Biomedical subjects
Publications and source records attributed to J Drumm.
Three cases of choledochal cyst are presented, with a review of previous publications. We re-emphasize the diagnostic dilemma involved and discuss current surgical management. A new complication is illustrated and an association with polycystic kidneys is reported. Choledochal cysts are uncommon, but correct management ensures a symptom-free future for the patient. Recent reports support cyst excision if technically feasible.
With improvement in the medical management of diverticular disease, perforation has become the most common indication for surgical intervention. It is a source of considerable morbidity and mortality and consequently has provoked a considerable and controversial challenge for surgeons. We are proposing that all patients found to have purulent peritonitis secondary to perforating diverticulitis at laparatomy, should be managed initially by a defunctioning transverse colostomy, drainage and the administration of appropriate antibiotics. Subsequent management should consist of simple closure of the colostomy following a check barium enema and the commencement of a high fibre diet. We substantiate this by reporting 20 cases from Dudley Road Hospital and 20 others mentioned in the current literature.
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Thirty patients undergoing elective abdominal surgery were given 1 g amoxycillin plus 0 . 2 g clavulanic acid as a single intravenous injection at varying times prior to the operation. Sterile assay discs were placed on the peritoneal surface in order to measure peritoneal fluid levels of each agent. Simultaneous serum levels were also measured. A total of 44 simultaneous serum and peritoneal samples were analysed. There was rapid penetration of both agents into peritoneal fluid. The mean peritoneal fluid levels of amoxycillin were 84% (S.D. 34) of the serum level and 66% 42) for clavulanic acid. The peritoneal levels of both agents declined in parallel to the serum levels (the half-lives all being about 1 h) and the ratio of amoxycillin: clavulanic acid in serum and peritoneal fluid was similar to that as administered.
The intraperitoneal penetration of temocillin was studied following a 1 g iv injection in 28 patients undergoing elective gastrointestinal surgery. Temocillin penetrated rapidly and during the first hour post administration the peritoneal level was 48% of the serum level. The mean peritoneal level of temocillin over the period of the study (3.5 h) was 49.1 mg/l. It was concluded that 1 g of temocillin twice daily would achieve sufficiently high intraperitoneal levels to inhibit susceptible pathogens.
The intraperitoneal penetration of cefotetan was studied after a 1-g intravenous injection in 25 patients undergoing elective gastrointestinal surgery. Levels of peritoneal fluid were high within 10 min after administration and increased to 44% of the serum levels after 30 min, rising to 115% at 3 h. The mean concentration of cefotetan between 3 and 5 h after administration was 32.3 micrograms/ml. These findings suggest that 1 g of cefotetan administered before abdominal surgery would result in intraperitoneal cefotetan levels necessary to inhibit susceptible pathogens for 5 h or more.
Twenty-five patients undergoing elective intraabdominal surgery received either 1 or 2 g of ampicillin together with 1 g of sulbactam intravenously before surgery. The peritoneal levels of the agent were measured. Both compounds penetrated peritoneal fluid readily; the mean percentage of penetration by ampicillin was 92%; that of sulbactam was 96%. After 1 g of each agent, the peritoneal levels of sulbactam were 47% greater than those of ampicillin. Our results suggest that 2 g of ampicillin plus 1 g of sulbactam should provide peritoneal levels that would inhibit most susceptible beta-lactamase-producing pathogens encountered in intraabdominal sepsis.
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A combination of pulsed echo and continuous wave Doppler ultrasound was used to obtain blood flow velocity signals from the umbilical arteries of 10 patients during uncomplicated spontaneous labour. Audio frequency analysis of these signals yielded fetal blood velocity waveforms. Analysis of these waveforms demonstrated that placental vascular resistance to feto-placental blood flow is not altered by uterine contractions, artificial rupture of the membranes, the infusion of oxytocin nor the administration of analgesia during uncomplicated labour.
A combination of pulsed echo and continuous wave Doppler ultrasound was used to obtain blood flow velocity signals from the umbilical arteries of 18 normal patients from the 16th until the 40th week of pregnancy. Audio frequency analysis of these signals yielded fetal blood velocity waveforms. Analysis of these waveforms demonstrated that the placenta is an organ of low vascular resistance and that placental resistance to blood flow declines with advancing gestational age in normal pregnancy.
The random cell movement of BALB/c 3T3 and SV40 virus-transformed BALB/c 3T3 cells within homogeneous aggregates was studied by observing the degree of penetration of newly attached [3H]thymidine-labeled cells into the interior of the aggregates. The 3T3 cells penetrated into 3T3 aggregates an average of 0.89 cell diameter in 1.5 days, whereas the SV40-3T3 cells penetrated into SV40-3T3 aggregates an average of 3.20 cell diameters in the same time. Treatment of the aggregates with theophylline, theophylline plus prostaglandin E1, or theophylline plus dibutyryl cyclic AMP all decreased the penetration of the SV40-3T3 cells into SV40-3T3 aggregates (2.36, 1.22, and 0.79 cell diameters, respectively). The same treatments had little effect on 3T3 aggregates. The ultrastructure of 3T3 and SV40-3T3 cells in aggregates was examined by transmission electron microscopy. The 3T3 cells in aggregates were surrounded by microvilli and lamellipodia which were in contact with neighboring cells, whereas SV40-3T3 cells were nearly devoid of microvilli and lamellipodia and made contact at broader, less regular surface undulations. Treatment with theophylline plus dibutyryl cyclic AMP resulted in the appearance of microvilli on SV40-3T3 cells and also appeared to increase the area of intercellular contacts in both 3T3 and SV40-3T3 cells. These observations were supported for the surface cells of the aggregates by scanning electron microscopy.
The sorting-out behavior (self-segregation of two cell types from mixtures of the two) of five different established cell lines was studied. Eight of the ten possible binary combinations of these lines, cultured as cellular aggregates, were examined. Mouse BALB/c 3T3 cells sorted out internally to the corresponding malignant SV40 virus-transformed 3T3 cells. The transformed 3T3 line (SVT-2) did not sort out from a revertant line selected from SVT-2 cells by resistance to concanavalin A (con A). The revertant cells sorted out externally to the parent BALB/c 3T3 cells, although segregation was generally incomplete. BALB/c 3T3 cells did not sort out from another contact-inhibited line of 3T3 cells derived from Swiss albino mice (Swiss 3T3). Both BALB/c 3T3 and Swiss 3T3 cells sorted out from cells of the contact-inhibited hamster line, NIL B. Instead of a two-layered sphere, however, a three-layered structure was observed with most of the NIL B cells external to the 3T3 cells, and a few NIL B cells comprising the center of the sphere. On the other hand, NIL B cells did not consistently sort out from either the SVT-2 or con A cells. In general, sorting out between pairs of these five lines are slower and less complete than is generally observed between the more extensively studied chick embryonic tissue cells, suggesting that the cultured cells may be more closely related in their adhesive properties. The internal segregation of BALB/c 3T3 cells relative to SVT-2 cells is consistent with the hypothesis that transformed cells are less adhesive than their nontransformed counterparts.
The mobility of embryonic chick cells and cells of four established cell lines was examined in cellular aggregates. This was done by preparing aggregates of unlabeled cells and allowing cells of the same type, but prelabeled with [3H]thymidine, to adhere to the surface of the aggregates. After 2-1/2 days in agitated liquid culture the positions of the labeled cells within the aggregates were determined by autoradiographic techniques. Since the labeled and unlabeled cells were otherwise identical, the degree of penetration of the labeled cells into the aggregates was taken as a measure of the mixing or mobility of cells in the aggregate. With this procedure, embryonic chick liver, heart, and neural retina cells were found to move an average of 2.12, 2.68, and 4.00 cell diameters inward, respectively. Mouse fibroblast BALB/c 3T3 cells moved an average of 1.13 cell diameters inward, while Simian virus 40 (SV40)-transformed BALB/c 3T3 cells moved as much as 8.80 cell diameters inward, indicating that cells of the malignant SV40-transformed line were considerably more mobile than the corresponding nonmalignant 3T3 cells. In contrast, cells of the hamster fibroblast line NIL B moved 4.17 cell diameters in 2-1/2 days, while SV40-transformed NIL B cells moved 3.00 cell diameters in the same time. It was therefore concluded that infection with oncogenic viruses does not necessarily result in increased cellular mobility.
BACKGROUND: Contralateral groin exploration in children with unilateral inguinal hernia is still controversial, particularly in infants. The patency rate of processus vaginalis is highest in infants but there are few data on the subsequent risk of contralateral hernia development in infants. In this retrospective study, we aimed to find out the incidence of contralateral inguinal hernia following unilateral inguinal herniotomy in infants aged less than one year. METHODS: All infants who underwent a unilateral Inguinal herniotomy between January 1990 and December 1998 were studied retrospectively. Infants with bilateral hernia (n = 7) were excluded from the study. RESULTS: One hundred and one infants (93 boys and 8 girls) were studied. Median age at operation was 23 (range 2-52) weeks. The herniotomy was right-sided in 75% of the infants. Follow-up ranged from three and a half years to 11 years. A contralateral hernia developed in nine infants (9.0%). One of the initial hernias was incarcerated. Median time from operation to occurrence of contralateral hernia was 18 (range 2-60) months. None of the contralateral hernia was incarcerated. Age, sex, incarceration and side of initial hernia did not influence the development of contralateral hernia. CONCLUSION: The low incidence and benign nature of contralateral hernia development in infants undergoing a unilateral inguinal herniotomy does not justify routine contralateral groin exploration.
BACKGROUND: It has been suggested that only specialist paediatric surgeons should manage infantile hypertrophic pyloric stenosis (IHPS). AIM: The aim of this retrospective study was to ascertain whether the majority of these infants might be managed in a well-equipped regional centre. METHODS: Using the Hospital Inpatient Enquiry database, all cases of IHPS within a single administrative health region were identified over a six-year period. A chart review was performed to obtain demographic and clinical information for each patient. Reports from the Central Statistics Office were used to obtain data on population and live births for the region. RESULTS: Seventy patients with IHPS were identified from this region from 1991 to 1996, 63 (90%) of which were treated in the region. Of the remaining seven, four were referred directly to specialised paediatric surgical hospitals because of prematurity (n = 1), low birth weight (n = 1), capillary haemangioma (n = 1) and severe metabolic derangement (n = 1) while three were assessed and treated in general hospitals outside the region. Of the 63 infants undergoing pyloromyotomy in this region, the duodenal mucosa was breached in four (6%); there were wound complications in three (5%); and one required a re-pyloromyotomy. The mean postoperative stay was eight days (range 2-42 days). CONCLUSION: The majority of infants with IHPS may be safely managed in regional centres with transfer to specialist paediatric centres reserved for 'high risk' cases. The management of IHPS at a regional level has important implications and presents opportunities for surgical training.
BACKGROUND: In Ireland, general surgeons provide paediatric surgical services to patients remote from specialist paediatric units. AIM: To review general paediatric surgical services in the Mid-Western Health Board (MWHB) region with a view to informing future policy decisions in Ireland. METHODS: From 1995 to 2000, the paediatric surgical workload at the Mid-Western Regional Hospital was reviewed. Operations performed, level of operating surgeon, morbidity and mortality were recorded. RESULTS: There were 3,166 general paediatric surgical patients cared for by three general surgeons and one urologist, all with paediatric surgical training. There was an increase in day cases (55% to 70%) and operations at which the consultant was the main operator (40% to 67%). There was no mortality and the morbidity rate was less than 1%. CONCLUSIONS: General paediatric surgery and urology is well provided for in the MWHB by appropriately trained surgeons. Lack of opportunity for surgeons in training to obtain general paediatric surgical experience will put this service at risk as the current cohort of surgeons retire. Expansion in specialist paediatric surgical services, changes in general surgical training to include general paediatric surgery or proleptic appointments may be required.
BACKGROUND: In the Republic of Ireland there are no paediatric surgeons outside Dublin. Most paediatric trauma is managed in general hospitals by general or orthopaedic surgeons. AIM: In this study we audited our experience with paediatric trauma in a regional setting. METHODS: We carried out a retrospective review of all non-orthopaedic paediatric trauma patients admitted to our institution over a two-year period.The method of injury, management and outcome were recorded and the TRISS (revised trauma injury severity score) method was used to calculate the probability of survival. RESULTS: One hundred and fifty four paediatric patients were admitted following trauma. Falls, RTAs and burns were the commonest reasons for admission. Twenty nine of these patients (19%) required surgical procedures. There were no unexpected deaths. CONCLUSION: The majority of paediatric trauma admissions were for minor injuries. A number of seriously injured children were successfully treated with no unexpected deaths.
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