Antibiotic prophylaxis in umbilical and incisional hernia repair: a prospective randomised study.

OBJECTIVE: To find out if preoperative prophylaxis would reduce infection rates after umbilical and incisional hernia repair. DESIGN: Randomised controlled trial. SETTING: Teaching hospital, Israel. SUBJECTS: 35 Patients who presented with umbilical (n = 19) or incisional (n = 16) hernias during a period of 8 months. INTERVENTIONS: Cefonicid 1 g was given by intravenous infusion to alternate patients 30 minutes before the operation. MAIN OUTCOME MEASURES: Wound infection. RESULTS: The groups were comparable for age, body mass index, grade of surgeon, operating time, and size of hernial ring. The wound infection rates were 0/8 compared with 4/8 for incisional hernia repairs (p = 0.08) and 1/9 compared with 4/10 for umbilical hernia repairs (p = 0.3). The overall rate was 1/17 compared with 8/18 (p = 0.02). CONCLUSIONS: Single dose antibiotic puphylaxis seems to exert a beneficial effect on the wound infection rate after umbilical and incisional hernia repair.

Student abuse in medical school: a comparison of students' and faculty's perceptions.

A perceived abuse or mistreatment has been identified in the United States as a major source of stress for undergraduate medical students. The objective of this paper is to explore whether medical students in Israel have similar complaints, and if so, whether medical faculty members are aware of students' perceptions of mistreatment. Third and fifth year medical students of the 6 year undergraduate program of the Hebrew University-Hadassah Medical School were asked to respond to a self-administered questionnaire similar to those used in previous studies in the USA. An additional questionnaire was developed for faculty members. Response rates were 75% for students and 39% for faculty members. Analysis of the responses indicated that similar to the results of American studies, the number and severity of all forms of perceived incidents of abuse increased from the third (pre-clinical) to the fifth (clinical) year. Verbal abuse was the most frequently reported form of mistreatment. The most frequently identified abusers were nurses, followed by clinical faculty members, and general surgery was reported as the most abusive clinical department. Students' complaints of denial of basic privileges were more common than those reported in the USA, while verbal abuse and physical threats were more frequently reported by American medical students. Analysis of the responses of faculty members indicated that clinical faculty, residents and interns were unaware of the extent of these students' perceptions, while pre-clinical faculty overestimated the extent of verbal and psychological abuse. We conclude that the perception of abuse or mistreatment among Israeli medical students is more prevalent than either students or faculty believe.

[Repair of esophageal perforation with a diaphragmatic flap].

Perforation of the esophagus is life-threatening and requires prompt diagnosis. Immediate surgery with primary suture of the perforation is the treatment of choice. Any delay in diagnosis or treatment results in a sharp increase in mortality due to the combination of rapid development of necrotizing mediastinitis and inability to close the perforation surgically. To avoid leaks from the anastomosis the suture line can be buttressed with adjacent structures. The fundus of the stomach, parietal pleura and muscular flaps have been used to cover the perforation. We describe 2 patients with perforation of the lower esophagus. Both were operated on within 8 hours, the perforation was closed primarily and a diaphragmatic flap was formed to cover the suture line. There were no postoperative leaks and recovery was uneventful.

Anorectal malformations and Down syndrome.

During 1980 to 1986, 89 children with Down syndrome and 42 with imperforate anus were diagnosed among 64,870 liveborn infants in the Jewish population of Jerusalem. Two of the children had both Down syndrome and imperforate anus. This indicates a high incidence of imperforate anus among children with Down syndrome (2.2%).

Problem-solving instruction during the clinical clerkship: description and preliminary evaluation of a programme.

A clerkship programme in general surgery is described whereby students acquire factual knowledge about disease entities through independent learning rather than through formal teaching. The objectives of the programme are to promote problem-solving skills. It consists of clinical work (patient work-up, clinical rounds, participation in the activities in the operating room, out-patient clinic and emergency room) and of small-group tutorial sessions. The described programme has met with approval and satisfaction from both students and teachers. There were no significant differences in the average grades on the written and oral final examinations between the graduates of this clerkship programme and those of a traditional one. Independent learning and problem-solving instruction, which have been adopted by some medical schools in the preclinical phase of the curriculum, can be effectively implemented during the clinical phase as well.

Lung resection for bronchiectasis in children.

Twenty children with bronchiectasis underwent pulmonary resections during an 8-year period. All patients suffered from significant symptoms that did not respond to medical treatment and had localised disease. In 7 patients bronchiectasis developed following foreign body aspiration and in two the aetiology was cystic fibrosis and immune deficiency, respectively. The lower lobes were most commonly involved. Atelectasis of the remaining ipsilateral lung was the most common postoperative complication occurring in four patients. One patient required reoperation for recurrent symptoms. Fifteen out of 18 patients who underwent curative resections were asymptomatic in the longterm follow-up. It is concluded that for children with significant symptoms due to localised bronchiectasis that fails to respond to medical treatment, resection of the affected lobes is indicated.

Nerve mediated responses to drugs and electrical stimulation in aganglionic muscle segments in Hirschsprung's disease.

The activity of isolated muscle strips from normal and aganglionic human large bowel was studied in vitro. The intrinsic nerves were stimulated electrically and by nicotinic agonists. The ganglionic preparations displayed a strong inhibitory response due to the release of both norepinephrine and a noncholinergic, nonadrenergic inhibitory neurotransmitter. In the aganglionic strips (obtained from patients with Hirschsprung's disease), nerve activation tended to evoke contraction, apparently due to enhancement in the release of acetylcholine. At the same time, the release of norepinephrine appeared to be less than normal. A particularly interesting finding in the aganglionic muscle strips was the presence of a substantial inhibitory response due to the release of a noncholinergic, nonadrenergic substance. These results provide further evidence for the importance of the innervation of the aganglionic segment in Hirschsprung's disease.

Abdominal actinomycosis.

Abdominal actinomycosis seldom occurs before puberty. The symptomatology of abdominal actinomycosis is non-specific and the diagnosis is difficult to make. Previously, this condition was associated with a high mortality rate. The following patient had a flank abscess due to actinomycosis as a late complication of perforated appendix which was diagnosed by biopsy and culture. The patient responded to a prolonged course of chemotherapy with intravenous penicillin and metronidazole. This case illustrates the problems encountered in the diagnosis and management of childhood actinomycosis.

Primary hyperparathyroidism presenting as cervical myelopathy.

Quadriplegia as a presenting syndrome in a case of primary hyperparathyroidism is reported. The clinical picture was misdiagnosed as a space-occupying lesion in the cervical spinal canal, for which an unnecessary laminectomy was performed. The neurologic deficits disappeared following the removal of a parathyroid adenoma. The neurologic presentations of hyperparathyroidism are reviewed and discussed.

Brain abscess: a complication of oesophageal dilatations.

A 16-month-old boy underwent oesophageal dilatations following an unsuccessful attempt to locally resect a 3 cm long lye stricture. He then developed a brain abscess which was surgically drained. Subsequently, a right colon interposition was performed to bypass the stricture. Following oesophageal dilatations, bacteraemia and fever are common but the occurrence of metastatic brain abscesses is rare. This serious complication should be kept in mind when long-term treatment by repeated oesophageal dilatations is planned.

Bilateral congenital posterolateral diaphragmatic hernia.

A female neonate with bilateral congenital posterolateral diaphragmatic hernia is presented. The correct diagnosis was established only after repair of the left hemidiaphragm. Repair of the right hemidiaphragm failed to prevent a downhill course with progressive respiratory failure which led to her death. This extremely rare anomaly is discussed in view of the complex embryological development of the diaphragm.

Strangulated congenital diaphragmatic hernia in infants.

Two previously healthy children, 7 and 12 months old, respectively, presented with respiratory distress and severe sepsis. Chest x-rays were suggestive of inflammatory disease of the left lung. At operation, necrotic bowel was found to be herniated through a left congenital posterolateral diaphragmatic hernia. These patients illustrate the difficulty in establishing the diagnosis of strangulated congenital diaphragmatic hernia and the grave consequences when operation is delayed.