirmation of ongoing nucleosynthesis in the Galaxy. The presence of a low-lying 0^{+} isomer (^{26}Al^{m}), however, severely complicates the astrophysical calculations. We present for the first time a study of the ^{26}Al^{m}(d,p)^{27}Al reaction using an isomeric ^{26}Al beam. The selectivity of this reaction allowed the study of ℓ=0 transfers to T=1/2, and T=3/2 states in ^{27}Al. Mirror symmetry arguments were then used to constrain the ^{26}Al^{m}(p,γ)^{27}Si reaction rate and provide an experimentally determined upper limit of the rate for the destruction of isomeric ^{26}Al via radiative proton capture reactions, which is expected to dominate the destruction path of ^{26}Al^{m} in asymptotic giant branch stars, classical novae, and core collapse supernovae.

Hearing loss in survivors of childhood head and neck rhabdomyosarcoma: a long-term follow-up study.

OBJECTIVES: To determine the hearing status of survivors treated for head and neck rhabdomyosarcoma (HNRMS) at long-term follow-up. DESIGN: Cross-sectional long-term follow-up study. SETTING: Tertiary comprehensive cancer centre. PARTICIPANTS: Survivors treated for HNRMS during childhood in two concurrent cohorts; survivors in London had been treated with external beam radiotherapy (EBRT-based local therapy); survivors in Amsterdam were treated with AMORE (Ablative surgery, MOuld technique afterloading brachytherapy and surgical REconstruction) if feasible, otherwise EBRT (AMORE-based local therapy). MAIN OUTCOME MEASURES: We assessed hearing status of HNRMS survivors at long-term follow-up. Hearing thresholds were obtained by pure-tone audiometry. METHODS: We assessed the hearing thresholds, the number of patients with clinically relevant hearing loss and hearing impairment graded according to the Common Terminology Criteria for Adverse Events version 4.0 (CTCAEv4) and Boston criteria. Furthermore, we compared hearing loss between survivors treated with EBRT-based local therapy (London) and AMORE-based local therapy (Amsterdam). RESULTS: Seventy-three survivors were included (median follow-up 11 years). We found clinically relevant hearing loss at speech frequencies in 19% of survivors. Multivariable analysis showed that survivors treated with EBRT-based treatment and those with parameningeal tumours had significantly more hearing impairment, compared to survivors treated with AMORE-based treatment and non-parameningeal tumours. CONCLUSIONS: One in five survivors of HNRMS developed clinically relevant hearing loss. AMORE-based treatment resulted in less hearing loss compared to EBRT-based treatment. As hearing loss was highly prevalent and also occurred in survivors with orbital primaries, we recommend systematic audiological follow-up in all HNRMS survivors.

First Direct Measurement of (12)C((12)C,n)(23)Mg at Stellar Energies.

Neutrons produced by the carbon fusion reaction (12)C((12)C,n)(23)Mg play an important role in stellar nucleosynthesis. However, past studies have shown large discrepancies between experimental data and theory, leading to an uncertain cross section extrapolation at astrophysical energies. We present the first direct measurement that extends deep into the astrophysical energy range along with a new and improved extrapolation technique based on experimental data from the mirror reaction (12)C((12)C,p)(23)Na. The new reaction rate has been determined with a well-defined uncertainty that exceeds the precision required by astrophysics models. Using our constrained rate, we find that (12)C((12)C,n)(23)Mg is crucial to the production of Na and Al in pop-III pair instability supernovae. It also plays a nonnegligible role in the production of weak s-process elements, as well as in the production of the important galactic γ-ray emitter (60)Fe.

An unusual cause of chronic otitis media with effusion.

OBJECTIVE: To describe an unusual cause for hearing loss in an adult. CASE REPORT: A 37-year-old man presented with a year's history of right-sided hearing loss. He had no history of trauma, or local or systemic infection. He was otherwise well, took no medication and had no allergies. He had a two-year history of low back pain. On examination, he had a retracted right tympanic membrane with no perforation, and a middle-ear effusion. Nasendoscopy was normal. Examination of other systems was unremarkable. Computed tomography of the temporal bones with contrast demonstrated a large, right, intra-cerebral internal carotid artery aneurysm compressing the eustachian tube. After a balloon occlusion test, he underwent endovascular occlusion of the parent vessel. He made a good post-operative recovery. A subsequent abdominal ultrasound excluded an abdominal aneurysm as a cause of his low back pain. His hearing had not improved three days post-operatively, and was to be formally assessed and monitored in the clinic. DISCUSSION: A carotid aneurysm is a rare cause of eustachian tube compression but must be considered in the differential diagnosis of conductive hearing loss. Aneurysms may have systemic causes, and their presence in other systems should be excluded as they may be multiple.

Renal autotransplantation as savior in hybrid surgery for aortic aneurysm repair.

Renal autotransplantation is a safe and effective procedure to reconstruct the urinary tract. The current indications for autotransplantation include renal vascular disease, severe ureteral damage, tumours of the kidney and ureter, complex nephrolithiasis and retroperitoneal fibrosis. We report a rare case where we had to perform renal autotransplantation along with hybrid surgery for aortic aneurysm repair. To our knowledge, this is the first case report of its kind for this specific condition.

Pleural and transdiaphragmatic retroperitoneal metastasis developing two and half years after resection of invasive thymoma.

We report transdiaphragmatic pleural and retroperitoneal metastasis developing two and half years after resection of invasive thymoma (Masaoka stage III; WHO type B1, lymphocyte-rich) in a 34-year-old man. Post-surgery, he received radiotherapy and chemotherapy. Follow-up computed tomography (CT) one year post-surgery did not reveal any local recurrence or metastasis. He remained asymptomatic throughout. A follow-up CT done two and half years later revealed an enhancing retrocrural-retroperitoneal (posterior pararenal space) soft tissue mass measuring 12 cm x 10 cm x 6 cm. Another enhancing deposit was found in the left pleural space. This lesion was found infiltrating into the subjacent lung. Both these deposits were resected along with wedge resection of the affected subsegment of the lung. Histopathology confirmed these lesions to be metastases from the lymphocyte-rich thymoma.

Outcome of Dorsal Onlay Buccal Mucosa Substitution Urethroplasty in Long Strictures of Anterior Urethra.

BACKGROUND: The surgical treatment of adult anterior urethral strictures is constantly evolving. Controversy exists over the best means of reconstructing the anterior urethra. METHODS: Twelve patients underwent buccal mucosal urethroplasty for long segment anterior urethral stricture between 2003 and 2005 . Eleven patients with a salvageable urethral plate were treated with one stage dorsal onlay urethroplasty, using a perineal or circumcoronal incision. One patient with a severely scarred urethral plate underwent two-stage urethroplasty. RESULTS: At a mean follow up of 14.2 months (range 2 to 26) one (8.3%) patient had short recurrent stricture, which was treated with optical urethrotomy. The mean maximal urine flow rate improved from 8.3 ml/sec to 18.1 ml/sec after the surgery. There were no donor site complications. All patients had a normal slit like meatus and none had chordee or erectile dysfunction. CONCLUSION: In long stricture of anterior urethra, dorsal onlay buccal mucosa urethroplasty provides excellent intermediate term results with a normal, wide caliber urethra.

Intravesical Explosion during Transurethral Resection of Prostate - a reminder.

Intravesical explosion during transurethral resection of the prostate (TURP) is an extremely rare but dreaded complication and results in rupture of the bladder. It is believed that intravesical explosion occurs due to formation of explosive gases in the bladder during TURP and its admixture with air. A case of intravesical explosion during TURP resulting in bladder rupture at our institution is described. Though the management of this catastrophe is relatively straightforward, it has the potential for dire consequences. We emphasize that, despite its rare occurrence, it is preventable and suggest measures to avoid it.

Dispelling inhibition for laparoscopic surgery in younger children with Cushing's syndrome. Case report and literature review.

Laparoscopic adrenalectomy (LA) is now the gold standard for the treatment of small, benign adrenal tumors in adults. In Cushing's syndrome (CS), LA is difficult and seldom done, especially in younger children. A 6-year-old girl was diagnosed with CS due to a juxtaadrenal tumor. She underwent LA and made an uneventful recovery. The histopathology was reported as paraganglioma which is a very rare cause of CS. LA is seldom done in younger children with CS owing to extreme obesity, abundant perinephric fat and a high incidence of pre- and postoperative complications.

Assessing the efficiency of extracorporeal shockwave lithotripsy for stones in renal units with impaired function: a prospective controlled study.

The objective was to determine the efficiency of extracorporeal shockwave lithotripsy (ESWL) in clearing stones from renal units with impaired function. Thirty-five patients with poorly functioning kidneys determined by intravenous urogram and 99mtechnetium diethylene triamine pentacetic acid renal dynamic scan underwent ESWL. Stone clearance was assessed at 3 months and compared with that in normally functioning kidneys. The study group was divided into two subgroups. Those with split glomerular filtration rate (GFR) of the concerned kidney between 10 and 20 ml/min were in group 1. Group 2 consisted of patients with split GFR between 20 and 30 ml/min. A control group (group 3) was formed from patients with urolithiasis and normally functioning kidneys. The overall retreatment rate was 84.4%. The overall stone clearance rate in the study group was 34.2% while it was 57.7% in the control group. The stone clearance rate in group 2 was 40%. The difference in stone clearance rate between the study and control groups was statistically significant (P=0.023) but that between group 2 and the control group was not (P=0.159). The incidence of steinstrasse between the study group 2 and control group was not statistically significant (P=0.408). The clearance rate for ureteral stones was comparable in all the three groups. The stone-free rate and rate of steinstrasse for renal stones in kidneys with moderately impaired function were comparable to normally functioning kidneys. However, kidneys with severely impaired function had poor results. The clearance rate for ureteral stones was not influenced by the impairment of renal function.

A Comparative Study of Laparoscopic with Conventional Open Donor Nephrectomy in Renal Transplantation.

BACKGROUND: Laparoscopic donor nephrectomy (LDN) has been gaining popularity among kidney donors. There have been concerns about the safety and efficacy of the procedure as compared to open donor nephrectomy (ODN). We compare our results on LDN with ODN. METHODS: We retrospectively analysed our data of LDN and ODN. Duration of surgery, blood loss, period of hospitalisation, per oral intake and analgesic requirements. RESULT: 22 LDNs were done, the operation time ranged from 220-300 minutes, and blood loss from 100-150ml. In the first 10 laparoscopic operations four cases required conversion to open surgical dissection. Only one case was converted to open surgery in the subsequent 12 laparoscopic cases. Oral intake was started on the first postoperative day. Analgesic requirement in laparoscopy cases was less. Patients were mobilised on the first day after surgery. Patients were discharged by seventh day. There was no significant difference in the functioning of the graft after revascularisation in the recipient. CONCLUSION: Laparoscopic donor nephrectomy is a safe and effective technique of donor nephrectomy.

Experience with marginal living related kidney donors: are they becoming routine or are there still any doubts?

OBJECTIVES: To analyze donor and recipient outcome of grafts from marginal kidney donors (ie, elderly or suffering from some anomaly). METHODS: We had 81 marginal donors from July 1996 to July 2004; 46 were older than 60 years, and 39 had renal or nonrenal anomaly. The donors and recipients were evaluated for morbidity, graft and recipient survival, and the number of rejection episodes. RESULTS: The mean (+/- standard deviation) age of elderly donors was 62.2 +/- 3.1 years. Follow-up ranged from 6 months to 50 months (mean 21.15 +/- 0.9 months). Actuarial 1-year and 3-year graft survival rates were 95% and 81%, respectively. Twenty-six percent of recipients maintained serum creatinine levels less than 1.4 mg/dL. The mean age of hypertensive donors was 46.2 years, and blood pressure was controlled with one drug. Serum creatinine levels in the recipients were less than 1.4 mg/dL in 10 and less than 2.5 mg/dL in the rest. Eleven percent of hypertensive donors required an increase in their antihypertensive medication. All donors showed a 15% to 20% increase in their glomerular filtration rate. Donors underwent simultaneous surgery when indicated. CONCLUSIONS: Criteria to reject donors need to be reviewed periodically. The elderly and donors with other anomalies are consistently showing acceptable results. Hypertensive donors require assessment with awake ambulatory blood pressure monitoring.

A study of malnutrition among children aged 6 months to 2 years from a resettlement colony of Delhi.

Nutritional status of 1661 children aged 6 months to 2 years who attended the Well Baby Clinic of UHC Gokulpuri, Delhi during the year 2000 was studied. 60.7% of them were malnourished. Undesirable practices of discarding the colostrum, not exclusively breast feeding the child till at least 4 months of age, delayed weaning, dilution of top milk, use of bottle and nipple for feeding the children are still widely prevalent.