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Effects of guidelines on adeno-tonsillar surgery on the clinical behaviour of otorhinolaryngologists in Italy  [cached]
Motta Giovanni,Motta Sergio,Cassano Pasquale,Conticello Salvatore
BMC Ear, Nose and Throat Disorders , 2013, DOI: 10.1186/1472-6815-13-1
Abstract: Background Several guidelines on adeno-tonsillar disease have been proposed in recent years and some discrepancies in relation both to clinical manifestations and indications for surgical treatment have emerged. The aim of the study was to verify what influence (adeno)-tonsillectomy guidelines have had on the clinical behaviour of ENT specialists in Italy. Our study is a retrospective and multi-centre case series with chart review. Methods The survey involved 14,770 children, aged between the ages of 2 and 11, who had undergone adeno-tonsillar surgery between 2002 and 2008 in fourteen Italian tertiary and secondary referral centres. Anova test was used for the statistical analysis, assuming p < 0.05 as the minimum statistical significance value. Results The frequency of adeno-tonsillar surgeries did not change significantly (p>0.05) during the study period and following the Italian policy document publication. Overall, adeno-tonsillectomy was the most frequent intervention (64.1%), followed by adenoidectomy (31.1%) and tonsillectomy (4.8%). The indications for surgery did not change significantly for each of the operations (p>0.05), with the exception of adeno-tonsillectomy in case of feverish episodes due to acute recurrent tonsillitis ≥ 5 without nasal obstruction (decreased p= 0.010) , even when the feverish episodes due to acute recurrent tonsillitis were < 5 over the last year. Nasal obstruction was associated with feverish episodes due to acute recurrent tonsillitis in 65.2% of operated cases, while otitis media had been diagnosed in 43.3% of the patients studied. Conclusions The recommendations first developed in Italy in a 2003 policy document and then resumed in guidelines in 2008, were not implemented by ENT units involved in the survey. The study highlights the fact that the indications for adeno-tonsillar operations are based on the overall clinical presentation (comorbidity) rather than on a single symptom. Guidelines are necessary to give coherent recommendations based on both the findings obtained through randomized controlled trials and the data collected from observational studies.
Anaesthesia for Ambulatory Paediatric Surgery: Common techniques and complications
C Imarengiaye, D Osifo, S Tudjegbe, I Evbuomwan
West African Journal of Medicine , 2009,
Abstract: BACKGROUND: Ambulatory surgical care accounts for over 70% of elective procedures in Northern America. Ambulatory paediatric surgical practice is not widespread in Nigeria. This report examined clinical indicators for quality care in paediatric ambulatory surgery using common outcomes after day case procedures as benchmark. METHODS: This was a cross-sectional study of children who were presented for ambulatory surgical care in the University of Benin Teaching Hospital. A standardized questionnaire was employed to record the age, gender, indication for surgery, type of anaesthesia, timelines for the surgery and associated complications. RESULTS: A total of 93 patients had surgical procedures on ambulatory basis. The mean age of the patients was 4.1 ? 4.0yr and duration of surgical procedure 31.3 ± 12.1 min. The male/female ratio was 3:1, and herniotomy was the most frequent procedure on ambulatory paediatric surgical care 60 (64.5%). The common anaesthetic techniques employed in the paediatric ambulatory setting were spontaneous respiration with face mask 40 (43%), Inhalation technique with tracheal intubations 31 (33.3%), general anaesthesia with relaxant technique five (5.4%), local infiltration with or without sedation eight (8.6%), GA plus caudal block eight(8.6%), and subarachnoid block one(1.1%). The indicators of quality care were unanticipated admission (5.4%), repeat hospital visit (4.3%), readmission (2.2%) and delayed discharge (21.5%). CONCLUSION: The practices of paediatric surgery on ambulatory services are feasible in our setting. The observable complications are within acceptable limits. The timelines in the scheduling and discharge appear not to be optimal for an effective ambulatory service. WAJM 2009; 28(5): 304–307.
Treatment of postoperative pain in paediatric day surgery
M. Cascelli,A. Tarquini,G. Pedini,F. Gori
Pathos : Trimestrale di Algologia , 2007,
Abstract: In 767 paediatric patients, undergoing different day surgery interventions, the Authors compared two anaesthetic approaches: general anaesthesia or combined anaesthesia, where the loco-regional administration was followed by general anaesthesia, as maintenance.According to the Steward Recovery Score, these Author concluded that combined modality is highly effective. When general anaesthesia has been applied, a major support to the patient outcome was provided by the use of clonidine and dexamethasone, due to the peculiar characteristics of the two drugs.
Cutaneous Adenoid Cystic Carcinoma with Perineural Invasion Treated by Mohs Micrographic Surgery—A Case Report with Literature Review  [PDF]
Yaohui G. Xu,Molly Hinshaw,B. Jack Longley,Humza Ilyas,Stephen N. Snow
Journal of Oncology , 2010, DOI: 10.1155/2010/469049
Abstract: We report a 58-year-old woman with cutaneous adenoid cystic carcinoma arising on the chest treated with Mohs micrographic surgery. The patient remained tumor-free at 24-month follow-up. To date, only six other cases of cutaneous adenoid cystic carcinoma were reportedly managed by Mohs surgery. Cutaneous adenoid cystic carcinoma has low potential for distant metastasis but is notorious for its aggressive infiltrative growth pattern, frequent perineural invasion, and high risk of local recurrence after excision. We propose that Mohs surgery is an ideal method to achieve margin-free removal of cutaneous adenoid cystic carcinoma. A brief literature review is provided. 1. Introduction Adenoid cystic carcinoma (ACC) is commonly known as a malignant neoplasm of salivary glands in the head and neck region [1]. Rarely, ACC arises directly in the skin, for which wide local excision is the standard treatment. Cutaneous ACC has low potential for distant metastasis but is locally aggressive. Perineural invasion has been reported in 76% of cases with a local recurrence of 44% following traditional surgical excision [2], warranting a better management modality. We propose that a margin-free excision achieved by Mohs surgery is theoretically superior to traditional wide local excision. A brief literature review with regard to clinical presentation, histopathology, and treatment of cutaneous ACC is provided. 2. Case Report A 58-year-old, otherwise healthy, Caucasian female was referred to the Department of Dermatology at the University of Wisconsin for treatment of a biopsy proven adenoid cystic carcinoma on the right mid-chest. She had a lesion of “basal cell carcinoma” surgically excised on her right mid-chest 14 years previously. The actual slides of the previous excision were not retrievable, while the pathology report did state that the lesion was “a basal cell carcinoma which in some areas presents gland-like formations, adenoid cystic characteristics and focal areas of keratinization, but it predominantly is an adenoid basal cell carcinoma.” The patient had done well until one year prior to the referral when she noted two tender, flesh-colored nodules adjacent to the scar. A punch skin biopsy confirmed the diagnosis of adenoid cystic carcinoma concerning for its infiltrative growth pattern and perineural invasion. A thorough preoperation physical examination revealed a healthy-appearing Caucasian female with an approximately 15 × 15?mm, poorly defined, tender, erythematous patch with focal crust and a hypopigmented scar notable on the right mid-sternum region
The undergraduate paediatric surgery curriculum in Nigeria – how have we fared?
FA Uba, JY Chinda, LO Abdur-Rahaman, A Mohammad, SC Uba
South African Journal of Surgery , 2010,
Abstract: Background. In the Nigerian setting the curriculum of each medical school is the sole responsibility of the senate of the respective university. This arrangement results in variability in learning objectives and in students’ acquisition of skills to manage clinical problems. Educational objectives can be used to both standardise and evaluate curricula. This study aimed to: (i) identify main objectives of paediatric surgery at he undergraduate level; (ii) establish students’ knowledge with regard to these objectives; (iii) evaluate the input of both specialists and non-specialists to these objectives; and (iv) examine the status of undergraduate paediatric surgery instruction in our medical schools. Materials and methods. This was a cross-sectional survey of students, teachers and undergraduate deans with regard to undergraduate paediatric surgery teaching. The cognitive and perceived level of knowledge about common paediatric surgical conditions of 4th- and 6th-year medical students in four randomly selected Nigerian universities was surveyed using educational objectives. The same objectives were used to survey 26 paediatric surgeons, 46 senior house officers and 46 general surgeons. Undergraduate paediatric surgery curricula, obtained from the offices of the deans of the four medical schools, were also reviewed. Data were analysed using descriptive methods and one-way analysis of variance (ANOVA). Results. The 6th-year students’ and house officers’ perceived knowledge of the objectives was remarkably similar. Overall, students’ familiarity scores increased from the 4th to the 6th year (p<0.05), but fell short of the expected proficiency levels in the 6th year. The general surgeons and paediatric surgeons expressed similar expectations. Thirty items on the objectives were considered to be essential (mean score >2.0) and 8 items to be non-essential (mean score <1.5) by paediatric surgeons, whereas the general surgeons regarded 27 items to be essential (mean score >2.0) and 11 to be non-essential (mean score <1.5). Data from the deans’ offices varied, but indicated limited exposure to paediatric surgery in the undergraduate curriculum in 2 (50%) of the 4 institutions. Conclusion. The study clarified the relationship between the expected and perceived students’ knowledge of these objectives, and identified areas requiring specific attention. These results, and perhaps similar ones in future, can be used towards establishing a unified, standardised undergraduate paediatric surgery curriculum.
Factors affecting outcome of emergency paediatric abdominal surgery
AM Abubakar, CPK Ofoegbu
Nigerian Journal of Surgical Research , 2003,
Abstract: Background: Paediatric surgical abdominal emergencies are important causes of morbidity and mortality in children. None of the previous studies on abdominal surgical emergencies specifically addressed the problem as it affects children. Methods: An eight-year retrospective review of all children aged 0 – 15 years who presented with acute abdominal emergency. Results: Two-hundred and fifty one (251) children, male to female ratio of 1.5:1 and median age of presentation of 78 months (range 1 day – 15 years). The median duration of symptoms before presentation to hospital was 96 hours. The median duration between admission and surgical intervention was 24 hours. Intestinal obstruction accounted for 87 (34.7%) of acute abdominal emergency. This was the commonest emergency encountered overall. Typhoid perforation (TP) was responsible for 71 (28.3%) of all acute abdominal emergencies and was the commonest condition encountered in children above the age of one year. Others included 55 (21.9%) cases of appendicitis, 18 (7.2%) of abdominal trauma, 6 (2.4%) anterior abdominal wall defects and 5 (2.0%) each of infantile hypertrophic pyloric stenosis and primary peritonitis. Postoperative complications were observed in 85 (33.9%) of patients. The commonest complications were wound infection 31 (12.4%) and wound dehiscence 23 (9.2%), while mortality rate was 16% overall, and 31.8% in the neonatal period. Overwhelming sepsis was responsible for 26 (63.4%) of all deaths recorded. Multiple congenital anomalies were the cause of death in 5 (12.2%). Other causes of death were prolonged ileus with malnutrition in 4 patients, respiratory insufficiency in 2 patients and a patient each died from necrotising enterocolitis, acute renal failure, enterocutaneous fistula and over hydration. Conclusion: intestinal obstruction was the commonest acute abdominal emergency in children. The high rates of postoperative morbidity observed could be attributed to delayed presentation to hospital. Key Words: Paediatric, emergency, abdominal surgery, outcome Nigerian Journal of Surgical Research Vol.5(1&2) 2003: 85-91
Recognition and prevention of neurological complications in paediatric cardiac surgery
Fenella J Kirkham
Critical Care , 2000, DOI: 10.1186/cc672
Abstract: Some children are more at risk of neurodevelopmental problems, either because of their cardiac (egextensive aortopulmonary collaterals) or cerebrovascular (eg the propensity to large vessel dissection) anatomy or because of genetic predisposition (eg to prothrombotic disorders). The incidence may vary with the surgery (eg the Fontan operation) and the cardiopulmonary bypass technique neccessary to achieve an adequate technical repair (eg low or no flow at deep hypothermia). Recognition of the population at risk will lead to prevention of serious sequelae. Data collected in adults may be misleading, and many paediatric units have developed their own practice, but recent studies in animal models of infant surgery and in children have produced some evidence to guide management to ensure the optimal cerebral as well as cardiac outcome.Pump flow should be maintained at least 30 ml/kg per min where possible, with inotropic support to maintain blood pressure if necessary. If pump flow must go lower or circulatory arrest is essential, thorough cerebral cooling to deep hypothermic temperatures is mandatory; a pH-stat strategy may make this easier, but an α-stat strategy may be better in those operations that can be performed at moderate hypothermia. There is no evidence that the available pulsatile pumps offer an advantage. Tissue oxygenation may reach critical levels and a high haematocrit and oxygen tension may reduce the risk of significant hypoxia. There is a risk of embolization in children, which can be reduced with membrane oxygenators and careful monitoring; the role of arterial filtration remains controversial. The only protective agent that can be recommended at the present time is methylprednisolone to protect the spinal cord (eg in operations on the aortic arch). Further studies are needed in this important area.
Postoperative follow up Challenge in Paediatric Cataract Surgery in Nepal  [PDF]
UD Shrestha
Journal of Nepal Paediatric Society , 2011, DOI: 10.3126/jnps.v31i3.4062
Abstract: Introduction: Paediatric ophthalmology is a branch of specialty care for the health of the eyes of children. It focuses on the removal of paediatric cataracts and management of refractive error, strabismus etc. Perioperative and post-operative challenges related to paediatric cataract are known to all ophthalmologists worldwide. However, in a developing country like Nepal the main challenge of these patients are the post-operative follow up. The aim of the study is to find out the ways to reduce the post-operative follow up challenges in paediatric cataract surgery. Hence the ophthalmic assistants in the community eye centers need to be trained to examine the eyes of children. Materials and Methods: This was a retrospective study. A review of patient records, operated from July 2006 to December 2007, at Tilganga Institute of Ophthalmology was done. One hundred eyes of 69 patients were operated during the study period. Results: Follow-up assessment of visual acuity was available for 19 eyes only at the end of six weeks. Conclusion: At the end of six postoperative weeks, refractive status is important. This helps to prescribe the glasses to children as per need. If the post-operative visual status is not known, it is as equal as not performing the surgery. Ophthalmic assistants at community eye centers need to be trained to evaluate and record postoperative visual status of the paediatric age group. For this regular training and refreshers course on the pediatric eye care service is being conducted at the tertiary level for the ophthalmic assistants. This is more practical in the developing countries like Nepal. Key words: Cataract; Intraocular lens; Pediatric cataract surgery DOI: http://dx.doi.org/10.3126/jnps.v31i3.4062 J Nep Paedtr Soc 2011;31(3):198-201
A survey on the current status of laparoscopic training in paediatric surgery in South Africa
PS Stevens, M De Villiers, M Van Niekerk
South African Journal of Surgery , 2011,
Abstract: Objectives. To document the current status of laparoscopic training of paediatric surgical registrars in South Africa. Methods. An anonymous questionnaire was distributed. Participants were asked to document their involvement in a number of index laparoscopic procedures during the preceding year, as well as additional non-operative training they received and their satisfaction with their training thus far. Results. All registrars (N=16) completed the questionnaire. Registrars were from the Universities of KwaZulu-Natal, Cape Town, Stellenbosch, Pretoria, the Witwatersrand, and Walter Sisulu University. The ratio of consultants proficient in paediatric laparoscopy to registrars was between 0.6 and 1. Junior registrars were more likely to assist with, and senior registrars more likely to perform, procedures. Registrar satisfaction varied greatly across institutions, with 44% of registrars satisfied with their training. Conclusions. The consultant-to-registrar ratio is favourable, and high patient load provides opportunity for laparoscopic education. However, there are a number of obstacles to adequate training. These include the feasibility of after-hours laparoscopic surgery and the availability and use of training aids. The introduction of a structured training programme across all institutions will improve laparoscopic proficiency and satisfaction among paediatric surgical registrars in South Africa.
Dual isolation technique for paediatric lung surgery.  [cached]
Pantvaidya S,Golam K,Pai R,Saksena S
Journal of Postgraduate Medicine , 1994,
Abstract: This report describes a dual isolation technique adopted to isolate the lungs from one another at the time of right pneumonectomy in a child (age: 5 yrs, 10 kg weight) with evidence of infective lung disease associated with copious purulent secretion and compromised respiratory function. The isolation of right lung from left was achieved by placing Fogarty embolectomy catheter in right main bronchus and a plain polyvinylchloride endotracheal tube (which was aseptically preshaped to have a distal 45 degrees angulation towards left) in left main bronchus. No soiling of left lung occurred during surgery and patient remained hemodynamically stable. In the same child, post-thoracotomy pain was relieved for five days with buprenorphine, administered through a lumbar epidural catheter. The child had an uneventful post-operative course and cooperated for physiotherapy.
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