Laparoscopic incisional hernia repair in an ambulatory surgery-extended recovery centre: a review of 259 consecutive cases.

PURPOSE: The high prevalence of incisional hernias and an average stay of 3-10 days for open procedures have made this pathology both a health problem and an economic issue. A protocol was developed for performing this procedure in an Ambulatory Surgery Center (ASC) with extended recovery. METHODS: From January 2000 to December 2011, data about all laparoscopic incisional hernia repairs were gathered prospectively. The patients' clinical features, hernia type, intraoperative and postoperative complications and reasons for hospital admission are studied. RESULTS: A total of 259 patients have been operated for incisional hernia (185) or recurrent hernioplasty (74) in our ASC. Laparoscopic repair was successful in 254 patients (98.07 %). Conversion to open surgery was necessary in five patients (1.93 %). A total of 50 patients (19.69 %) in whom surgery was completed laparoscopically were discharged the same day of surgery, 179 (70.47 %) at 24 h and 25 (9.84 %) required a stay of over 24 h. Postoperative pain was severe in 10 % of patients, moderate in 40 %, and mild in 50 %. Complications, mostly minor and self-limiting, were observed in 25 patients (9.84 %) during hospital stay. Five major complications that occured were: bile peritonitis, an acute peritonitis, due to an inadvertent intestinal perforation, and one intestinal obstruction by partial detachment of the mesh, an intra-abdominal hematoma and a colo-cutaneous fistula. There were no deaths in the series. The mean follow-up of patients was 29.35 months (range 12-129 months). The recurrence rate was 7.03 % (n = 18). Four trocar-site hernias were detected. CONCLUSIONS: It is essential to create a protocol with selection criteria that take into account the patient, his entourage, the anesthetic-surgical procedure, and a team dedicated to surgical laparoscopic surgery in an ASC with extended recovery to achieve good results in terms of morbidity and patient safety.

Bleeding diathesis and gastro-duodenal ulcers in inherited cytosolic phospholipase-A2 alpha deficiency.

Arachidonic acid (AA), when cleaved from phospholipids by cytosolic phospholipase A2 alpha (cPLA2a), generates eicosanoids, with pro-hemostatic, pro-inflammatory, vasoactive and gastro-protective functions. We describe a patient (27-year-old man) and his twin-sister with early-onset bleeding diathesis and recurrent gastro-intestinal (GI) ulcers. Platelet aggregation/δ-granules secretion by collagen was impaired, but normal by AA; serum levels of thromboxane (Tx) B2 and 12-hydroxyeicosatetraenoic acid, and urinary levels of 11-dehydro-TxB2 were extremely low. Patients were homozygous for 1723G>C transition in PLA2G4A gene, which changed the codon for Asp575 to His. GI ulcers affected 5/14 heterozygous (< 40 years) and 1/16 wild-type homozygous (> 60 years) family members; none had bleeding diathesis. The proband, his sister and mother also had mildly reduced factor XI levels. Platelet messenger RNA expression did not differ among subjects with different PLA2G4A genotypes. Conversely, platelet cPLA2a was undetectable by Western Blotting in the proband and his sister, and decreased in 1723G>C heterozygous subjects, suggesting that the variant is transcribed, but not translated or translated into an unstable protein. We described a syndromic form of deficiency of cPLA2a , characterised by recurrent GI ulcers and bleeding diathesis, associated with mild inherited deficiency of factor XI. Unlike other reported patients with cPLA2a deficiency, these patients had extremely low levels of platelet TxA2 biosynthesis.

Valoración manométrica del esófago de pacientes operados de acalasia mediante cirugía laparoscópica / Manometric assessment of the esophagus in patients operated on of achalasia by laparoscopic surgery

La acalasia esofágica es un trastorno motor primario con ausencia de peristaltismo e incapacidad de relajación del esfínter esofágico inferior. El presente estudio tuvo como objetivo comparar la evolución clínica y las características manométricas del esófago de pacientes con acalasia esofágica, antes y después cirugía laparoscópica. Se realizó un estudio prospectivo descriptivo con 17 pacientes (6 del sexo masculino y 11 del femenino), con edad comprendida entre 38 y 70 años y diagnóstico radiológico y endoscópico de acalasia esofágica, confirmado por estudio manométrico. Posteriormente, estos pacientes fueron sometidos a tratamiento quirúrgico, mediante esofagocardiomiotomía de Heller con funduplicatura antirreflujo de Dor o Toupet, por videolaparoscopia de forma aleatoria. A todos se les realizó manometría esofágica evolutiva entre los 6 y 18 meses después de la operación. Se encontró notable mejoría clínica en todos los pacientes, aunque persistió una disfagia ocasional mínima a sólidos en el 64,7 por ciento y dolor retroesternal ligero en el 47 por ciento. La presión del esfínter esofágico inferior disminuyó de X= 47,7 mm Hg a X= 17,5 mm Hg (p < 0,01). La relajación del esfínter esofágico inferior aumentó de X= 59 por ciento a X= 75,5 por ciento. (p < 0,01). La presión intraesofágica se normalizó en el 70,6 por ciento de los casos, (p < 0,05). Persistió el aperistaltismo en los pacientes operados y asimetría del esfínter esofágico inferior en el 82,4 por ciento. Tras la valoración clínica y manométrica, se consideraron satisfactorios los resultados de la cirugía laparoscópica en el grupo estudiado.

Esophageal achalasia is a primary motor disorder with abscence of peristaltism and incapacity for relaxation of the lower esophageal sphincter. The present study was aimed at comparing the clinical evolution and manommetric characteristics of the esophagus of patients with esophageal achalasia before and after laparoscopic surgery. A prospective descriptive study was conducted in 17 patients (6 males and 11 females) aged 38-70 with radiological and endoscopic diagnosis of esophageal achalasia confirmed by manometric study. Later on, these patients underwent surgical treatment by Heller esophagocardiogram with Toupet or Dor's antireflux funduplication by randomized video-assisted laparoscopy. Evolutive esophageal manometry was performed in all of them between 6 and 18 months after surgery. A marked clinical improvement was found in all the patients, although a minimal occasional dysphagia to solids persisted in 64,7 percent, and mild retrosternal pain in 47 percent. The pressure of the lower esophageal sphincter decreased from X= 47,7 mm Hg to X= 17,5 mm Hg (p < 0.01).The relaxation of the lower esophageal sphincter increased from X= 59 percent to X= 75,5 percent. (p < 0.01).The intraesophageal pressure was normal in 70,6 percent of the cases, (p < 0.05). Aperistaltism persisted in the operated on patients and the asymmetry of the esophageal sphincter in 82,4. The results of laparoscopic surgery in the studied group were considered satisfactory after the clinical and manometric assessment.

Carotenoids and color of fruit juice and milk beverage mixtures.

Seventeen commercially available, "ready to drink" fortified beverages consisting of mixtures of fruit juices and milk were analyzed to evaluate their carotenoid profile (including their Z/E stereoisomers) and color during their commercial shelf life. Lightness (L*) was found to be correlated with the content of milk in the mixtures (r= 0.649) whereas red-yellow colors were correlated with the contents of alpha-carotene, beta-cryptoxanthin, and beta-carotene supplied by the fruit. The beverages stored under refrigeration (4 +/- 2 degrees C) showed higher luminosity (L*) and higher saturation of color (C*) and yellowness (b*). Differences (P < 0.05) in the levels of carotenoids were found among the beverages. Common fruits such as apple, lemon, pear, strawberry, kiwifruit, pineapple, and banana were low in carotenoids. However, orange, apricot, mango, and peach contributed significantly (P < 0.05) to increasing beta-cryptoxanthin and beta-carotene concentrations. Passion fruit supplied zeta-carotene, and the presence of carrot increased the levels of alpha-carotene and beta-carotene. Conversion of all-Ebeta-carotene and beta-cryptoxanthin to their Z isomers took place in 8 of the 17 samples containing alpha-carotene and in 9 of the 13 samples containing beta-cryptoxanthin, respectively, which resulted in some loss of provitamin A activity and nutritional value.

CO2 laser cordectomy as a day-case procedure.

OBJECTIVE: To evaluate the safety of CO2 laser cordectomy in the treatment of glottic carcinoma as a day-case procedure. STUDY DESIGN: This was a retrospective study of a cohort of 73 patients with glottic carcinoma treated by laser cordectomy as a day-case procedure using a CO2 laser, between January 2000 and June 2004. RESULTS: There were no major complications and no patients required reintubation. More than 90 per cent of the patients were discharged on the day of the procedure. There were seven unplanned admissions to hospital but none of these appeared to be the direct result of the surgery, and the patients were discharged the next day. All the patients stated they would have further surgery in this manner if required. CONCLUSION: Laser cordectomy for glottic carcinoma can be safely performed as an out-patient procedure if patients are carefully selected according to specific criteria.

[Inverted papilloma: treatment and evolution]. / Papiloma invertido: tratamiento y evolución.

Inverted Papilloma is a frequent bening nasosinusal tumour. The high frequency of recurrences and the malignant potential are its clinical characteristics. We present our experience in a retrospective study done in the last 10 years. 10 patients with Inverted Papilloma have been treated during that period. According to the Classification made by krouse who divides the Inverted Papilloma in four stages, we found 3 in stage I, 6 in stage II and 1 in stage IV. The treatment in almost all of the patients in Stage I and II was endonasal surgery. External approach was performed for stage IV. The recurrence rate was 30% and malignization occurred in 10% of the cases. Finally, we have compared other publications, and revised the literature.

Epidemiologic aspects of American visceral leishmaniasis in an endemic focus in Eastern Venezuela.

An endemic focus of American visceral leishmaniasis (AVL) in eastern Venezuela has been evaluated in terms of patients (n = 48), immunologic reactivity to Leishmania in household contacts (n = 187) and neighborhood controls (n = 170), detection of Leishmania (L. donovani complex) in dogs and wild animals by the polymerase chain reaction (PCR) and characteristics of the sandfly population. The male:female ratio of patients was 1.18:1; 89.6% were < or =12 years old. Serologic reactivity was significantly higher in household contacts than in controls (P = 0.0008), as was the size of leishmanin reactions in contacts < or =10 years of age (P = 0.0141). Leishmania donovani complex-specific PCRs were positive in dogs, an opossum (Didelphis marsupialis), and a black rat (Rattus rattus). Lutzomyia longipalpis and Lu. evansi, both implicated in the transmission of AVL, were identified among the 386 sand flies examined. These observations provide the bases for an active control program as well as further studies of reservoirs and vector-host relationships in this area.

[Differential characteristics of families of adolescents and young adults that have attempted suicide]. / Aspectos diferenciales de las familias de adolescentes y jóvenes adultos que realizan tentativas de suicidio.

INTRODUCTION: Families of adolescent and young adult suicide attempters are studied to analyze their role in these extremely dangerous behaviors. METHOD: 72 adolescents and young adults (aged 15-24) who have made a suicide attempt and 72 normal controls matched by sex, age and marital status, are studied in a case-control design. Several aspects of each family are explored: composition, degree of stability in parental couple, type of relationships among the members, labor status of parents and medical-psychiatric and legal family history. RESULTS AND CONCLUSIONS: Only parameters analyzing parents-offspring interactions can differentiate both groups. Keep an unsatisfactory relation with any of the living parents are the family factors which place the young or adolescent subject in risk of making a suicide attempt in our surrounding.

Leprosy in women: characteristics and repercussions.

"Health is often measured in terms of low mortality; nevertheless, merely being alive is not a measure of the quality of life" H. Méndez Castellanos. Physiological, socioeconomic and cultural factors play important roles in the response of women to Mycobacterium leprae and in the impact of leprosy on their lives. They appear to develop stronger immunological responses to M. leprae than men, as suggested by lower incidence and less severe clinical forms of disease in most areas of the world, as well as stronger reactions of cell-mediated immunity after prophylactic vaccination. Genetic factors and physiological status including pregnancy, intercurrent infection and malnutrition might be among the factors which modulate this response. Women in leprosy-endemic areas of the world, with few exceptions, suffer from marked economic and social dependency and inferiority which can only be heightened by the social stigma associated with leprosy. Nevertheless, they bear an enormous responsibility for the health of their families, often as head of the household, and they often possess a unique capacity to influence community opinion. With the introduction of multidrug therapy, leprosy control throughout the world is no longer an unrealistic goal. Active vaccination may constitute the other factor necessary for eventual eradication of the disease. The incorporation of women at all levels into active roles in health care programs may constitute one of the decisive factors in the success or failure of leprosy control.

Generalized anxiety disorder: some biochemical aspects.

Fifty-one patients who met DSM-III criteria for generalized anxiety disorder, and who were recruited to participate in a drug outcome study, filled out a variety of rating scales and had blood samples drawn for plasma norepinephrine, epinephrine, and free 3-methoxy-4-hydroxyphenylglycol (MHPG) after a 20-min rest period. This group was compared to 15 normal controls who also had their blood drawn after a 20-min rest period. While the two groups were initially found to have significantly different levels of plasma free MHPG through the use of t tests, this finding was not confirmed by subsequent discriminant analysis.

Alprazolam, propranolol, and placebo in the treatment of panic disorder and agoraphobia with panic attacks.

Fifty-five patients completed a 5-week double-blind study comparing alprazolam, propranolol, and placebo in the treatment of panic disorder and agoraphobia with panic attacks. There was no concomitant behavioral treatment. Patient and therapist rating scales included Sheehan's Panic and Anxiety Attack Scales, the Marks-Sheehan Phobia Scale, the Hamilton Anxiety Scale, the Hamilton Depression Scale, and the Side Effects Checklist. The results generally support the efficacy of alprazolam, but not propranolol, in the treatment of panic disorder and agoraphobia with panic attacks. The significance of the results are discussed, as well as a number of the unique aspects of our procedures and patient population.

Nortriptyline in the treatment of panic disorder and agoraphobia with panic attacks.

Thirty-four consecutive patients with panic disorder or agoraphobia with panic attacks were treated with nortriptyline at the LAC-USC Medical Center's Anxiety Disorders Clinic. Fourteen (67%) of the 21 completers totally lost their panic attacks, five (24%) showed partial improvement, and two (10%) showed no improvement. The relationship of treatment outcome to pretreatment and posttreatment measures of depression is discussed, in addition to the potential role of nortriptyline in treating panic attacks in clinical practice.

[Familial reciprocal translocations: estimation of the most probable imbalance in the offspring]. / Translocaciones recíprocas familiares: estimación del desbalance más probable en la descendencia.

Four familial reciprocal translocations detected in a chromosomic study made to a population of newborn babies with two or more congenital defects following the methodology of ECEMC is analyzed. We followed the criteria of pachytene-dyagrem model of Jalbert et al (1980) to predict the most probable mode of imbalance for reciprocal translocations is followed. On the four translocations it was observed the type of segregation which was most probable following that model: three of them produced imbalance by a 3:1 segregation and the other one be adjacent 1. According to these results and regarding that a given translocation produces imbalances almost always by the same mechanism, we can provide a useful information for genetic counselling for these families.

Rational-emotive therapy in the treatment of erectile failure: an initial study.

Sixteen males with erectile failure, married or living with their partners, were assigned to either 12 bi-weekly sessions (6 weeks) of Rational Emotive Therapy (RET) or a 6-week waiting-list control group. Active treatment administered by a graduate student in psychology with special training in RET resulted in patients making significantly more sexual intercourse attempts, reporting significantly reduced sexual anxiety, and having a significantly higher number of successful intercourse attempts than the waiting-list control group. While 6-9 month follow-up revealed that most treated patients had fallen back toward the pretest baseline (lower rates of successful intercourse), group means as a whole were still significantly higher than pretreatment intercourse success rates. The significance of these findings are discussed.

Effects of glucocorticoid deficiency on renal medullary cyclic adenosine monophosphate of rats.

1. The effects of adrenalectomy on the adenylate cyclase--adenosine 3':5'-cyclic monophosphate (cyclic AMP) system of rat renal medulla were examined to evaluate the mechanism of the impaired water diuresis in glucocorticoid deficiency. 2. Concentrations of cyclic AMP in medullary tubules from adrenalectomized rats were significantly higher than in the tubules from control animals both in the presence and absence of antidiuretic hormone. 3. This abnormality was corrected by the treatment in vivo of the adrenalectomized rats with dexamethasone, but addition of this drug to the incubation medium did not abolish the differences in cyclic AMP between tubules from adrenalectomized and normal rats. 4. The activity of adenylate cyclase or cyclic AMP phosphodiesterase in vitro was not affected by adrenalectomy. 5. In glucocorticoid deficiency, the concentration of cyclic AMP in medullary tubules is increased both with and without antidiuretic hormone. This abnormality may render medullary tubules more permeable to water and may underlie the impaired water diuresis in glucocorticoid deficiency.

[1st finding of the Ancylostoma braziliense nematode (Gómez de Faria, 1910) in Canis familiaris in Cuba]. / Primer hallazgo del nematodo Ancylostoma braziliense (Gómez de Faria, 1910) en Canis familiaris de Cuba.

According to the results obtained by investigators who have been devoted up to date to the study of dog helminthiases in Cuba dog ancylostomiasis is produced by Ancylostoma caninum. Now, Ancylostoma braziliense (Gómez de Faria, 1910) has been found in two dogs from the Havana province. The knowledge of the invasion extension as well as of the intensity of infestation should wait for the exhaustive study of the collected material.