The changing picture in surgery of pulmonary tuberculosis

In a review of the operative treatment of 1,271 patients with pulmonary tuberculosis in an 11-year period, it was noted that, beginning with 1947, there was a great increase, relatively, in the number of cases in which pulmonary resection was carried out. In 1943, the first year of the period of study, there were six minor operative procedures to every four major operations; in 1953 the ratio was one minor to nine major. This reversal reflects the discoveries of antibiotics for conservative therapy on the one hand and the advances in surgical techniques for major operative treatment on the other. Now that it is safer, resection will probably be used more and more-including bilateral resection in "salvage" cases. On the other hand, with specific antibiotics available, there is a tendency at present to treat conservatively for longer periods in cases in which, formerly, minor operative procedures would have been carried out early.     

The Problem of Routine Circumcision

One hundred male infants were studied at the Kingston General Hospital, Kingston, Ontario, to determine the incidence and complications of routine circumcision. The parents were also interviewed concerning the reason for operation.In these 100 infants, complications, usually minor, were very common, and included hemorrhage (35), meatal ulcers (31), infection (eight), phimosis (one) and meatal stenosis.The reasons given for operation were prophylactic—to avoid the psychological trauma of later operations for infection, phimosis and “troubles” (40), cleanliness (11) and phimosis (four). The remaining cases were for social and other non-medical reasons. Attitudes of parents and physicians regarding circumcision varied from firm belief in its value to a casual approach. One-half of the babies had partial circumcisions, confirming previous suspicions that non-Jewish males frequently had partial operations. Partial operations do not always guarantee cleanliness and probably do not eliminate the risk of penile carcinoma in all cases, if smegma is carcinogenic. Routine circumcisions spare a few children psychologically traumatic operations at a later date and relieve parents of anxiety about the future of the uncircumcised child. This should be balanced against the complications which, although usually minor, may occasionally be serious.Between 1961 and 1962, at the Kingston General Hospital, 349 (48%) of 727 male newborn babies were routinely circumcised.     

The Use of Day Beds in Gynaecology

Over a ten-year period more than 3,000 patients have been admitted to 12 day beds for minor gynaecological operations. Of the first 500 women, five were detained in hospital, but subsequent experience indicated that in only about 0·4% was admission necessary. Most patients approved of the scheme and underwent their operations more readily. Provided sufficient day beds, theatre accommodation and equipment, and staff are available, greater use of day beds for minor procedures would reduce both gynaecological waiting lists and costs.     

Caseload or workload? Scoring complexity of operative procedures as a means of analysing workload.

OBJECTIVE--To present a more realistic assessment of surgical workload than that provided by a case count. DESIGN--Prospective study of all the operative procedures performed in one year, classified according to the British United Provident Association''s schedule of procedures and scored by the "intermediate equivalent" value (taking the recommended fee value of an intermediate operation as 1.0) compared with the number of operations performed. SETTING--General surgical unit of Taunton and Somerset Hospital, comparing four consultant surgeons and their teams. PATIENTS--Inpatients and day patients admitted under the care of general surgeons during 1989. MAIN OUTCOME MEASURE--Difference between the apparent workload represented by simple case counting (caseload) and the actual workload represented by calculation of the total "intermediate equivalent" value. RESULTS--The workload assessed in terms of intermediate equivalent values was greater than that suggested by case counting for complex operations (12% v 4%), operations at the district hospital (82% v 74%), and operations performed by consultants (53% v 35%) and was lower for minor operations (20% v 42%), operations at the community hospitals (18% v 26%), and operations performed by surgeons in training grades and clinical assistants (47% v 66%). CONCLUSIONS--The use of the intermediate equivalent values as an indicator of complexity allows a more realistic assessment of the operative workload than a simple case count of the number of different operations and is recommended for comparing workload in different hospitals and departments.     

Laparoscopic colon surgery: our results

Formerly, the laparoscopic surgery was accepted as a method of choice for benign diseases, and for palliative operations in progressive stages of malignant diseases of the colon. Today, the laparoscopic surgery of the colon has been also adopted in treating malignant diseases. The first laparoscopic colon resection was performed in our Clinic on December 12, 2002, and 114 patients have been successfully operated until June 1, 2007. Among those 114 patients 56 were men and 57 were women with the average age 65 (ranging from 28-86) years. A series of various laparoscopic operations have been performed for malignant disease mainly (almost 80%). The pre-surgical treatment, preparation of patients and the types of the operations were identical to those applied in patients treated by open surgery. Patients with colon carcinoma have been operated on with the principles of oncologic radicality. In post-operative period we encountered eight complications (four minor and four major) with only one fatal outcome. According to our experience and the facts found in literature, the results of laparoscopic colon surgery are comparable with open surgery.     

Unsuspected Carcinoma Found Histologically After Minor Anorectal Operations

The unsatisfactory results of radical operations in advanced anal cancer could be bettered by earlier diagnosis of the malignant lesion. The possibility of cancer should always be kept in mind when treating any of the common chronic anal diseases. Preliminary biopsy studies should be done more frequently if suspicious lesions are present and all tissues removed during minor anorectal operations should always be examined by a pathologist. Each surgical specimen should be labeled to show the site from which it was removed. Follow-up care of the patient would be simplified if the exact site of cancer origin could be identified.A recent ten-year survey of minor anorectal surgical procedures at the University of California Medical Center showed clinically unsuspected anal cancer found in 2 per cent of cases on tissue examination by the pathologist. The cancers were generally early and of the keratinizing squamous cell and nonkeratinizing varieties.     

Survey of equipment in general practice.

Partners in general practice have to buy any equipment they want themselves. As a result partners in high investing practices have lower net incomes. Of the 297 practices in Devon and Cornwall, 265 responded to a questionnaire listing 115 possible items of practice equipment. Overall, practices seemed to be fairly well equipped. Key findings were that 193 of those who responded had an electrocardiograph, 206 had a kit for minor operations, 119 owned a computer, and less than one third owned a microscope. Most of these practices were high investors. There seems to be a shift away from some traditional instruments towards expensive information technology. Government policies are encouraging the use of computers and such equipment, though funds are not necessarily being made available for this purpose.     

Traditional Chinese acupuncture: a potentially useful antiemetic?

Two consecutive studies were undertaken to evaluate the effectiveness of acupuncture as an antiemetic used in addition to premedication with opioids in patients undergoing minor gynaecological operations. In the first study 25 of the 50 patients underwent acupuncture immediately after premedication with 100 mg meptazinol, the rest receiving the drug alone, and in the second 75 patients were allocated randomly to one of three groups: a group receiving 10 mg nalbuphine and acupuncture, a group receiving premedication and dummy acupuncture, and a group receiving premedication alone. Manual needling for five minutes at the P6 acupuncture point (Neiguan) resulted in a significant reduction in perioperative nausea and vomiting in the 50 patients who underwent acupuncture compared with the 75 patients who received no acupuncture. These findings cannot be explained, but it is recommended that the use of acupuncture as an antiemetic should be explored further.     

Anæsthesia in Gynæcology: (Section of Anæsthetics)

The operations of gyn?cology are divided into two classes: (1) Minor: including perineal repairs, colporrhaphies, vaginal hysterectomies, dilatations and curettings, etc., and (2) Major: abdominal sections. For both groups routine premedication is a combination of morphia and nembutal, the former in ?-grain, and the latter in 3-grain doses.For Group 1 three methods of an?sthesia are described: (a) Ethylene and oxygen, producing in nearly all cases an adequate depth of an?sthesia without the addition of ether. A safe type of an?sthesia and one from which recovery takes place quickly. (b) Planocaine in 20% solution, made up with sodium bisulphate, as a spinal an?sthetic, described by Mr. Dickson Wright. The dose usually injected is 0·5 c.c. (c) Sodium evipan given intravenously, though rather uncertain in action seems to serve well for such minor operations as curettage and insertion of radium.In Group 2 (major operations), the author's choice is between (a) ether administered with a little additional oxygen to counteract the asphyxial tendency which the Trendelenburg position occasions, and (b) spinal an?sthesia with percaine. For intra-abdominal pelvic surgery the latter is a very safe method for two reasons: (1) The dose required is comparatively small, and (2) the Trendelenburg position helps materially to prevent the fall of blood-pressure which a spinal an?sthetic tends to produce.     

Patch esophagoplasty with free forearm flap for focal stricture of the pharyngoesophageal junction and the cervical esophagus.

Focal stricture of the cervical esophagus can be caused by corrosive injury or irradiation or following esophageal reconstruction. For severe stricture that cannot be relieved by bougie dilatation, surgical correction should be done. Among the operations performed, the myocutaneous flap is considered the first choice. Patch esophagoplasty with a free flap is indicated in the following situations: (1) when the patient is a young woman, (2) when the patient is obese, and (3) following irradiation that renders myocutaneous flaps unreliable. For correction of focal stricture of the cervical esophagus, six patients underwent esophagoplasty with a patch of free forearm flap. In comparison with other methods, this approach is associated with less morbidity and a better aesthetic result. The patients started oral intake at 1 month. Only one patient had minor leakage, and this healed after conservative treatment. The skin patch inserted in the esophageal wall caused no problem in motility, and the patients could eat smoothly after surgery.     

Laparoscopic cholecystectomy as a safe and effective treatment for severe acute cholecystitis.

OBJECTIVE--To evaluate the feasibility and safety of laparoscopic cholecystectomy in severe acute cholecystitis. DESIGN--Analysis of data collected prospectively from a consecutive series of 350 laparoscopic operations. SETTING--Two general surgical units in a teaching hospital. SUBJECTS--31 patients with a diagnosis of severe acute cholecystitis based on clinical examination, investigation results, and operative findings. INTERVENTIONS--Initial intravenous fluids and broad spectrum antibiotics followed by laparoscopic cholecystectomy within 72 hours of presentation. MAIN OUTCOME MEASURES--Failure to complete the operation laparoscopically, length of postoperative stay in hospital, early postoperative morbidity, interval from operation to full activity, and return to work. RESULTS--Laparoscopic cholecystectomy was attempted in 19 patients with empyema of the gall bladder and 12 who had severe cholecystitis which failed to settle on medical management. A total of 29 operations were successfully completed with two conversions to open surgery. Two minor postoperative complications occurred, and one case of retained common bile duct stones with jaundice was treated by endoscopic retrograde cholangiopancreatography and papillotomy. Median postoperative hospital stay was two days, with return to normal activity in seven days and to work in two weeks. There were no deaths related to the operation. CONCLUSIONS--In the presence of severe acute cholecystitis laparoscopic cholecystectomy is feasible in most patients, with minimal risk of injury to surrounding structures and considerable benefits. It is recommended that laparoscopic cholecystectomy should be attempted in these patients when appropriate surgical skill is available.     

Evidence for the existence of an expressed minor variant tRNAPhe in yeast

Two expressed brewer's yeast tRNAsPhe, a major and a minor one, have been purified and sequenced. The major tRNAPhe corresponds to the already known tRNAPhe, whereas the minor one differs from the former in the substitution of T6-A67 by C6-G67 base pair in the "acceptor stem". The minor tRNAPhe contaminates all preparations of yeast tRNAPhe except those prepared by polyacrylamide gel electrophoresis.     

Mass spectrometric monitoring of solid phase phosphate triester synthesis of DNA fragments

A new and convenient pyrolysis mass spectrometric approach for monitoring solid phase phosphate triester synthesis of oligodeoxyribonucleotides in 5'-3' direction has been developed. The base-typical fragment ions produced by pyrolysis at 280 degrees C of the polymer-bound oligonucleotide triesters in the mass spectrometer permit the analytical monitoring of DNA chain growth, using simple mathematical operations. The base composition can be determined directly from the polymer. In addition, minor nucleosides can easily be detected.     

Use of local anaesthetics and adjuncts for spinal and epidural anaesthesia and analgesia at German and Austrian University Hospitals: an online survey to assess current standard practice

Background

The present anonymous multicenter online survey was conducted to evaluate the application of regional anaesthesia techniques as well as the used local anaesthetics and adjuncts at German and Austrian university hospitals.

Methods

39 university hospitals were requested to fill in an online questionnaire, to determine the kind of regional anaesthesia and preferred drugs in urology, obstetrics and gynaecology.

Results

33 hospitals responded. No regional anaesthesia is conducted in 47% of the minor gynaecological and 44% of the urological operations; plain bupivacaine 0.5% is used in 38% and 47% respectively. In transurethral resections of the prostate and bladder no regional anaesthesia is used in 3% of the responding hospitals, whereas plain bupivacaine 0.5% is used in more than 90%. Regional anaesthesia is only used in selected major gynaecological and urological operations. On the contrary to the smaller operations, the survey revealed a large variety of used drugs and mixtures. Almost 80% prefer plain bupivacaine or ropivacaine 0.5% in spinal anaesthesia in caesarean section. Similarly to the use of drugs in major urological and gynaecological operations a wide range of drugs and adjuncts is used in epidural anaesthesia in caesarean section and spontaneous delivery.

Conclusions

Our results indicate a certain agreement in short operations in spinal anaesthesia. By contrast, a large variety concerning the anaesthesiological approach in larger operations as well as in epidural analgesia in obstetrics could be revealed, the causes of which are assumed to be primarily rooted in particular departmental structures.     

The presence of minor histone components in the chromatin of Pisum sativum L. seedlings

Summary Two minor basic protein components (M1 and M2) were found in the histone extract from chromatin of pea seedlings. In the histone extract of pea cotyledons only one minor component (M1) was detected. These minor components show a high affinity for chromatin, have a molecular weight of 20.200 and 17.800 respectively and a basic amino acid composition. They are not contaminants of cytoplasmatic origin. Two similar minor components were found in the chromatin of Pisum arvense and Lens culinaris-seedlings, one component was present in the chromatin from cotyledons of these species.     

Drosophila lactate dehydrogenase: Developmental aspects

Partially purified lactate dehydrogenase (LDH) from third-instar larvae displays two bands (one major and one minor) on polyacrylamide gels. Analogous preparations from pupae and adults exhibit three LDH-staining bands (one major and two minor) in a similar pattern. The migration of the major band is similar for larvae, pupae, and adults, while the two minor LDH bands of pupae and adults migrate more slowly than the minor larval band. It has been shown that larval LDH incubated with beta-nicotinamide adenine dinucleotide exhibits two additional minor bands with an electrophoretic mobility similar to that of the minor bands of both pupae and adults. The intensity of the minor larval LDH band (exhibited also by untreated preparations) is drastically reduced. This fact indicates that the life-cycle stage-dependent LDH isozymic distribution is possibly due to a posttranslational effect(s). Highly purified LDH from larvae, pupae, or adults, obtained by an affinity chromatography procedure, displays just one dispersed band, located in the area between the band 5 and the band 6 exhibited by crude extract preparations. These data, in combination with the lack of difference in catalytic properties among enzymes from larvae, pupae, and adults, suggest that LDH synthesis is controlled by the same single structural gene at all developmental stages.     

Deep inferior epigastric perforator dermal-fat or adiposal flap for correction of craniofacial contour deformities

Craniofacial contour deformities are difficult to reconstruct. This article summarizes the authors' use of deep inferior epigastric perforator dermal-fat or adiposal flaps in eight patients with such deformities. Of these patients, three had traumatic craniofacial or facial deformities, one had congenital craniofacial deformity, two had hemifacial atrophy (one because of radiation), one had hemifacial microsomia, and one had localized frontonasal lipodystrophy. Stable restoration of the facial contour was achieved in all eight patients. The advantages of this flap are numerous. It has minimal donor-site morbidity, because the rectus abdominis muscle is preserved as a whole, and it accommodates pregnancy in female patients. Simultaneous elevation of this flap during preparation of the recipient site makes it possible to complete surgery in a shorter time than with the scapular flap. Furthermore, a considerable amount of the superficial or deep fatty layer can be removed primarily, making a bulky flap into a thinner one. This flap also allows the use of a large transverse abdominal ellipse of skin, fat, and Scarpa's fascia with abdominoplasty closure. Conversely, it requires a technically difficult dissection of the muscle perforator and skin grafting of donor defects in patients with a large dermal-fat flap. Also, additional minor operations may be necessary to reduce fat volume around the perforator. Ultimately, the deep inferior epigastric perforator adiposal flap seems to be suitable for craniofacial contouring surgery. It is especially indicated for use in children and female patients who are expecting to have children.     

Minor Gynaecological Outpatient Operations

Altogether 143 patients had minor gynaecological operations performed under general anaesthesia in the outpatient department. This method proved to be very acceptable to patient, gynaecologist, and anaesthetist. No complications occurred requiring admission to hospital, and the short recovery time confirmed the safety of early discharge from hospital. This procedure had a beneficial effect on the waiting list, and expensive beds were used more efficiently for major surgical cases. It is recommended that this procedure should be more widely practised, provided that the patients are adequately screened.     

Reconstruction of bilateral metacarpal hands with multiple-toe transplantations.

Bilateral metacarpal hands, if not treated properly, leave a patient without prehensile ability in both hands. Since 1990, six patients with bilateral metacarpal hands caused by accidents have undergone reconstruction with multiple-toe transplantations. Four or five toes were used for each patient, with a total of 27 toes transplanted to the hands. There was no toe loss. One nonunion in a middle-finger reconstruction was treated successfully with bone grafting. Secondary operations for functional improvement included one joint fusion and one flexor tendon tenolysis. Only one patient required excision of a plantar callus 42 months postoperatively, whereas the other five patients reported no major donor-site problems in an average 57 months of follow-up time. The six patients continue all their daily activities independently. Although their jobs were changed, all adult male patients were able to return to regular work. Principles of reconstruction to achieve satisfying prehensile function combined with minor donor-site morbidity in bilateral metacarpal hands include an adequate soft-tissue coverage before toe transplantations, selection of digits to be reconstructed based on functional and individual requirements, selection of toes and number of toes to be harvested based on consideration of usefulness for the hands and of foot morbidity, and consideration of thenar function in planning the sequence of transplantations. In conclusion, given thorough planning, multiple toe-to-hand transplantations can provide adequate prehensile function in reconstructed bilateral metacarpal hands with acceptable donor-site morbidity.     

Mobile reconfigurable manufacturing unit for drilling and milling operations

A fraction of the customers demands variants of mass produced parts with minor changes, for example notches. Both the changes and the lot sizes are previously unknown. The mass production of semi-finished parts with variants is impossible under these circumstances. The manufacturers of the parts have also limited possibilities to use metal cutting machine tools at changing places in complex production systems. Therefore the Institute for Machine Tools designed and built a mobile reconfigurable manufacturing unit for drilling and milling operations. This paper discusses the units design, the static and dynamic properties, and the results of exemplary manufacturing tests.