Giant Kidney Worm: Novel Report of Dioctophyma Renale in the Kidney of a Dog in Greece.

Dioctophyma renale is the largest nematode that infects domestic mammals and is the aetiologic agent of a serious renal disease, dioctophymatosis. It has an indirect life cycle with carnivores serving as final hosts and earthworms as intermediate hosts. The parasite can infect humans with signifi cant zoonotic potential. The pathogenesis of dioctophymatosis is mainly associated with the extent of renal atrophy caused by the parasites, the risk of bilateral renal infestation and the location of the parasite (extrarenal cases). Clinical diagnosis is challenging, and the only treatment option is nephrectomy or nephrotomy to remove the adult nematode. A 6-year-old female crossbreed dog presented with tachypnea, tachycardia and severe hematuria, but died shortly after presentation. Postmortem examination found the right kidney was enlarged and two adult nematodes were found in the renal pelvis. The left kidney was normal. The nematodes were collected and submitted for identifi cation. The two specimens were identifi ed as D. renale using specific identifi cation keys. Herein we present the first case of renal parasitosis by the nematode D. renale in a dog from Greece. This case highlights the need for investigation of the actual prevalence of the parasite and the use of measures for the control of its expansion aiming the protection of dogs and public health.

Comparison of the effects on lipoproteins and apolipoproteins of a diet high in monounsaturated fatty acids, enriched with avocado, and a high-carbohydrate diet.

A randomized trial was conducted to compare effects of a diet high in monounsaturated fatty acids, enriched with avocado (AE), and a high-complex-carbohydrate diet (AHA-III) on blood lipid concentrations. Fifteen females between 37 and 58 y of age were allocated either to AE followed by AHA-III, or vice versa. Each dietary phase lasted 3 wk. Both diets were found to lower total cholesterol compared with baseline values. AE was more effective, with an 8.2% decrease (P less than 0.05) whereas AHA-III was associated with a 4.9% decrease (NS). Low-density-lipoprotein cholesterol and apolipoprotein B decreased significantly on AE but not on AHA-III (P less than 0.05). The high-density-lipoprotein (HDL) concentration did not change on AE but decreased 13.9% on AHA-III (P less than 0.01). It is concluded that AE is more effective than is AHA-III in decreasing total cholesterol, and, unlike AHA-III, it does not decrease HDL concentrations.

Malignant pleural effusion.

Malignancy is the most common cause of exudative pleural effusion in patients over the age of 60 years. Control of the effusion significantly reduces morbidity and improves quality of life. Tube thoracostomy with subsequent chemical pleurodesis is the treatment of choice for patients with tumors that are relatively insensitive to systemic chemotherapy. The agents most commonly used for chemical pleurodesis are tetracycline and bleomycin. A 13-center randomized trial compared tetracycline 1 g and bleomycin 60 U. Median time to recurrence or progression of the malignant effusion was 32 days for tetracycline and more than 46 days for bleomycin (P = .037). The recurrence rate within 30 days of instillation was 36% for bleomycin (10 of 28 patients) and 67% (18 of 27 patients) for tetracycline (P = .023). At 90 days, the recurrence rate was 30% (11 of 37) for bleomycin, and 53% (19 of 36) for tetracycline (P = .047). From this study, the authors concluded that intrapleural bleomycin appears superior to tetracycline for controlling malignant pleural effusions. Selected patients who fail tube thoracostomy and chemical pleurodesis should be considered for pleuroperitoneal shunting or pleurectomy.

The adverse effect of perioperative blood transfusion in lung cancer.

Perioperative blood transfusion appears to increase the risk of recurrence and death in patients with surgically resected lung cancer. This finding is consistent with that in other cancers and several studies in lung cancer report similar risk elevations. We have reanalyzed the Lung Cancer Study Group data relevant to this question, assessing the potential confounding effects of some prognostic factors not examined previously. The results are nearly identical to those reported earlier, suggesting that increased risk is attributable to blood transfusion and not to confounding by known prognostic factors.

Nuclear scan-guided rib biopsy.

The bone scan is a sensitive screening device that is frequently used to stage the condition of patients with known or suspected malignant disease. Abnormal findings on bone scan are associated with corresponding normal findings on radiographs in approximately 50% of cases. Definitive tissue diagnosis of the bone lesion is often needed to determine optimal therapy, but localization of the lesion is imprecise unless it is palpable. Use of the nuclear scan to localize and mark the rib enhances the precision of the biopsy procedure. Thirty-three consecutive patients with cancer who had bone scans suggestive of rib abnormalities underwent nuclear scan-guided biopsy. Each patient had a repeat localizing scan with a maximum permissible dose of technetium 99m radionuclide on the day of the planned biopsy. The site of abnormality was marked with methylene blue injected into the skin overlying the lesion and down to the periosteum at the specific site. The patient was then taken to the operating room and the marked area was excised through a small incision. Pathologic abnormality was identified in all but one of the resected specimens, an accuracy rate of 97%. Despite a presumed or proved diagnosis of cancer in 33 patients, 16 specimens (48%) were benign. There were no complications associated with this technique, which reduces the morbidity and increases the precision of rib biopsy.

One-stage reconstruction for pharyngolaryngectomy. Esophagectomy and pharyngogastrostomy without thoracotomy.

From 1969 to 1981, a total of 22 patients underwent laryngopharyngectomy and nonthoracotomy esophagectomy, with immediate pharyngogastrostomy, for hypopharyngeal or postcricoid carcinoma. Thirteen initially had been treated by high-dose radiotherapy, but the tumor had either persisted or recurred. Four patients underwent planned preoperative irradiation on the morning of the operation. Two patients had had previous high-dose local irradiation to the neck for other disease, and three patients had no irradiation. There was one operative death. Anastomotic leaks developed in four patients, but only one of the leaks was considered a serious problem. Three patients had transient dysphagia, but only one required dilatation. Transient delayed gastric emptying was a problem in three other patients. The average postoperative stay was 31 days, with 38% of patients being discharged by 21 days. All patients were discharged eating a normal diet. Fifty percent survived longer than 12 months, with an actuarial survival rate of 30% at 5 years. The patient surviving longest is disease free at 12 years. Palliation was considered excellent in all 21 operative survivors. Immediate pharyngogastrostomy via nonthoracotomy esophagectomy is a safe and excellent means of palliation in this group of patients, for whom palliation is often the only option.

Intrapleural therapy for malignant pleural effusions. A randomized comparison of bleomycin and tetracycline.

Between December 1985 and August 1988, there were 115 patients at 13 centers who were entered on a randomized comparison of tetracycline and bleomycin for treatment of malignant pleural effusions. Fifteen patients were not treated, primarily due to rapid progression of systemic cancer. Fifteen patients entered on a high-dose regimen of bleomycin (120 units) were excluded from this analysis (following early closure of that arm), leaving 85 patients randomized to low-dose bleomycin (60 units; 44 patients) or tetracycline (1 g; 41 patients). Patients were required to have a cytologically positive pleural effusion, good performance status (0, 1, or 2), lung reexpansion following tube thoracostomy with drainage rates of 100 ml/24 or less, no prior intrapleural therapy, no prior systemic bleomycin therapy, no chest irradiation, and no recent (four weeks) change in systemic therapy. A total of 11 patients (five with bleomycin and six with tetracycline) were not evaluable due to technical problems with tube drainage (one), loss to follow-up (two), sudden death due to pulmonary embolus (one), and rapid progression of systemic disease (seven). There were no clinically significant differences in demographic factors, primary site, performance status, or presence of metastases other than pleural effusion. Overall survival did not differ between the two groups. Median time to recurrence or progression of the effusion was 32 days for tetracycline-treated patients and at least 46 days for bleomycin-treated patients (p = 0.037). The recurrence rate within 30 days of instillation was 36 percent (10/28) with bleomycin and 67 percent (18/27) with tetracycline (p = 0.023) (not all patients were restudied in the first 30 days). By 90 days the corresponding recurrence rates were 30 percent (11/37) for bleomycin and 53 percent (19/36) for tetracycline (p = 0.047). Toxicity was similar between groups.

Subxiphoid pericardial drainage for pericardial tamponade.

As a result of recent reports and enthusiasm for video-assisted thorascopic pericardiectomy, we reviewed our experience with subxiphoid pericardial drainage. From August 15, 1988, to June 7, 1993, 155 patients underwent subxiphoid pericardial drainage for pericardial effusion associated with pericardial tamponade. The group comprised 85 female (55%) and 70 male patients whose ages ranged from 5 weeks to 88 years. The procedure was carried out with general anesthesia in 113 patients (72%) and with local anesthesia and sedation in 42 patients. Underlying cancer was present in 82 patients; 73 patients had benign disease. Follow-up is complete in all patients. The overall 30-day mortality was 20%; in patients with cancer it was 32.9% (27/82) versus 5.4% (4/73) for patients with benign disease. No postoperative death was attributed to the surgical procedure. Recurrent pericardial tamponade necessitating further surgical intervention occurred in four patients (2.5%), two with cancer (2.4%) and two with benign disease (2.7%). Median survival after subxiphoid pericardial drainage in patients with benign disease was more than 800 days versus 83 days in patients with cancer (p < 0.01). Median survival after pericardial drainage in patients with cancer who had malignant pericardial effusion was 56 days compared with 105 days for patients with cancer who did not have tumor in the pericardium (p < 0.05). We believe that subxiphoid drainage is the procedure of choice for patients with pericardial tamponade. It is accomplished quickly, is associated with minimal morbidity, and prevents recurrent tamponade in 97.4% (151/155) of patients.

Treatment of esophageal obstruction with covered, self-expanding esophageal Wallstents.

BACKGROUND: Conventional endoluminal plastic prostheses used for relieving esophageal obstruction allow variable palliation. Covered, expandable metal stents provide an 18-mm lumen to allow improved deglutition. METHODS: From December 1994 to December 1995, 20 patients underwent placement of self-expanding, silicone-covered Wallstents (Schneider, Plymouth, MN) for esophageal obstruction. Fifteen patients had obstruction secondary to carcinoma and 5 patients had benign esophageal stricture. There were 13 men and 7 women, ranging in age from 54 to 94 years. All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation to 42F or 45F, placement of the stent was performed under fluoroscopic control. RESULTS: Follow-up was complete in all patients, ranging from 4 weeks to 12 months. Technical success was achieved in all patients. There was one postoperative death (bronchoesophageal fistula) and one migration of the stent requiring removal (peptic stricture). The remaining stents were well tolerated, even in the cervical region (4 patients). All patients successfully intubated were able to eat well, including solid foods. CONCLUSIONS: Covered, self-expanding esophageal Wallstents are technically simple and safe to insert and appear to provide durable, excellent palliation of esophageal obstruction due to either benign or malignant conditions. A larger patient population is required to make firm conclusions.

Effect of perioperative blood transfusion on outcome in patients with surgically resected lung cancer.

Three hundred thirty patients with non-small cell lung cancer were evaluated to assess the effect of perioperative blood transfusion on overall survival and time to recurrence. One hundred sixty-nine patients received blood products during the perioperative period, and 161 received none. The mean length of follow-up was 3.6 years. There were 90 recurrences, including second primaries, and 99 deaths in the group receiving transfusion; in the group without transfusion, recurrent cancer developed in 74 patients, and 68 died. Survival comparisons, adjusted for stage and cell type using the stratified log-rank statistic, showed significant reduction in survival (p = 0.007) for patients receiving transfusion. Time to recurrence was shorter for patients receiving transfusion (p = 0.035), but became less significant when adjusted for both cell type and stage (p = 0.11). Blood transfusion within the perioperative period appears to have an adverse effect on survival and recurrence in patients undergoing surgical resection for lung cancer.

Treatment of stage I lung cancer (T1N0M0, T2N0M0).

Patients with stage I lung cancer can be offered surgical treatment with an excellent prognosis for recovery and long-term cure. The recent revision of the staging definition has rearranged the prognostic categories, further improving the prognosis in Stage I disease by eliminating patients with a higher risk of recurrence. The most vexing issues remaining are the infrequency of diagnosis of lung cancer at this stage and the increasing incidence of lung cancer of all stages, even among nonsmokers. Economical screening, abolition of cigarette smoking, control of airborne environmental carcinogens, and the continued search for effective systemic treatment remain challenges for the future.

Issues in the modification of American sign language for instructional purposes.

The use of manual communication and sign languages for language education of autistic, deaf retarded, and mentally retarded individuals is receiving increasing attention by educators. Modifications of sign systems for this purpose emphasize simplicity, redundancy, and English word order. Effective utilization of manual communication for these populations requires a better understanding of the physical and linguistic bases of sign languages than now exists. Preliminary evidence from studies of oral-only, manual-only, and oral-manual modes of communication suggests that flexibility in utilizing all modes is the most effective teaching method. The present paper will consider the possible utilization of modifications of the American Sign Language for use in three general areas: instruction of deaf students in the classroom, communication between hearing parents and young deaf children, and communication with individuals with handicaps other than deafness.

Self-expanding esophageal metallic stents in the treatment of esophageal obstruction.

Esophageal obstruction from any cause is debilitating. In patients with malignant obstruction palliation to relieve pain and dysphagia is the primary goal. Conventional endoluminal prostheses allow variable palliation. Covered expandable metallic stents with an 18-mm lumen allow improved deglutition. From December 1994 through December 1998, 59 patients underwent placement of self-expanding silicone-covered esophageal stents for esophageal obstruction. There were 36 men and 23 women ranging in age from 41 to 94. All patients underwent esophageal dilation using a flexible gastroscope and Savary bougies. After dilation placement of the stent was performed under fluoroscopic control. Follow-up was complete in all patients. Technical success was achieved in all patients. There was one postoperative death (bronchopulmonary fistula), one migration of the stent requiring removal, and one recurrent obstruction. The remaining stents were well tolerated even in the cervical region (four patients). All patients returned to a diet of solid foods. We conclude that covered self-expanding esophageal metallic stents are technically simple and safe to insert and appear to provide durable excellent palliation of esophageal obstruction due to either benign or malignant conditions.

Laparascopic excision of pelvic kidney with single vaginal ectopic ureter.

An ectopic vaginal ureter is an uncommon cause of urinary incontinence. Most cases are associated with a duplex kidney where the orthotopic lower moiety ureter enters the bladder. The authors present a case of chronic, continuous low-grade urinary incontinence caused by the rare combination of a pelvic kidney and a single ectopic ureter draining into the vagina. This ectopic kidney was successfully removed laparoscopically. A review of the English-language literature showed this to be only the second reported case treated by laparoscopic nephrectomy.

Laparoscopic bladder 'wrap' technique for repair of vesicoureteric reflux in a porcine model.

PURPOSE: The aim of this study was to determine if vesicoureteric reflux (VUR) can be successfully corrected laparoscopically by a bladder "wrap" technique in a pig model. METHODS: In 15 female piglets (mean weight, 22.5 kg) bilateral VUR was created by an open technique (11 grade 3, 2 each of grades 2 and 4). Eight weeks later (range, 4to 16 weeks) VUR was confirmed by fluoroscopic cystogram, and unilateral laparoscopic correction was performed. The contralateral ureter was used as a control. The bladder was emptied, and a 3F ureteric catheter was inserted on the repair side. Four 11-mm ports were inserted transperitoneally. The ureter was dissected to the ureterovesical junction (UVJ). Commencing at the UVJ, 2 (n = 9) or 3 (n = 6) black silk sutures were placed through the bladder muscle on either side of the ureter creating a bladder wrap around the distal 2 to 4 cm of ureter. At a mean of 16 weeks (range, 4 to 24 weeks) cystograms were repeated. The animals were killed the bladder and ureters underwent histopathology examination. RESULTS: VUR was corrected in 12 animals (80%). There was persistence of VUR in 2 and ureteric obstruction in 1. The wrap was intact in all animals. CONCLUSIONS: Laparoscopic correction of VUR by the bladder wrap technique is successful in pigs. Long-term follow-up studies will determine if this will be a satisfactory alternative surgical treatment for correction of VUR in children.

Gastroschisis: a simple technique for staged silo closure.

In conjunction with the Neonatology Department at Loma Linda University Children's Hospital, a new protocol has evolved for the management of infants with gastroschisis, which obviates both risks associated with primary and staged silo closure. After stabilization of the infant in the neonatal intensive care unit, under sterile conditions, a 5- or 7-cm SILASTIC silo with a spring-loaded ring is placed over the exposed viscera, under the fascial defect. No sutures are required. A fentanyl drip is given, and the bowel is gradually reduced over the next few days. The transparent material of the silo allows for continuous monitoring of the condition of the bowel. Second-stage closure in the operating room is performed using a purse-string suture in the fascia to create a pseudoumbilicus. From October 1992 to April 1994 the authors managed 10 infants using this protocol. The results are compared with those of infants with gastroschisis treated at the same institution between August 1982 and June 1993. Outcome parameters to be compared include time until closure, time on ventilation, days of total parenteral nutrition, time until start of oral feeding, time until toleration of full-volume oral feeding, and time until discharge. The authors conclude that silo closure in the neonatal intensive care unit is simple, quick, and effective. It eliminates multiple trips to the operating room, allows the natural accommodation of the bowel into the abdominal cavity with little edema and minimal vascular compromise, and has become the authors' treatment of choice for infants with gastroschisis.

Pediatric laparoscopic splenectomy.

Laparoscopic surgery is becoming widely accepted as an alternative to conventional procedures. It is becoming more and more evident that laparoscopic techniques can be applied successfully to pediatric patients. Advantages of these techniques include less postoperative pain, decreased ileus, fewer pulmonary complications, and shorter hospital stays. Elective splenectomy for hematologic disease or for staging of Hodgkin's lymphoma also appears to be amenable to laparoscopic techniques. This report details 12 consecutive splenectomies successfully performed laparoscopically since July 1993. No case required conversion to laparotomy. Each case was reviewed with respect to operative time, estimated blood loss, identification of accessory spleens, time until full oral intake, analgesia requirements, and length of stay. Factors contributing to morbidity such as ileus, pulmonary complications, and would infections were evaluated. Documentation was also reviewed for late sequelae such as intestinal obstruction and incisional hernias. These patients were compared with 20 consecutively treated patients who underwent open splenectomy in the period immediately preceding the use of laparoscopic splenectomy. Laparoscopic splenectomy, in the authors' experience, is a safe alternative to open splenectomy, has few complications, is cost effective, and has been well accepted by patients and families.

Mathematics achievement of hearing impaired adolescents in different placements.

This study, involving 215 students and 63 teachers, addressed three concerns related to mainstreaming for hearing imparied students: the selection process, the difference between a mainstream placement with an interpreter and a self-contained placement, and the quality of the educational experience. Almost half of the variance in achievement between the two settings is described. Three conclusions can be drawn. First, student background factors are a primary determinant of achievement. Second, mainstreaming with an interpreter has no specific effect on achievement for hearing impaired students. Third, the quality of instruction is the prime determinant of achievement, regardless of placement.

Is telemedicine a subset of medical informatics?

Informatics has a key characteristic of a new discipline in a technically transient environment--there is no universal definition of it. This is not surprising, given its complex and diverse nature. In a broad sense informatics is the interface between developing technologies and the decision sciences, in particular clinical sciences. Telemedicine has no universally accepted definition either. Telemedicine requires the use of electronic communication networks for the transmission of information and data related to the diagnosis and treatment of, as well as education about, medical conditions. The debate ensues over whether it is or is not a subset of medical informatics. The care of the elderly diploma programme is a telemedicine project within the department of family medicine at the University of Alberta; it is a distance learning programme directed towards educating and training physicians in rural Alberta. This project provided us with the practical experience of addressing both informatics and telemedicine issues jointly.