To provide guidelines for the choice of treatment of intussusception, 10 factors that are known to be related to the outcome of treatment were studied in a series of 146 children with intussusception.
Nine children presented with intussusception lasting for 14 days or more. Their mean age was 8.5 years. Diagnosis of intussusception was delayed considerably, probably due to an unusual presentation. Compared with acute intussusception, symptoms consist of infrequent attacks of abdominal pain, sporadic vomiting and no, or small, changes in defecation. Marked weight loss and an abdominal mass assume diagnostic significance, in contradiction to bloody stools. Ultrasonography can be of diagnostic value. An attempt at hydrostatic reduction is often unsuccessful. A high frequency of organic lesions precipitating intussusception warrants early surgical intervention.
A combination of conservative measures was used to treat 105 patients with 119 ingrowing toenails. The method proved to be simple and cheap, but time consuming. Post-treatment discomfort and the time taken to return to normal activities were acceptable; the cosmetic result was good. Two-year follow-up revealed that the success rate of the method in less advanced cases (stages I and II) was high (96 per cent), although in the long term there was a tendency to recurrence in stage II cases. The failure rate in advanced cases (stage III) was high (up to 62 per cent). Conservative treatment can be used successfully in mild cases of ingrowing toenails.
We describe the characteristics of a group of 140 children with intussusception. They differed strikingly from the classical picture of intussusception given in textbooks and in publications concerning large series. We found a low incidence of intussusception especially in infants and young children. There were far more children of older ages, the delay in diagnosis was significantly longer and there was a very high percentage of leading points. These factors explained our low hydrostatic reduction rate. The weight of most children was under the fiftieth percentile. The percentage of small bowel intussusceptions was somewhat higher. These differences are important in the light of early diagnosis and evaluating the results of treatment.
We read with interest the article 'Conservative treatment of ingrowing toenails' by Reijnen and Cons (Br J Surg 1989; 76: 955-7). We acknowledge that a period of conservative treatment should be considered before surgical intervention; yet is it necessary for patients to endure such prolonged suffering for very little reward?The absence of an alternative treatment group, such as simple nail edge packing or gutter insertion and the heterogeneous nature of the patient population combine to make this a poorly designed study. Eleven doctors undertook conservative treatment on only an average of I 1 nails but each individual's performance is not specified. The authors claim that their treatment is 'time consuming' but fail to report how long each primary treatment took. As patients were not reviewed independently, an unbiased, objective assessment cannot be made. The results of conservative management in the 30 patients who had previously undergone toenail surgery, and therefore demonstrated resistance to previous treatments, have been omitted.The 'conservative' technique in itself appears to border on the barbaric. Analgesia requirements and the amount of pain suffered by each patient during this procedure are not stated. We suspect that lifting embedded nail edges out of the nail fold and filling the central portion of an ingrowing nail would be extremely distressing for the majority of patients if no analgesia was administered. Furthermore, 31 nails (26 per cent) ruptured as a result of filing. This morbidity is excessive and unacceptable.Nail edge excision and phenolization under digital block anaesthesia in our experience can be completed in 15min and has a recurrence rate of i 1 0 per cent at one-year review'. The cosmetic results are satisfactory and the treatment is not attended by the complication of nail rupture.Reijnen and Goris' proposed technique has not been shown to be superior to conventional methods of conservative treatment and cannot be justified in ingrowing toenail management. Authors' reply SirWe would like to comment on the remarks of Mr J. H. Anderson et al. point by point. Our study was started because the literature furnishes little information on the conservative treatment of ingrown toenails. The aim was to establish the value of this specific approach in different stages of ingrown toenail. We did not intend to prove its superiority to another method. Our study clarifies that by using this initial approach an important proportion of patients is cured completely. We do not consider a 94 per cent cure rate after 1 month, nor an 84 per cent cure rate after 1 year in stage I and I1 ingrown toenail 'very little reward'. We recommend a conservative approach for stage I and I1 only.We consider it an advantage of our study that this success was achieved by 1 1 doctors following a fixed protocol. It reflects the practical value of this approach.In our opinion the number of (check) visits justifies the use of the term 'time consuming' although primary treatment takes up to 15 min, at its maximum.We...
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