Poland syndrome with dextrocardia: case report.

Poland syndrome is a rare congenital condition presentingwith typical features including an absent costosternal head of pectoralis major andipsilateral brachysyndactyly. There are many clinical variations of the syndrome including rib defects, absence of shoulder girdle muscle and breast hypoplasia or agenesis. Dextrocardia is rarely associated with Poland Syndrome with only 22 cases being previously reported in the worldwide literature. Whereas 'classical' Poland syndrome is predominantly right sided, all cases associated with dextrocardia have been left sided. We report a further case of left sided Poland syndrome with dextrocardia which might have important implications for the understanding of the pathogenesis of this unusual condition.

Clinical experience and pre-test probability scores in the diagnosis of pulmonary embolism.

BACKGROUND: The Geneva and Wells pre-test probability scores are intended to replace empirical assessment of patients with suspected pulmonary embolism (PE). The effect of clinical experience on the inter-rater variability of these scores, and on empirical judgement, is unknown. AIM: To determine whether medical staff appointment grade affects the inter-rater variability of these pre-test probability scores, or empirical assessment, in patients with suspected PE. DESIGN: Questionnaire survey. METHODS: Doctors were grouped by grade (mean number of years since graduation+/-SEM): house officers 0.7+/-0.2, registrars 6.3+/-0.6, consultants 25+/-4 and applied pre-test probability scores to actual case scenarios. RESULTS: The Geneva score was the most consistent method of determining pre-test probability and was unaffected by clinical experience (Geneva kappa=0.73, Wells kappa=0.38, empirical kappa=0.23, p<0.001 ). With empirical judgement, inter-rater variability was inversely proportional to clinical experience (house officers kappa=0.37, registrars kappa=0.24, consultants kappa= 0.16, p<0.05). DISCUSSION: The Geneva score was the least variable method and can be applied by junior or senior doctors. Using empirical judgement, junior doctors were more likely to agree on the pre-test probability of PE than were their more senior colleagues. This may imply that as physicians gain experience, they recognize that the diagnosis of PE can be difficult to assess and are reluctant to exclude it on clinical grounds.

A protocol for safe anasthesia for cleft lip and palate surgery in developing countries.

A project to perform surgical correction of cleft lips and palates was carried out in Uganda in 1998. Twenty centres were visited and 336 cleft lips and 41 cleft palates were repaired. The age of the patients ranged from 2 weeks to 60 years. Many of the centres visited were remote and lacked even the most basic equipment. Patients were anasthetised using ketamine, ether or halothane according to a protocol that we developed. There was no anasthetic mortality and only one case of significant morbidity. We report our experience and discuss recommendations regarding the provision of anasthesia in remote circumstances based on our outcome. An additional benefit of the project was that we provided training to local medical personnel in anasthesia and surgery for cleft lips and palates.

A rural cleft project in Uganda.

Over an 8-month period a cleft project was organised across Uganda. The aim of the project was to travel to as many districts as possible in the available time and repair all the cleft patients who could be mobilised. Local surgeons were trained and the results of the project were assessed. This was a prospective study which assessed immediate patient outcome, feedback from participating hospitals and cost. The team visited 20 hospitals, many in remote rural areas. All equipment necessary for surgery was transported to the hospitals. 336 cleft lip repairs and 41 cleft palate repairs were performed on 343 patients. There was no anaesthetic morbidity or mortality and no immediate perioperative morbidity. Two cleft lip repairs developed partial wound dehiscence and there was one palatal fistula. Five local surgeons underwent cleft training. All centres participating in this project requested further visits. The total cost for each cleft repair was 27 pounds sterling. Visiting remote centres with a mobile team is an efficient, safe and cost-effective method to treat the large numbers of unrepaired clefts in developing countries.

The Mitrofanoff urinary diversion for complex vesicovaginal fistulae: experience from Uganda.

OBJECTIVE: To evaluate the results of Mitrofanoff continent urinary diversion in a group of women with persistent severe incontinence after vesicovaginal fistula (VVF) secondary to obstructed labour. PATIENTS AND METHODS: Seven women with severe incontinence following a VVF were offered the Mitrofanoff procedure after all other attempts had failed to restore continence. In three patients a caecocystoplasty formed the urinary reservoir and in four the bladder was used. In all seven patients the appendix was used as the conduit for self-catheterization. The mean (range) follow-up was 10 (3-14) months. RESULTS: One patient died postoperatively from hepatic failure, which could not be attributed to the particular procedure. One patient required re-operation at 10 days to adjust the conduit, but of the six patients who recovered, all are fully continent and self-catheterizing with no difficulty. CONCLUSION: The Mitrofanoff procedure appears to be a valuable technique to restore continence in this difficult group of patients.

Surgery in the Tropics--a waste of time?

Surgeons have a valuable contribution to make to the health care in a developing country, be it for a flying visit or for longer input. This article written from personal experience also suggests that the particular conditions which one has to work under lead to many new skills being learnt rapidly-surgical, management, and personal. I believe that such experience can only benefit the individual and such experience should therefore be encouraged during the formative years of a surgeon in training.