Reconstruction of the symphysis pubis to repair a complex midline hernia in the setting of congenital bladder exstrophy.

PURPOSE: A 40-year-old man with congenital midline defect and wide pubic symphysis diastasis secondary to bladder exstrophy presented with a massive incisional hernia resulting from complications of multiple prior abdominal repairs. Using a multi-disciplinary team of general, plastic, and urologic surgeons, we performed a complex hernia repair including creation of a pubic symphysis with rib graft for inferior fixation of mesh. METHODS: The skin graft overlying the peritoneum was excised, and the posterior rectus sheath mobilized, then re-approximated. The previously augmented bladder and urethra were mobilized into the pelvis, after which a rib graft was constructed from the 7th rib and used to create a symphysis pubis using a mortise joint. This rib graft was used to fix the inferior portion of a 20 × 25 cm porcine xenograft mesh in a retro-rectus position. With the defect closed, prior skin scars were excised and the wound closed over multiple drains. RESULTS: The patient tolerated the procedure well. His post-operative course was complicated by a vesico-cutaneous fistula and associated urinary tract and wound infections. This resolved by drainage with a urethral catheter and bilateral percutaneous nephrostomies. The patient has subsequently healed well with an intact hernia repair. The increased intra-abdominal pressure from his intact abdominal wall has been associated with increased stress urinary incontinence. CONCLUSIONS: Although a difficult operation prone to serious complications, reconstruction of the symphysis pubis is an effective means for creating an inferior border to affix mesh in complex hernia repairs associated with bladder exstrophy.

[Surgery education in the USA]. / Chirurgische Ausbildung in den USA.

Surgical education in the United States historically was influenced by the German educational system. Currently residents spend five years to become general surgeons. Education focuses on the teaching of surgical basic sciences and practical instruction in the operating room and at the bedside. Students interested in General Surgery are selected largely based on their performance in medical school. Admission into first-rate programs is highly competitive. In many university-based programs residents are expected to spend an additional two years in research as part of their training. While on their clinical rotations residents usually spend 80 to 100 hours per week in the hospital. Resident salaries are moderate.

Changing epidemiology of dengue hemorrhagic fever in Thailand.

Dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) are reportable diseases, the third most common causes for hospitalization of children in Thailand. Data collected from the Ministry of Public Health were analysed for trends. Rates of DHF increased in Thailand until 1987 when the largest epidemic ever, 325/100000 population, was recorded. Whereas the disease used to be confined to large cities, the rate is now higher in rural (102.2 per 100000) than urban areas (95.4 per 100000 in 1997). The age of highest incidence has increased, and the age group most severely affected is now those 5-9 years old (679/100000 in 1997). The case fatality rate has decreased with improved treatment and is now only 0.28%.

Can a one-day workshop alter surgeons' teaching practices?

BACKGROUND: A 1-day workshop, consisting of five sections with small group discussions and opportunities for practical application of participants' knowledge, was developed to enhance the teaching skills of practicing surgeons. Immediate and long-term follow-up surveys were completed by the participants. METHODS: Post-workshop evaluations were obtained from all participants who took the workshop; follow-up surveys were mailed 4 to 6 months later. RESULTS: Workshop quality was rated as good (25%) or excellent (75%) by all participants. Follow-up survey results indicated that many participants had rarely/never utilized cited references, looked for additional resources on specific topics, or referred to the section syllabus/handout materials provided during the workshop. However, 100% of the participant respondents reported that they had changed the way they teach as a result of their workshop attendance. CONCLUSION: An abbreviated course on surgical education can result in long-term changes in the participants' perceptions of their teaching practices. Further study is required to determine if these perceived changes in teaching practices, which the participants have directly attributed to their workshop attendance, have resulted in measurable improvement in their effectiveness and efficiency as teachers.

Patterns and determinants of use of antibiotics for acute respiratory tract infection in children in China.

BACKGROUND: Use of antibiotics for acute respiratory infection (ARI) of presumed viral etiology is a worldwide problem. The World Health Organization (WHO) has provided guidelines for diagnosis and treatment of ARI for developing countries. METHODS: Specially trained observers applied the WHO criteria to study the diagnosis and treatment of ARI given by 100 randomly selected health care workers (HCWs) in a rural county in China. A total of 750 cases of ARI were evaluated. RESULTS: Before the parents sought medical care, 47% of children in the county hospitals, 25% of those in the townships and 18% of those in the villages had already received antibiotics, available without prescription. Among the HCWs antibiotic abuse (antibiotics for presumably viral disease) was detected in the treatment of 97% of cases, and severe abuse (such as prescription of two incompatible antibiotics) was detected in 37%. Most (197 of 200) patients with bacterial disease received antibiotics, but inappropriate antibiotic treatment (dose or type) was observed in 63% of these cases. HCWs with university training and those with higher test scores on knowledge and attitude prescribed antibiotics more judiciously than those lacking those attributes. CONCLUSIONS: Abuse of antibiotics for ARI is a serious and costly problem in rural China, potentially leading to widespread antibiotic resistance. Educating HCWs in the management of ARI and proper use of antibiotics has high priority in China.

Evaluation of the MycoDot test for the diagnosis of tuberculosis in HIV seropositive and seronegative patients.

SETTING: Patients were recruited from Siriraj, Bamrasnaradura, and Central Chest Hospitals, the three major hospitals responsible for tuberculosis patients in Bangkok, Thailand, and vicinity. OBJECTIVE: To evaluate a new rapid serologic test, the MycoDot test, for diagnosis of tuberculosis (TB). DESIGN: The study was conducted as a cross-sectional survey. A total of 594 patients were tested with the MycoDot test. This included 142 human immunodeficiency virus (HIV) seropositive patients with active TB, 144 HIV seronegative patients with active TB, 153 HIV seropositive controls, and 155 HIV seronegative controls. RESULTS: The sensitivity of the MycoDot test for detection of TB was 40.1% in HIV seropositive patients, compared with 63.2% in HIV seronegative patients (P < 0.001). If only patients with laboratory proven TB were evaluated, the sensitivity was 40.6% in seropositive and in 70.8% seronegative patients. The sensitivity of the MycoDot test was similar in TB patients with pulmonary and extra-pulmonary disease. The sensitivity of the test in patients with CD4 counts > or = 200 cells/mm3 was significantly higher than in those with CD4 counts < 200 cells/mm3. The specificity of the test was 97.4%, and was identical in HIV seropositive and seronegative individuals. CONCLUSION: The MycoDot test had a higher sensitivity for the diagnosis of TB among HIV seronegative than HIV seropositive patients. Although the MycoDot test has a less than optimal sensitivity, the test specificity approaches 100%. It may be useful in patients with suspected TB and negative smears and in extra-pulmonary TB.

Frequency and risk of HIV infection among men attending a clinic for STD in Chiang Mai, Thailand.

A prospective study was conducted in the Chiang Mai Sexually Transmitted Diseases Clinic to determine the frequency of HIV seroconversion among men following high risk sexual contacts and to establish risk factors for HIV infection. HIV antibodies were detected in 26 out of 150 men on the initial recruitment with a seroprevalence rate of 21%. Among 124 initial HIV negative subjects; 100, 77, 68, and 55 subjects were followed for 2, 4, 12, and 24 weeks, respectively. One subject had HIV seroconversion documented with the rate of 1.0% (1/100, 95% confidence interval [CI] = 0.03-5.4%). Logistic regression analysis found significantly independent associations of HIV prevalence with prostitute visits at least once a month (OR = 3.6, 95% CI = 1.2-10.9), and with cigarette smoking (OR = 3.5, 95% CI = 1.2-10.5). Intensive health education should be elucidated to decrease the high rate of HIV infection among this population.

Outbreak of hepatitis A in a college traced to contaminated water reservoir in cafeteria.

A sharp but short outbreak of hepatitis A occurred in a college during September and October 1992. The epidemic pattern suggested a common source. The attack rate of clinically recognizable hepatitis A was 8% all cases were HAV IgM positive. Among 31 students with minor symptoms but without jaundice 8 (26%) were also HAV IgM positive, as were 8 (10%) of 77 totally asymptomatic students tested. A case control study of eating and drinking habits of the students showed no other significant differences other than that 45 of 56 cases and 18 of 34 controls interviewed had filled their water glasses by dipping them in a overflow water reservoir. This gives an odds ratio of 3.8. The reservoir was heavily contaminated with coliform bacteria and the residual chlorine was at lower than standard concentration, whereas other water resources were clean. It is suggested that the reservoir had been contaminated with hepatitis A virus by somebody with fecally contaminated hands a couple of weeks prior to the beginning of the outbreak.

Cerebrospinal fluid analysis in children with seizures.

Cerebrospinal fluid (CSF) examinations of 212 children aged two to 24 months with idiopathic nonfebrile seizures, complex febrile seizures, or status epilepticus, who had a lumbar puncture within 24 hours of the convulsion, were reviewed to determine whether an idiopathic convulsion can result in CSF abnormalities. Children with complex febrile seizures had a median CSF white blood cell count of 1 cell/mm3 (range 0-19 cells/mm3) and a median CSF polymorphonuclear (PMN) cell count of 0 cells/mm3 (range 0-8 cells/mm3). The CSF white blood cell (WBC) count was elevated above the upper limit of normal of 5 cells/mm3 in 9.8% and the absolute number of polymorphonuclear cells was more than 0 cells/mm3 in 26.2% of the complex febrile seizure subjects. Values at the 95th percentile were calculated; a total of 8 WBC/mm,3 4 PMN/mm,3 protein of 73 mg/dl and glucose of 119 mg/dl determined the 95th percentile CSF values for the patients with complex febrile seizures. Patients with nonfebrile seizures or with status epilepticus had similar findings. We conclude that complex febrile, idiopathic nonfebrile convulsions or status epilepticus may affect CSF findings in children: CSF with > 20 WBC/mm3 or > 10 PMN/mm3 should not be attributed to seizures.

Factors influencing outcome in stab wounds of the heart.

BACKGROUND: The purpose of this study was to identify factors associated with unfavorable outcome following stab wounds to the heart in order to improve selection of patients who may benefit from aggressive resuscitative efforts. METHODS: Preoperative and operative variables were reviewed for all patients treated for cardiac stab wounds at a level I trauma center from 1987 to 1993 in an attempt to identify factors influencing survival. RESULTS: Twenty-nine (53%) of the 55 patients who were resuscitated following stab wounds to the heart during the study period survived. Although profound hypotension (systolic blood pressure < 40 mm Hg), cardiopulmonary resuscitation, and emergency room thoracotomies were associated with poor outcome, none were uniformly predictive of death. Some patients survived with each of these characteristics. CONCLUSIONS: We recommend that all patients suspected of having cardiac stab wounds be fully resuscitated and undergo thoracotomy, as significant survival can be achieved and death is not always the outcome.

HIV-1 subtypes and male-to-female transmission in Thailand.

We examined the risk factors for heterosexual transmission of HIV in a case-control study of couples in Thailand. 90 HIV-positive men and their regular sex partners were enrolled at the immune clinic, Chulalongkorn Hospital, where 92% of male index cases had HIV-1 serotype A (subtype E). Most index cases had acquired HIV through sexual intercourse. 95 couples were enrolled at 15 detoxification clinics, where 79% of them had HIV-1 serotype B (subtype B). Most men had acquired HIV through injecting drug use (IDU).

PIP: A case control study was conducted during February 1992-April 1993 in Bangkok, Thailand, among 62 couples of which both partners were HIV seropositive (concordant couples [cases]) and 46 couples of which the man was HIV seropositive and the woman was HIV seronegative. The subjects were patients in the Immune Clinic in Chulalongkorn Hospital and in 15 drug detoxification (IDU) clinics. Couples in the immune clinic were more likely to be HIV seroconcordant than those in the IDU clinics (69% vs. 48%; 67% vs. 27%, after excluding females who were intravenous [IV] drug users; p 0.01). HIV-1 serotype B (subtype B) was more common among men in the IDU clinics while HIV-1 serotype A (subtype E) (79%) was more common among men in the immune clinic (92%). Seroconcordance was much more common when HIV-1 was of serotype A than when it was of serotype B (70% vs. 52%; odds ratio [OR] = 2.1; p 0.05). Further, when the researchers did not include couples of which the woman was an IV drug user, the difference in concordance was even greater (70% vs. 26%, OR = 6.8; p 0.01). These differences in concordance suggest that HIV-1 serotype A may be more efficiently transmitted than HIV-1 serotype B. The multivariate logistic regression analysis showed that independent risk factors of HIV seroconcordance were HIV-1 serotype A of male partners (adjusted OR = 3.1) and history of IV drug use in female partners (AOR = 4.8). HIV-1 subtype E may be linked to a higher risk of heterosexual transmission than subtype B. If so, the predominance of HIV-1 subtype E in Thailand could explain the rapid spread of HIV infection in Thailand.

Respiratory rate and signs in roentgenographically confirmed pneumonia among children in China.

A clinical study was conducted in three Chinese community hospitals to investigate the reliability of respiratory rate and various clinical signs in the diagnosis of pneumonia among 54 children less than 5 years of age. Anteroposterior chest film was used as the diagnostic standard. The cutoff criterion for rapid breathing was 50 breaths/minute for infants ages 2 to 11 months and 40/minute in children 1 to 5 years old. Rapid breathing was a better predictor of pneumonia than rales (positive predictive values of 74.5 and 66.9%). Nasal flaring, chest indrawing, stridor and cyanosis of the tongue had predictive values of > 86%, but these clinical signs were observed in only a small proportion of patients. We recommend that village health workers use rapid breathing for diagnosis of pneumonia, rather than auscultation which is difficult and has proved unreliable. Sensitivity, specificity and positive and negative predictive values are presented for seven signs and symptoms of pneumonia.

PIP: During October 1989 to March 1990 pediatricians and radiologists conducted a clinical study in Shunyi, Nanbu, and Shifang County Hospitals, China, of 160 healthy children and 541 children with fever and cough to examine the reliability of respiratory rate and various clinical signs in the diagnosis of radiologically confirmed pneumonia among 54 children under 5 years of age. The mean respiratory rate among children with cough and fever was 50 breaths/minute for infants aged 0-11 months and 40 breaths/minute for children aged 1-5 compared with about 40 breaths/minute and 30 breaths/minute, respectively, for healthy children . The researchers deemed these rates to be the cutoff criterion for rapid breathing. Rapid breathing could better predict pneumonia than rales could (positive predictive values, 74.5% vs. 66.9%). Nasal flaring, chest indrawing, and cyanosis of the tongue had high specificities (86.5%, 92.5%, and 93.5%, respectively). Yet these signs occurred in only a small percentage of the population (25.2% for nasal flaring and 10% for chest indrawing and cyanosis of the tongue). Based on these findings, the researchers call for village health workers to use rapid breathing to diagnose pneumonia rather than ausculatory signs, especially rales. Ausculatory signs are unreliable predictors of pneumonia.

Enhancing student practicum opportunities: the outbreak investigation option.

An outbreak investigation practicum option for graduate students at the University of Washington School of Public Health and Community Medicine has three goals of education, scientific investigation, and exposure to operations of public health agencies. Over a six-year period, 48 students performed 40 outbreak investigations in collaboration with adjunct faculty based in local public health agencies. An outbreak investigation practicum at Yale University had similar goals, but the rapid-response team approach there generally involved one regular faculty member and a team of graduate students. In either program, the level of faculty involvement necessary for outbreak investigations is sustainable only if the faculty value public health practice as part of the school's mission. Since public health students need to acquire many practical skills, a short outbreak investigation practicum experience should not be viewed in isolation, but rather should be one of a variety of practicum offerings available to students at schools of public health.

Engine block burns: Dupuytren's fourth-, fifth-, and sixth-degree burns.

We recently treated two patients with engine block-muffler contact burns and greatly underestimated the devastating injuries to bone, deep fascia, and muscle. As a result, each patient required multiple procedures to close their burn wounds. Ten-year data from the University of Washington Burn Unit confirmed our observation that these burns tend to be considerably deeper than suspected. Eighteen patients with contact burns from engine parts were identified from 1980 through 1990. Nine (50%) of these were initially recognized to be fourth-degree and five (28%) were third-degree thermal injuries, showing that these are deep burns. Eight patients required fascial excisions and four required debridement of devascularized bone. The mean burn size was only 6% total body surface area; however, the patients with fourth-degree burns had an average graft take of only 56% and required a mean hospital stay of 44 days. Patients with third-degree burns also had suboptimal graft take and some required prolonged hospitalization. Thirty-six percent of patients required flaps either as the initial procedure or as a second procedure following an autograft. The four patients with partial-thickness burns healed without surgery and their average length of hospital stay was 3 days. Of the entire group, only four healed without surgery and only five healed with a single operation. Our 10-year data indicate that engine block contact burns are usually small, but most are deceptively deep, involving tendon, muscle, or bone. If the burn appears full thickness, suspicion must be very high at the initial surgical procedure that there is deep tissue destruction.(ABSTRACT TRUNCATED AT 250 WORDS)

A second outbreak of cholera in the home for mentally handicapped, Nonthaburi.

A second outbreak of cholera, due to the Ogawa strain, occurred in the home for Mentally Handicapped Children in Nonthaburi between July 29 and August 9, 1992. An outbreak of cholera due to the Inaba strain was reported in the same institution and season tin 1987. In 1992, the clinical attack rate was 8 per cent of 440 children; there were two deaths. Bath water was contaminated with Vibrio cholerae O1 E1 Tor Ogawa, the same strain as was isolated from the ill children. Chlorination of the water supply, obtained from an underground well, was insufficient. The water supply needs further investigation, and the sanitary conditions in the institutions should be improved.

Risk of serious acute neurological illness after immunization with diphtheria-tetanus-pertussis vaccine. A population-based case-control study.

OBJECTIVE: To evaluate the association between serious acute neurological illness and receipt of whole-cell pertussis vaccine, given as diphtheria-tetanus-pertussis (DTP) vaccine. DESIGN: Population-based case-control study. SETTING: Outpatient and inpatient hospital settings, physician practices, and the general population in Washington and Oregon states. SUBJECTS: A total of 424 confirmed cases of neurological illness were identified prospectively during a 12-month period by statewide active surveillance from the population of 218,000 children 1 to 24 months of age living in Washington and Oregon (estimated 368,000 DTP immunizations given). Each case child was matched to two population control children by birth date (+/- 5 days), gender, and county of birth. Written immunization records were used to determine whether illness occurred within 7 days of immunization in case children, or within 7 days of the same reference date in control children, thus qualifying as exposed. MAIN OUTCOME MEASURES: Outpatient and inpatient cases of complex febrile seizures, seizures without fever, infantile spasms, and acute encephalitis/encephalopathy confirmed by an expert panel masked to immunization history. RESULTS: The estimated odds ratio (OR) for onset of serious acute neurological illness within 7 days for young children exposed to DTP vaccine was 1.1 (95% confidence interval [CI], 0.6 to 2.0). When the analysis was restricted to children with encephalopathy or complicated seizures and adjusted for factors possibly affecting vaccine administration, the OR was 3.6 (95% CI, 0.8 to 15.2). Odds ratios for specific study diagnoses varied, but all CIs included 1. No elevated risk was observed for the largest group of illnesses studied, nonfebrile seizures (OR, 0.5; 95% CI, 0.2 to 1.5). CONCLUSIONS: This study did not find any statistically significant increased risk of onset of serious acute neurological illness in the 7 days after DTP vaccine exposure for young children.

Infections caused by Mycoplasma pneumoniae and possible carrier state in different populations of patients.

Mycoplasma pneumoniae causes not only pneumonia but also other respiratory syndromes such as bronchitis, bronchiolitis, pharyngitis, and croup. These infections mimic viral respiratory syndromes. Most cases are treated on an outpatient basis. Epidemics take place at intervals of 4-7 years. The incidence rate is highest among school children and second highest among children < 5 years of age. Among persons who have had M. pneumoniae pneumonia, rates of subsequent infection with this organism are low, and immunity appears to increase with age. The carrier state may last for several months. Patients with humoral immunodeficiency often develop severe infections due to M. pneumoniae, with involvement of the joints; in these individuals the carrier state may persist. M. pneumoniae has been isolated from bronchial washings from children with AIDS. These children have recovered from mycoplasmal infection with appropriate antibiotic treatment. Dermatologic, neurological, cardiac, renal, and pulmonary complications occur, although data on their frequency are lacking.