Royal College of Physicians and Surgeons of Canada: annual meeting draws over 2000 physicians

In a review of 19 years'' experience with inhalation of foreign bodies by children the 33 patients (mean age 28 months) were found to have presented most frequently with wheezing or coughing, or both, of recent onset, and to have decreased air entry, rhonchi or respiratory stridor, or a combination of these signs. Eighteen children had inhaled a nut, a pea or a bean. The other 15 had inhaled various organic and inorganic objects. All the children underwent bronchoscopy, and the foreign body was completely removed in 19 during the first procedure; the remainder required repeated bronchoscopy or direct surgical removal of the foreign body, or both. Permanent disability or death was not encountered. The findingsof the study indicate that early bronchoscopic removal is the preferred treatment when a child inhales a foreign body.     

控制通气在全麻患儿支气管异物取出术中的应用研究

目的:探讨静脉全麻下小儿支气管异物取出术中控制通气的应用效果。方法:选择2014年1月～2018年7月本院收治的支气管异物患儿138例为研究对象,所有患儿均在静脉全麻下行支气管异物取出术,采用随机数字表法将其分为对照组(采用自主呼吸通气,69例)和观察组(采用控制通气,69例),比较两组手术时间、麻醉时间、苏醒时间、置镜首次成功率、置镜时间、置镜难易程度、心率、平均动脉压(MAP)、血氧饱和度(SpO_2)及不良反应发生率。结果:观察组手术时间、麻醉时间、苏醒时间均短于对照组(P0.05);观察组置镜首次成功率高于对照组,置镜难度低于对照组,置镜时间短于对照组(P0.05);观察组麻醉后心率、MAP水平低于对照组,SpO_2水平高于对照组(P0.05);观察组不良反应发生率均低于对照组(P0.05)。结论:静脉全麻患儿支气管异物取出术中,采用控制通气的方式效果较好,其具有较强的可控性,且安全性高,是一种较理想的手术麻醉方案。     

Coin ingestion,an unexpected finding at colonoscopy: case report

Gastrointestinal tract ingested foreign bodies are common problems, particularly in children. The most common ingested foreign bodies are coins. Once foreign bodies have passed through the esophagus and into the stomach, 80% will pass through the gastrointestinal tract unimpeded, with the remainder requiring endoscopic or surgical removal. It is rare to find ingested foreign bodies at routine colonoscopic examination, in particular in an adult without any prior history of ingestion.     

Oesophageal foreign bodies.

Impaction of foreign bodies in the oesophagus was analysed in 54 patients, 45 of whom were children. Of the 45 children 28 were aged 2-4 years. Coins were the most common foreign body in children (27 cases) while in adults a bolus of meat was most common (nine cases). In 41 children there was no predisposing factor, but an underlying mechanism was detected in 88% of the adults. The mechanisms were of three types: oesophageal (stricture), neuromuscular (myasthenia gravis), and extrinsic and mechanical (ankylosing spondylitis). In children most of the foreign bodies were impacted in the upper oesophagus at the cricopharyngeal junction, which is the narrowest part of the oesophagus, while in adults the foreign body was usually impacted at the site of the predisposing lesion or in the lower oesophagus. In all patients oesophagoscopy was performed under general anaesthesia to remove the impacted foreign body. Complications were more frequent in adults, mainly owing to the underlying condition.     

Swallowed foreign bodies

Of 98 swallowed foreign bodies demonstrated, 71 with fate definitely known are reported. Seventeen of 20 foreign bodies in the esophagus had esophagoscopic removal. Only two of 51 foreign bodies in the gastrointestinal tract had laparotomy, while 49 were spontaneously passed. Early esophagoscopic removal of foreign bodies lodged in the esophagus and conservative management of foreign bodies which have passed the esophagogastric junction are recommended. Laparotomy is rarely indicated in the management of swallowed foreign bodies, although various observers are not in full agreement as to the circumstances in which "watchful waiting" is advisable nor as to how long it is permissible to wait for spontaneous passage. In 20 of 71 cases of swallowed foreign bodies, the objects were in the esophagus at the time the patient was first examined. Esophagoscopic removal was carried out in 17 cases. In two cases a foreign body was passed per rectum and in one was vomited. Laparotomy for removal was done in only two of the 51 cases in which the foreign body was already in the stomach or bowel at the time of examination, and in one of them the operation probably could have been avoided.     

Management of Ingested Foreign Bodies in Childhood

A total of 660 patients with ingested foreign bodies admitted to the general surgical services in two children''s hospitals in Liverpool are reviewed. Endoscopic removal (205 cases) is recommended for all foreign objects impacted in the oesophagus, with the exception of rounded or blunt objects in the lower third, which should be observed for a maximum of 12 hours. The indications for laparotomy for removal of a foreign body (43 cases, 6·5%) are the danger of perforation and failure of progression. The ingestion of a long slender object—for example a hair-grip—in a child under 2 years of age, is an absolute indication for prophylactic operative removal owing to the high incidence of impaction and perforation of the duodenum.     

Sequential uterine horn versus simultaneous total uterine flush to recover bovine embryos nonsurgically

Beef cows were superovulated with follicle stimulating hormone (FSH) to compare two nonsurgical methods of embryo recovery from the uterus. In the first method each uterine horn was independently flushed with physiological saline solution (PSS) through a Foley catheter passed through the cervix and into the uterine horn. In the second method both uterine horns were simultaneously flushed with PSS by passing the catheter into the uterine body. In both methods, the numbers of ovulations were determined after embryo collection by counting the corpora lutea (CL) on both ovaries of each cow through a flank incision. Independent flushing (n = 19) averaged 6.4 embryos and 16.1 CL per cow for a recovery rate of 40%. Simultaneous flushings (n = 22) averaged 5.4 embryos and 17.7 CL per cow for a recovery rate of 31%. This difference between the recovery rates of the two flushing methods was not significant (P>0.05).     

Development of screening systems for evaluation of materials used in mammalian embryo transfer

Embryo transfer units use a wide variety of materials that come in contact with embryos. Studies were conducted to evaluate procedures that could be utilized to determine the toxicity of some commonly used materials in embryo collection, culture and transfer. Forty-five female mice were sacrificed on Day 3 or 4 of gestation (Day 1 = vaginal plug), and the uterus and oviducts were removed and minced. A total of 522 embryos was collected (4-cell to blastocyst stages). Four to 16 cell embryos were cultured in Phosphate Buffered Saline (PBS) plus 20% fetal bovine serum. Morula to blastocyst stage embryos were cultured in Nutrient Mixture F10 (HAM) plus 20% fetal bovine serum gassed with 5% CO(2), 5% O(2) and 90% N(2). In Experiment I, embryos and culture media were placed in a covered embryological watch glass (EWG, control) or sealed in the lumen of a siliconized Foley catheter or a section of 1) latex tubing, 2) tygon tubing or 3) silastic tubing. In Experiment II, embryos were placed in EWG and cultured alone (control) or cocultured with sections of 1) tygon tubing, 2) silastic tubing or 3) latex tubing. In Experiment III, embryos were cultured in covered plastic petri dishes containing 15 ml of media, alone (control) or co-cultured with two new plunger tips from sterile Monoject syringes. All embryos were cultured at 32 to 34 degrees C for 24 h. The Criterion used for development was two or more cellular divisions within the 24-h period. Embryo development in Experiment I was lower (P<0.05) in latex (0%) and tygon (24%) tubing and in the siliconized Foley catheter (2%) than in silastic tubing (51%) and the EWG (46%), which did not differ. Experiment II embryos that were co-cultured with latex tubing (5%) showed very little development as compared with those co-cultured with tygon tubing (76%), silastic tubing (76%) and EWG (93%), the last of which were not significantly different. Embryos co-cultured with Monoject syringe plunger tips had a reduced embryo development rate compared to embryos in the control group (0% vs 52%). Although the embryos did not remain in contact with these seemingly toxic materials for prolonged periods, our results indicate that a significant reduction in embryo viability may occur due to this exposure.     

介入室X线电视系统下眶内及眶周金属异物摘出术的临床观察

目的:探讨在介入室X线电视系统下摘出眶内及眶周金属异物的临床效果。方法:选择2002年7月至2012年7月我院收治的金属异物患者86例86只眼,在介入室X线电视系统直视引导下,根据影像学特点制定个体化手术方法,经皮肤或结膜进路摘出眶内及眶周金属异物。结果:86例均成功取出异物,其中一次手术取出83例(96.5%),二次手术取出3例(3.5%)。随访2~18(9.2±5.3)月。末次随访时视力达术前水平62例(72.1%),视力提高21例(24.4%)。术前及术后末次随访时眼球运动障碍分别为34例(39.5%)和16例(18.6%),术前及术后末次随访时外伤性上睑下垂分别为5例(5.8%)和3例(3.5%)。结论:在介入室X线电视系统下摘出眶内及眶周金属异物对眶内及眶周组织损伤小,手术时间短,疗效满意,便于操作,值得推广。     

Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.     

Ureteral stent retrieval using the crochet hook technique in females

Introduction

We developed a method for ureteral stent removal in female patients that requires no cystoscopy or fluoroscopic guidance using a crochet hook. In addition, we also investigated the success rate, complications and pain associated with this procedure.

Methods

A total of 40 female patients (56 stents) underwent the removal of ureteral stents. All procedures were carried out with the patients either under anesthesia, conscious sedation, or analgesic suppositories as deemed appropriate for each procedure including Shock Wave Lithotripsy (SWL), Ureteroscopy (URS), Percutaneous Nephrolithotomy (PCNL), and ureteral stent removal. At the time of these procedures, fluoroscopy and/or cystoscopy were prepared, but they were not used unless we failed to successfully remove the ureteral stent using the crochet hook. In addition, matched controls (comprising 50 stents) which were removed by standard ureteral stent removal using cystoscopy were used for comparison purposes.

Results

A total of 47 of the 56 stents (83.9%) were successfully removed. In addition, 47 of 52 (90.4%) were successfully removed except for two migrated stents and two heavily encrusted stents which could not be removed using cystoscopy. Ureteral stent removal using the crochet hook technique was unsuccessful in nine patients, including two encrustations and two migrations. Concerning pain, ureteral stent removal using the crochet hook technique showed a lower visual analogue pain scale (VAPS) score than for the standard technique using cystoscopy.

Conclusions

Ureteral stent removal using a crochet hook is considered to be easy, safe, and cost effective. This technique is also easy to learn and is therefore considered to be suitable for use on an outpatient basis.     

Nonsurgical collection of blastocysts from dairy goats

In two trials, eight attempts were made to collect fertilized ova from dairy goats by nonsurgical methods. In both trials the cervix of each doe was dilated by inserting a Laminaria japonica tent device into the cervical canal prior to flushing. In Trial 1, an attempt was made to collect embryos from four nonsuperovulated does by flushing phosphate-buffered saline (PBS) through a rigid pipette. Little fluid and no embryos were recovered from the does. All four donors were in estrus two days after the procedure. In the second trial, FSH-superovulated does were collected on day 5 following estrus. The donors were anesthetized, and a modified Foley catheter was passed through the cervical canal. In three does, a 24 ga. two-way Foley was stiffened with a size 10 (French) polypropylene catheter which penetrated the Foley, extending 7 cm beyond the tip. Recovery of flushing medium with this device was minimal, and laparotomy of one doe revealed a punctured uterus. Replacement of this device with a different catheter, through which a polypropylene catheter (size 5 Fr.) penetrated only 1 to 2 cm, resulted in satisfactory return of infused PBS, and recovery of two blastocysts and one degenerated ovum from this doe. Use of the same device on a second doe without laparotomy resulted in collection of seven blastocysts and three degenerated ova. Of three observed donors that received Laminaria tents (including one which was not flushed) two were in estrus three days after the procedure, while unused synchronized recipients showed normal cycle lengths. Surgical transfer of two blastocysts from each donor to each of two synchronized recipients resulted in the birth of twin kids from one recipient doe. The study demonstrates the feasibility of embryo collection from dairy goats by nonsurgical means.     

90% of general hospital care now accredited

Embolization of catheter fragments or fractured spring guidewires used during cardiac catheterization or fractured central venous pressure (CVP) lines is not uncommon. Although CVP lines are usually used in seriously ill patients, often with complications secondary to prior surgical intervention, if the catheter fragments are not removed they can give rise to serious illness or death in about 50% of patients. Experience with the removal of nine such catheter fragments is reported. In eight patients a helical basket was available for removal through a Dotter retrieval catheter. With prolonged hyperalimentation therapy polyethylene catherters become very brittle. They are relatively easy to grip with the wire basket. Silicone elastomer catheters remain pliable but are so bouncy that they are difficult to grip. For removal of catheter fragments from vessels of small diameter, such as the subclavian vein, or vessels in which the catheter has to take an acute bend to enter, such as the right or left pulmonary artery, a smaller, more pliable Bean-Smith-Mahorner biliary stone helical basket was adapted by extending the length of wire to 100 cm. For removal of catheter fragments from the right pulmonary artery it is probably better to use a softer, 100-cm-long no. 8 French right heart catheter. A Dotter retriever catheter set with both large and small helical wire baskets should be available in any cardiac catheterization laboratory.     

Number conservation is related to children's prefrontal inhibitory control: an fMRI study of a piagetian task

Although young children can accurately determine that two rows contain the same number of coins when they are placed in a one-to-one correspondence, children younger than 7 years of age erroneously think that the longer row contains more coins when the coins in one of the rows are spread apart. To demonstrate that prefrontal inhibitory control is necessary to succeed at this task (Piaget's conservation-of-number task), we studied the relationship between the percentage of BOLD signal changes in the brain areas activated in this developmental task and behavioral performance on a Stroop task and a Backward Digit Span task. The level of activation in the right insula/inferior frontal gyrus was selectively related to inhibitory control efficiency (i.e., the Stroop task), whereas the activation in the left intraparietal sulcus (IPS) was selectively related to the ability to manipulate numerical information in working memory (i.e., the Backward Digit Span task). Taken together, the results indicate that to acquire number conservation, children's brains must not only activate the reversibility of cognitive operations (supported by the IPS) but also inhibit a misleading length-equal-number strategy (supported by the right insula/inferior frontal gyrus).     

CHEST INJURIES AMONG KOREAN CASUALTIES

Major wounds of the chest usually cause immediate or early death. Of 35 patients with major thoracic battle injuries who were treated in one naval hospital, six had non-penetrating wounds of the chest and other areas. Of the 29 with penetrating wounds of the chest, 23 were treated by aspiration of hemothorax, decortication in three cases, and thoracotomy for control of hemorrhage in one case and for removal of a foreign body in another.Four cases are reported, two to illustrate the usual course of treatment and two in which the patient died.     

An experimental model of tryptic haemorrhagic enteropathy of the dog.

To study the enteropathy characteristics of the shock state of the dog a simple experimental model has been developed. The cranial mesenteric artery was perfused with 2 micrograms/kg/min norepinephrine for an hour via a diagnostic cardiac catheter inserted under fluoroscopic control. This caused a "pharmacological occlusion" of the artery by local alpha receptor stimulation, and tryptic haemorrhagic enteritis was produced without hypovolaemia or assay operative procedure.     

Roentgeno-functional studies in ectopia of the anal canal in children

Analysis of x-ray data on 70 pediatric patients aged one day-15 yrs, was performed. In 55 cases the investigation was conducted before the correction of ectopia of the anal canal, in 11 cases after the previously described operation for forming the anal orifice (FAO), in 4 cases there was stenosis of the anal orifice without ectopia. Radiograms performed during irrigoscopy and (or) with a Foley catheter were assessed. Weakening and then complete incompetence of the puborectal muscle, determining incontinence of feces, were shown to be proportional to age and a degree of stenosis of the colon orifice. A necessity of radical operation in the second half-year of the life or measures to ensure adequate bowel evacuation were shown.     

Effects of larval energetic resources on life history and adult allocation patterns in a caddisfly (Trichoptera: Phryganeidae)

Abstract 1. How populations respond to environmental change depends, in part, on the connection between environmental variance during early life stages and its effect on subsequent life‐history traits. For example, environmental variation during the larval stage can influence the life histories of organisms with complex life cycles by altering the amount of time spent in each stage of the life cycle as well as by altering allocation to life‐history traits during metamorphosis. 2. The effects of larval energetic resources on developmental timing, adult mass, fecundity, mating success, and allocation to adult body structures (thorax, abdomen, wings) were examined in an aquatic caddisfly (Agrypnia deflata Milne, Trichoptera: Phryganeidae). Larval energetic reserves were manipulated by removing larval cases just prior to pupation. In the first experiment, cases of all individuals were removed just prior to pupation; experimental individuals were required to build a new case whereas control individuals were allowed to re‐enter their case without building. In the second experiment, energy differences were maximised between the two treatments by supplementing the larval diet of the control group and removing cases and not supplementing the diet of the experimental group. 3. Male and female development time, adult mass, and female fecundity were not influenced by case removal or diet supplementation. In contrast, allocation to adult body parts indicated a trade‐off between abdominal and thoracic mass among case‐removal females, suggesting that, under larval resource stress, females adjust resource allocation during metamorphosis to alleviate potential negative impacts on clutch size. In addition, latency to copulation increased when cases were removed, indicating larval resource stress could influence male mating success. 4. This study suggests that, under larval energetic stress, the negative impacts on female reproduction might be mitigated by re‐allocating resources during metamorphosis, whereas male allocation strategies might not be as flexible as female strategies.     

A new urethral catheter

A new balloon catheter for women with a flexible urethral portion that conforms to the shape of the closed urethra was tested. In sheep control catheters caused epithelial destruction, which was absent with the conformable catheter. A 12 week crossover trial compared control catheters in 52 long stay geriatric patients. Eighty two out of 91 conformable catheters were rated as comfortable compared with 68 of 87 control (p=0·006). The average length of time in situ was 15·9 days for the conformable catheter compared with 12·9 days for the control (p=0·001). The average number of bypasses a week with the conformable catheter was 1·1 compared with 1·3 for the control; this difference was not significant. Examination of 249 used catheters showed significantly fewer with intraluminal obstruction with struvite among the conformable than control catheters (1 (0·8%) versus 15 (11·5%); p<0·001).This new catheter for women is a substantial improvement over the Foley catheter and (except in urethral stricture) is suitable for all forms of drainage.     

Inhibitory effect of alcohol on the established suckling-induced prolactin surge in lactating rats

The effect of acute alcohol infusion on the established suckling-induced prolactin surge in lactating rats was examined. Dams were implanted with an atrial catheter on Day 6 of lactation and blood sampling was done on Day 10. Following the separation of litters from dams for a 6-hr period, a baseline blood sample was removed via a catheter extension. Pups were weighed and returned to dams. Subsequent blood samples were obtained 10, 30, and 60 min after initiation of suckling. Dams were then infused with alcohol doses of 0, 0.5, 1.0, 2.0, or 2.5 g/kg body wt. Infusion (0.1 ml/min) was completed in approximately 30 min. Additional blood samples were obtained 10 30, 60, and 120 min after the termination of infusion. In a separate group of rats, pups were removed from the dam after the first 60 min of suckling and additional blood samples were obtained 40, 70, 90, and 150 min after removal of pups (corresponding to 10-, 30-, 60-, and 120-min samples for rats infused with various alcohol doses). Alcohol, when administered after the establishement of suckling-induced prolactin surge and resulting in blood alcohol levels equal to or greater than legal human intoxication levels, inhibited prolactin release. However, continued suckling for an extended period (120 min in the present study) overcame this inhibitory effect, even when the blood alcohol level was comparable to (2.0 g/kg group) or greater than (2.5 g/kg group) the human legal intoxication level. Furthermore, in rats with established prolactin surges, the patterns of prolactin decline that followed alcohol administration or pup removal were comparable, indicating that similar mechanism(s) may be involved.