Unplanned adnexectomy for ovarian cystadenoma with undiagnosed autoamputation of the contralateral ovary, lessons learned from medical mistakes.

Autoamputation of the ovary is a rare occurrence of uncertain aetiology with only a few cases reported in literature. It usually develops following ovarian torsion or torsion of a dermoid cyst with subsequent necrosis of the pedicle and autoamputation. We present the case of a 42 year-old woman was admitted for a laparoscopic removal of a right ovarian cyst. The ultrasound showed a right ovarian cystic mass suggestive of a cystadenoma, and another heterogeneous small echogenic cyst of the left ovary. During laparoscopy, excessive bleeding from the ovarian cortex complicated the cyst stripping and, considering the age of the patient and the emerging technical difficulty of the procedure, a total adnexectomy for the right ovary was performed. While exploring the small cyst on the left ovary, a dermoid cyst was found in the Douglas pouch. This finding could be interpreted as an autoamputation of the adnexa due to an asymptomatic torsion of a previous ovarian cyst arising from the left ovary. Medical errors could occur due to lack of knowledge, expertise, as well as lack of training and surgical skills, but also due to an unfortunate association of very rare confounding factors. Even in the hands of experts, following the basic rules of surgery remains a milestone in teaching and preventing surgical complications.

Health needs and access to health care: the case of Syrian refugees in Turkey.

OBJECTIVES: Turkey is a principal destination and transit country for refugees from diverse countries. Turkey currently hosts Syrian refugees and provides free access to shelter, education and health care. The aim of this study is to determine the health needs and document the healthcare services available to Syrian refugees in Turkey. STUDY DESIGN: Literature review. METHODS: An examination of the scientific literature, reports and government policies about refugees in Turkey was performed. In addition, literature focussing on the understanding and development of the healthcare needs and systems in crisis situations in Turkey was analysed. RESULTS: The Turkish government has made several regulations for Syrian refugees, which allow them to benefit from emergency care units and primary, secondary and tertiary healthcare centres in Turkey's 81 provinces free of charge; the financial costs of these benefits are covered by the Disaster and Emergency Management Authority. Effectiveness of healthcare services for refugees is limited by language barriers, mobility of the refugees and some legal restrictions. Mental health and rehabilitation services are relatively weak because of the inadequate number of qualified practitioners. CONCLUSIONS: The current migration rules in Turkey do not enable refugees to access all human rights. Because the number of refugees has increased, there has been a subsequent increase in the financial and human resources needed for healthcare services. Multidynamic refugee-friendly systems, the provision of preventive health care (including primary and secondary prevention opportunities) and increasing the number of national and international organisations may help improve the health of refugees.

A study of dysphagia symptoms and esophageal body function in children undergoing anti-reflux surgery.

BACKGROUND: The role of high-resolution esophageal impedance manometry (HRIM) for establishing risk for dysphagia after anti-reflux surgery is unclear. We conducted a prospective study of children with primary gastroesophageal reflux (GER) disease, for whom symptoms of dysphagia were determined pre-operatively and then post-operatively and we examined for features that may predict post-operative dysphagia. METHODS: Thirteen children (aged 6.8-15.5 years) undergoing work-up prior to 360o Nissen fundoplication were included in the study. A dysphagia score assessed symptoms at pre-operative study and post-operatively (mean 1.4 years). A HRIM procedure recorded 5-ml liquid, 5-ml viscous and 2-cm solid boluses. We assessed esophageal motility, esophago-gastric junction (EGJ) morphology, EGJ contractility and pressure-flow variables indicative of bolus distension pressures and bolus clearance pressures. A composite pressure-flow index score was also derived. RESULTS: Pre-operative pressure-flow index was positively correlated with post-operative dysphagia score (viscous bolus r = 0.771, p < 0.005). Of three variables that comprise the pressure-flow index, the ramp pressure measured during bolus clearance was the main driver of the effect seen (viscous bolus r = 0.819, p < 0.005). CONCLUSIONS: In order to mitigate symptoms in relation to anti-reflux surgery, dysphagia symptoms and esophageal function need to be pre-operatively assessed. In patients with normal motility, an elevated pressure-flow index may predict post-operative dysphagia.

Inter- and intrarater reliability of the Chicago Classification in pediatric high-resolution esophageal manometry recordings.

BACKGROUND: The Chicago Classification (CC) facilitates interpretation of high-resolution manometry (HRM) recordings. Application of this adult based algorithm to the pediatric population is unknown. We therefore assessed intra and interrater reliability of software-based CC diagnosis in a pediatric cohort. METHODS: Thirty pediatric solid state HRM recordings (13M; mean age 12.1 ± 5.1 years) assessing 10 liquid swallows per patient were analyzed twice by 11 raters (six experts, five non-experts). Software-placed anatomical landmarks required manual adjustment or removal. Integrated relaxation pressure (IRP4s), distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL) and break size (BS), and an overall CC diagnosis were software-generated. In addition, raters provided their subjective CC diagnosis. Reliability was calculated with Cohen's and Fleiss' kappa (κ) and intraclass correlation coefficient (ICC). KEY RESULTS: Intra- and interrater reliability of software-generated CC diagnosis after manual adjustment of landmarks was substantial (mean κ = 0.69 and 0.77 respectively) and moderate-substantial for subjective CC diagnosis (mean κ = 0.70 and 0.58 respectively). Reliability of both software-generated and subjective diagnosis of normal motility was high (κ = 0.81 and κ = 0.79). Intra- and interrater reliability were excellent for IRP4s, DCI, and BS. Experts had higher interrater reliability than non-experts for DL (ICC = 0.65 vs ICC = 0.36 respectively) and the software-generated diagnosis diffuse esophageal spasm (DES, κ = 0.64 vs κ = 0.30). Among experts, the reliability for the subjective diagnosis of achalasia and esophageal gastric junction outflow obstruction was moderate-substantial (κ = 0.45-0.82). CONCLUSIONS & INFERENCES: Inter- and intrarater reliability of software-based CC diagnosis of pediatric HRM recordings was high overall. However, experience was a factor influencing the diagnosis of some motility disorders, particularly DES and achalasia.

[Exfoliatin in neonatal staphylococcal infections]. / L'exfoliatine dans les staphylococcies néonatales.

An outbreak of staphylococcal skin infection in neonates was investigated clinically, bacteriologically and epidemiologically with the following findings: (1) In 8 out of 13 cases, exfoliatin-producing staphylococci were present in the bullae, which is unusual with bullous lesions occurring at other ages; (2) exfoliatin producing staphylococci were present in all children with bullous lesions, as well as in carriers; (3) 39% of the phage II group staphylococci studied produced exfoliatin; (4) purulent lesions due to phage II staphylococci which did not produce exfoliatin were observed. The contaminating agent could be identified in most cases.