Biomedical subjects
Publications and source records attributed to C P Kirby.
Rectoperineal fistula is an unusual form of anorectal malformation in a boy. The authors report on a patient with this anomaly and the implications in terms of difficulty in diagnosis and neonatal management.
Congenital diaphragmatic hernia (CDH) is a common abnormality affecting 1 in 2,000 gestations. The mortality exceeds 50% despite recent advances in postnatal treatment. The widespread antenatal use of glucocorticoids to induce lung maturation in fetuses at risk of premature delivery suggests a potential for a therapeutic effect in other fetuses with impaired lung development. The parents of three fetuses referred with CDH and features suggesting a poor postnatal prognosis (early diagnosis, liver herniation, and lung area-to-head circumference ratio <1.0, or associated abnormalities) elected to receive maternal betamethasone starting at 24 to 26 weeks' gestation rather than undergo a fetal tracheal plug. All three infants survived and were extubated within 10 days. The long-term use of antenatal steroids in the treatment of CDH may thus be of benefit and warrants further study.
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BACKGROUND: Attempts to maximise diagnostic accuracy and reduce unnecessary surgery have led to the hospital observation of children with suspected appendicitis but unconvincing physical signs. However, morbidity associated with perforation necessitates the prompt management of acute appendicitis and increases anxiety concerning prolonged preoperative observation. METHODS: To assess the preoperative delay and subsequent complications associated with active observation of appendicitis, we reviewed the records of 378 children who had an appendicectomy performed at the Women's and Children's Hospital during a 4-year period. RESULTS: Active observation was associated with an overall diagnostic accuracy of 93%. The mean preoperative hospital time was 12 h. The incidence of gangrene or perforation was 32%, with a mean preoperative hospital time in this group of 7 h. In view of the short preoperative waiting time in this group, we do not believe perforation in hospital to have been a frequent occurrence. The overall incidence of postoperative infective complications was 4%, with an incidence of 12% following perforation. CONCLUSIONS: Children with advanced disease often have convincing signs on presentation and are not usually subjected to a significant delay. Active observation is not associated with high postoperative morbidity.
Gastric intubation, by oral or nasal route is an essential procedure in the management of premature infants, for gastric aspiration and for feeding. Oesophageal perforation is a rare but important complication of this commonly performed procedure. An illustrative case is presented. Difficulty passing a tube into the stomach is the first clue to the diagnosis. Understanding the evolution of clinical signs and recognizing the radiological changes facilitates an early diagnosis, thereby enabling successful non-operative management.
A patient aged 16 years was referred following numerous episodes of intense pruritus associated with persistently altered liver function tests. Ultrasound (US) demonstrated the superior mesenteric vein positioned more to the left than usual and abnormal orientation of the duodenum, consistent with a midgut malrotation. Endoscopic retrograde cholangiopancreatography the common bile duct, suggesting a malrotation with chronic or recurrent volvulus. A classic malrotation with 180 degrees volvulus was noted at operation. A second child previously thought to have recurrent idiopathic pancreatitis was noted to have ampullary distortion secondary to malrotation following presentation with an intestinal obstruction. Pruritus and pancreatitis have not been previously reported with malrotation, although cholestatic jaundice has been described. The diffculties in diagnosis and the role of US are discussed. Ladd's procedure is the appropriate treatment for this condition.
A 5-day-old baby presented with right inguinoscrotal bruising. The underlying testis and cord were normal on examination. Intra-abdominal bleeding was suspected. Abdominal ultrasound showed right adrenal hemorrhage. This was managed nonoperatively and with supportive therapy; the inguinoscrotal bruising resolved spontaneously.
Ninety-nine patients with simple symptomatic urinary tract infections from three general practices were treated with norfloxacin 400 mg bd for 3 days and were followed up for 2 to 4 weeks. Forty of the 99 patients had bacteriuria. Bacteriological eradication of initial pathogen was achieved by 5 to 7 days in 100%. At 2 to 4 weeks three patients had become reinfected but with a different organism. Ninety per cent of patients were symptomatically cured or improved by the fifth to seventh day after therapy started. Drug related adverse experiences were seen in 9% of patients. None necessitated cessation of therapy. No significant biochemical or haematological abnormalities occurred.