Functional Outcome of Lumbar Discectomy by Fenestration Technique in Lumbar Disc Prolapse - Return to Work and Relief of Pain.

INTRODUCTION: Low back pain affects every population and is one of world's foremost debilitating conditions. Clinically significant sciatica due to lumbar disc prolapse occurs in 4-6% of population. Fenestration discectomy as a surgical procedure is less time consuming, with lesser blood loss, lesser post-operative complications and does not compromise with stability of spine when compared to laminectomy. AIM: Present study was conducted to determine extent of functional recovery i.e. pain relief and return to work in patients with lumbar disc prolapse treated by fenestration technique. MATERIALS AND METHODS: From October 2010 to March 2012, 50 patients with signs and symptoms of prolapsed lumbar intervertebral disc who failed to respond to conservative treatment were operated for discectomy by fenestration technique and studied prospectively. Functional outcome was evaluated by 'Back Pain Functional Score (BPFS)' of Strafford et al., PROLO rating scale to determine preoperative functional and economical status and outcome at final follow up after 6 months. In order to identify physical signs from non organic signs Wadell's score system was used. Result of surgery was evaluated with help of McNab's criteria. RESULTS: In our study, according to Back Pain Functional Scale by Strafford et al., and PROLO scale, good results were found in 42 (84%) cases, fair result in 8 cases (16%) and none with poor results at follow up of six months. According to PROLO economical and functional scale, 84% cases were able to join their previous occupation at end of six months and 76% cases had complete pain relief. In our study, correlation of age and duration of symptoms to functional outcome was statistically significant (p=0.089 & p = 0.098+ respectively) showing more good results among patients with age less than 30 years and patients having duration of symptoms less than 6 months. CONCLUSION: Functional outcome of fenestration technique in terms of return to work and complete back and leg pain relief at end of six months had been satisfactory in our study. Moreover, old age, long duration of symptoms and presence multiple psychological issues are negative predictors of functional outcome.

Genital donovanosis with malignant transformation: An interesting case report.

Donovanosis is a chronic indolent sexually transmitted granulomatous ulceration of genito-inguinal region, caused by Calymmatobacterium granulomatis. It became uncommon due to indiscriminate use of broad spectrum antibiotics. In recent years, much interest is being focused on this condition because genital ulcers facilitate HIV infection. We report an interesting episode of genital donovanosis complicated with squamous cell carcinoma in a middle aged female for its rarity and clinical interest.

(6'R*,7'R*)-7'-(1,3,-Diphenyl-1H-pyrazol-4-yl)-1,2,5',6',7',7a',3'',4''-octa-hydro-1'H,2''H-dispiro-[acenaphthyl-ene-1,5'-pyrrolo-[1,2-c][1,3]thia-zole-6',3''-[1]benzopyran]-2,4''-dione.

In the title compound, C40H29N3O3S, the pyran ring adopts a sofa conformation, the thia-zolidine ring adopts a twisted conformation and the pyrrolidine ring adopts an envelope conformation with the N atom as the flap. The pyrazole ring is essentially planar [maximum deviation = 0.002 (2) Å] and forms dihedral angles of 4.8 (1) and 39.0 (1)°, respectively, with the benzene rings attached to the N and C atoms. The acenapthylene ring system is approximately planar [maximum deviation = 0.058 (2) Å] and forms dihedral angles of 85.9 (1) and 48.5 (1)°, respectively, with the pyrollothia-zole and chromene ring systems. The mol-ecular conformation is stabilized by three weak intra-molecular C-H⋯O hydrogen bonds, which generate one S(8) and two S(6) ring motifs. In the crystal, pairs of C-H⋯O hydrogen bonds link centrosymmetrically related mol-ecules into dimers, generating R 2 (2)(14) ring motifs. The crystal packing also features pairs of C-H⋯π inter-actions, which link the dimers into a supra-molecular chain along the b axis.

1'-(1,3-Diphenyl-1H-pyrazol-4-yl)-1''-methyl-2',3',5',6',7',7a'-octa-hydro-1'H-dispiro-[1-benzopyran-3,2'-pyrrolizine-3',3''-indoline]-2'',4-dione.

In the title compound C38H32N4O3, one pyrrolidine ring adopts an envelope conformation with the N atom as the flap while other pyrrolidine ring adopts an twisted conformation. The pyrrolizine ring forms dihedral angles of 79.24 (5) and 77.57 (5)° with the chromene and indole rings, respectively. The carbonyl O atoms deviate from the least-square planes through the chromene and indole rings by 0.0113 (12) and 0.0247 (12) Å, respectively. In the crystal, non-classical C-H⋯O inter-actions link the mol-ecules, generating an C(9) chain along the b-axis direction.

Day-case stoma surgery: is it feasible?

INTRODUCTION: The National Health Service (NHS) Modernisation Agency has identified ten high impact changes for health organisations to adopt in order to improve their service. Top of this list is increasing day-surgery rates. The basket of interventions offered as short-stay procedures will have to increase to achieve this target. The aim of this study was to investigate whether it is feasible to offer fashioning or reversal of loop stomas as a short-stay procedure. METHODS: Consecutive patients needing stoma fashioning or reversal were offered surgery as a day-case. All were recruited from a single colorectal consultant's caseload. Patients scheduled for stoma formation were taught how to manage the stoma by a specialist nurse prior to hospital admission. The stoma nurse then visited all patients at home one day after discharge. Laparoscopic-assisted techniques, opiate avoidance and early mobilisation were included in the management protocol. Data relating to patient demographics, length of stay and complications were collected prospectively. Results of continuous variables were presented as median and interquartile ranges (IQRs). RESULTS: All patients offered day-surgery accepted it readily. A total of twelve patients (M:F, 5:7) with a median (IQR) age of 70 (63-74) years were recruited. Seven had laparoscopically assisted loop ileostomy formation while five underwent loop stoma reversal (four loop ileostomies, one transverse colostomy). Four out of twelve patients were discharged the same day and 11/12 patients were home within 23 hours of admission. One patient needed admission for 72 hours for social reasons. None of the patients required readmission, and there were no observed complications associated with early discharge. CONCLUSIONS: With the appropriate supportive set up, 23-hour stoma surgery is indeed feasible. Day-case procedures are possible in some, however, as with all short-stay surgery, careful patient selection is required.

Randomized clinical trial of effect of synbiotics, neomycin and mechanical bowel preparation on intestinal barrier function in patients undergoing colectomy.

BACKGROUND: The aim of this study was to investigate whether it is possible to modulate gut microflora and preserve intestinal barrier function during elective colorectal surgery by using combinations of oral antibiotics, synbiotics and mechanical bowel preparation (MBP). METHODS: Ninety-two patients were randomly assigned to one of four groups. Group 1 had MBP only, group 2 had neomycin + MBP, group 3 had synbiotics + neomycin + MBP, and group 4 had synbiotics + neomycin but no MBP. Changes in gut microflora were assessed by culturing nasogastric aspirates and polymerase chain reaction-denaturing gradient gel electrophoresis of faecal samples. Intestinal barrier function was determined by microbiological confirmation of bacterial translocation and measurement of intestinal permeability. The inflammatory response was monitored by measurement of serum C-reactive protein and interleukin 6, and septic morbidity was recorded prospectively. RESULTS: Four patients were excluded owing to protocol violation, leaving 24 patients in group 1, 22 in group 2, 20 in group 3 and 22 in group 4 for analysis. There was a significant decrease in Enterobacteriaceae in group 3 compared with the other groups. Group 3 had a significantly lower incidence of translocation after bowel mobilization (P < 0.001). There was no significant difference between the groups in intestinal permeability, inflammatory response or septic morbidity. CONCLUSION: The combination of MBP, neomycin and synbiotics reduces the prevalence of faecal Enterobacteriaceae and bacterial translocation; however, this was not associated with a reduction in inflammatory response or septic morbidity in this study. Larger trials are needed before a change in practice can be recommended.

Surgical manipulation of the large intestine increases bacterial translocation in patients undergoing elective colorectal surgery.

OBJECTIVE: Several animal studies have suggested that surgical manipulation of the intestine alters the barrier function and promotes bacterial translocation (BT). Whether this occurs in humans has never been investigated. The aim of this study was to determine the effect of surgical manipulation of the intestine on the prevalence of BT in patients undergoing elective colorectal surgery. METHOD: This was a prospective observational study of 50 consecutive elective surgical patients in whom a sample of mesenteric lymph node (MLN) was harvested after mobilization of the colon, prior to ligation of the vascular pedicle. These results were compared with 472 historical controls, who had a sample of MLN taken before the mobilization of colon during laparotomy. A positive culture of MLN confirmed BT. RESULTS: BT was identified in 39/49 (79.6%) patients in the study group compared with 54/472 (11.4%) patients in the control group. This difference was statistically significant (P < 0.001, chi(2) test). CONCLUSION: Surgical manipulation of the bowel does increase the prevalence of BT and therefore is associated with changes in gut barrier function in elective surgical patients.

Sustained release of protein from poly(ethylene glycol) incorporated amphiphilic comb like polymers.

Amphiphilic comb like macromonomer containing hydrophilic poly(ethylene glycol) groups covalently linked to poly(hydromethyl siloxane) (PHMS) were prepared by hydrosilylation reaction. The epoxy reacting sites were introduced to this amphiphilic system by the reaction with allyl epoxy propyl ether (AEPE). Bovine serum albumin (BSA), a model protein drug was loaded to the PEG-PDMS system and very thin membranes were made from this macromonomer adopting solution casting technique. The in vitro protein release studies at various pH conditions showed a controlled release profile without exhibiting any initial burst. The control of the initial burst might be due to the strong linkages of the protein with the membrane and the aggregation of the protein at the surface. The morphology of the membrane before and after the protein release, and the mechanical strength were evaluated. The surface properties of the membrane were studied using the contact angle measurements.

Suction blister epidermal grafting for management of eyelid vitiligo: special considerations.

BACKGROUND: Suction blister epidermal grafting is an established technique for the treatment of resistant and stable vitiligo especially over small and cosmetically important areas like the face. However, certain areas, such as lips and eyelids, require special considerations because of their anatomic peculiarities. PATIENTS AND METHODS: The current study was carried out on six patients of stable eyelid vitiligo, not responding to medical treatment. Suction blister was obtained from the thigh using the suction apparatus and the roof was grafted on to the dermabraded eyelid. Certain precautions were taken during the procedure, which will be highlighted in the current study. RESULTS: Response was excellent in all the patients in 3 to 6 months, with no complications. CONCLUSIONS: If carried out properly, suction blister technique is the procedure of choice for cosmetically important sites like eyelids.

En bloc excision of proximal nail fold for treatment of chronic paronychia.

BACKGROUND: Chronic paronychia is a very recalcitrant dermatosis, which is particularly prevalent in housewives. Medical treatment for this condition is unsatisfactory in a significant number of cases. Surgical approach forms an important part of management, however, this area has received little attention. Various surgical approaches have been tried in the past but a comparative analysis has not been attempted. OBJECTIVES: The present study aims at assessing the efficacy of en bloc excision of proximal nail fold (PNF). Moreover, a comparative analysis has been undertaken to assess whether or not simultaneous nail plate avulsion improves the treatment outcome. METHODS: Thirty patients of chronic paronychia with nail plate irregularities were randomly divided into two treatment groups (15 patients each). After a detailed evaluation, en bloc excision of PNF with or without nail plate removal was performed. Postoperative measures were advised and the patients were kept under regular follow-up thereafter. Assessment of postoperative complications was also performed. RESULTS: Twelve patients in group I and 13 patients in group II completed the treatment protocol. Of these, 70% of patients were cured in group II (en bloc excision with nail avulsion) whereas only 41% were cured in group I (en bloc excision without nail avulsion). CONCLUSION: En bloc excision of the PNF is a useful method in recalcitrant chronic paronychia. Simultaneous avulsion of the nail plate improves the surgical outcome. Strict avoidance of irritant exposure is necessary to ensure complete treatment and prevent recurrence.

Association of phthalate esters with endometriosis in Indian women.

OBJECTIVE: To evaluate the possible association between phthalate esters (PEs) and the occurrence of endometriosis. DESIGN: Case-control study. SETTING: Department of Reproductive Medicine, Bhagawan Mahavir Medical Research Centre, Maternal Health and Reproductive Institute and Department of Analytical R&D, Hetero Research Foundation, Hyderabad, Andhra Pradesh, India. SAMPLE: Blood samples were collected from 49 infertile women with endometriosis (study group); 38 age-matched women without endometriosis (control group I) but with infertility related to tubal defects, fibroids, polycystic ovaries, idiopathic infertility and pelvic inflammatory diseases diagnosed by laparoscopy and a further group of 21 age-matched women (control group II) with proven fertility and no evidence of endometriosis and other gynaecological disorders during laparoscopic sterilisation. METHODS: Concentrations of PEs were measured using gas chromatography. MAIN OUTCOME MEASURES: Evaluation of PEs concentrations in women with endometriosis compared with women free from the disease. RESULTS: Women with endometriosis showed significantly higher concentrations of di-n-butyl phthalate (DnBP), butyl benzyl phthalate (BBP), di-n-octyl phthalate (DnOP) and diethyl hexyl phthalate (DEHP) (mean 0.44 [SD 0.41]; 0.66 [SD 0.61]; 3.32 [SD 2.17]; 2.44 [SD 2.17] micrograms/ml) compared with control group I (mean 0.08 [SD 0.14]; 0.12 [SD 0.20]; 0; 0.50 [SD 0.80] micrograms/ml) and control group II (mean 0.15 [SD 0.21]; 0.11 [SD 0.22]; 0; 0.45 [SD 0.68] micrograms/ml). The correlation between the concentrations of PEs and different severity of endometriosis was strong and statistically significant at P < 0.05 for all four compounds (DnBP: r=+0.73, P < 0.0001; BBP: r=+0.78, P < 0.0001; DnOP: r=+0.57, P < 0.0001 and DEHP: r=+0.44, P < 0.0014). CONCLUSIONS: This study suggests that PEs may have an aetiological association with endometriosis.

Bacterial translocation studied in 927 patients over 13 years.

BACKGROUND: Bacterial translocation (BT) describes the passage of bacteria from the gastrointestinal tract to normally sterile tissues such as the mesenteric lymph nodes (MLNs) and other internal organs. The clinical and pathophysiological significance of BT remains controversial. This report describes results obtained over a 13-year period of study. METHODS: MLNs were obtained from 927 patients undergoing laparotomy. Nasogastric aspirates were obtained from 458 (49.4 per cent) of 927 patients for culture; pH was measured in 172 (37.6 per cent) of 458. Preoperative clinical variables were evaluated and factors that influenced BT were included in a multivariate logistic regression analysis. RESULTS: BT was identified in 130 (14.0 per cent) of 927 patients. Postoperative sepsis was more common in patients with BT (42.3 versus 19.9 per cent; P < 0.001). Independent preoperative variables associated with BT were emergency surgery (P = 0.001) and total parenteral nutrition (TPN) (P = 0.015). Gastric colonization was confirmed in 248 (54.1 per cent) of 458 patients, and was associated with both BT (P = 0.015) and postoperative sepsis (P = 0.029). A gastric pH of less than 4 was associated with a significant reduction in gastric colonization (53 versus 80 per cent; P < 0.001) and postoperative sepsis (46 versus 70.3 per cent; P = 0.018) but not BT. CONCLUSION: BT is associated with postoperative sepsis. Emergency surgery and TPN are independently associated with an increased prevalence of BT.

Diagnosis of nail psoriasis: importance of biopsy and histopathology.

BACKGROUND: Involvement of the nail is quite common in psoriasis and at times may be the sole diagnostic clue. However, the histopathology of nail psoriasis has not been adequately evaluated. A confirmation of the diagnosis is required in cases suspected to have nail psoriasis in order to plan long-term therapy. OBJECTIVES: To assess the diagnostic significance and safety profile of nail biopsy in cases with nail psoriasis. METHODS: Clinical and mycological features were studied in 42 patients with nail psoriasis. Of these, 22 patients gave consent for nail biopsies to be taken and the histopathological changes were assessed. RESULTS: Males were affected more commonly (57%) with a peak incidence in the age group of 10-20 years (29%). Distal onycholysis, discoloration of nail plate, subungual hyperkeratosis and fine nail pitting were the predominant clinical features. In the 22 biopsies done, hyperkeratosis with parakeratosis (91%) was found to be the most common and hypergranulosis was the least common histological finding (36%). Clinicohistological correlation was possible only in 55% cases. Periodic acid-Schiff (PAS) staining was done for all biopsies. CONCLUSIONS: Histopathological examination of nails is a valuable diagnostic aid, especially in the absence of skin lesions. Examination of the PAS-stained sections is necessary before making a histological diagnosis of nail psoriasis because onychomycosis and psoriasis may show similar histology.

Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection.

BACKGROUND: The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing a wide range of colorectal procedures. METHODS: Thirty-nine patients undergoing major elective colonic resection were recruited prospectively. Patients were randomized to receive a ten-point multimodal optimization package or conventional perioperative care. All patients were administered epidural analgesia and opiates were avoided. Outcome measures recorded related to length of hospital stay, physical and mental function, and gut function. RESULTS: Optimization was associated with a significantly shorter median (interquartile range) hospital stay compared with conventional care (5 (4-9) versus 7.5 (6-10) days; P = 0.027). Duration of catheterization (P = 0.022) and duration of intravenous infusion (P = 0.007) were also less. Optimization was associated with a quicker recovery of gut function (P = 0.042). Grip strength was maintained in the postoperative period in the optimized group (P = 0.241) but not in the control group (P = 0.049). There were no differences in morbidity or mortality between the groups. CONCLUSION: Optimization is safe and results in a significant reduction in postoperative stay along with other improved endpoints. This cannot be directly attributed to improvement in any single outcome measure or to the use of epidural analgesia. Improvements are more likely to be multifactorial and may relate to an earlier return of gut function.

Congenital becker nevus with lichen planus.

We report an interesting and rare association of congenital Becker nevus with lichen planus occurring in an 11-year-old boy. Both conditions were confirmed histopathologically.

Leprosy with neurofibromatosis--a diagnostic dilemma.

The coexistence of leprosy with neurofibromatosis is a rare finding and can pose a diagnostic dilemma. Neurofibromatosis coexisting with borderline tuberculoid leprosy has previously not been reported. We report such a case in a 13-year-old boy where biopsy of clinically uninvolved nerve revealed the presence of acid-fast bacilli. A careful diagnostic workup is needed in such cases to ensure proper treatment. Both disorders affect Schwann cells and their relationship merits further consideration.

Cutaneous relapse in Hodgkin's disease: a case report.

BACKGROUND: Skin involvement in Hodgkin's disease is rare, can be seen in advanced stages of the disease and indicates a poor prognosis. CASE: A young male presented with multiple nodular lesions on the chest wall and matted cervical lymph nodes. Aspiration smears from skin lesions showed atypical mononuclear cells with a prominent nucleolus, many lymphocytes and plasma cells. Smears from the lymph nodes showed classical Reed-Sternberg cells in a polymorphous background. The cytologic diagnosis of Hodgkin's lymphoma was entertained and later confirmed on skin biopsy. Past history revealed that the patient had been diagnosed with Hodgkin's disease and treated for it 2 years earlier, but had been lost to follow-up during treatment. CONCLUSION: Cutaneous Hodgkin's disease should always be considered in smears from skin lesions showing atypical mononuclear cells in a polymorphous background, even in the absence of a definitive clinical diagnosis at the time of presentation.

Cutaneous tuberculosis in Indian children: the importance of screening for involvement of internal organs.

AIMS AND OBJECTIVES: Resurgence of skin tuberculosis especially with drug-resistant strains has been well documented in recent years, but this problem has not received much attention in the paediatric age group. Hence, we carried out the present study to analyse the clinical and therapeutic aspects of cutaneous tuberculosis in children. MATERIALS AND METHODS: A detailed clinical examination, investigations, such as haemogram, serology for HIV, Mantoux test, chest X-ray, cytology, culture and histopathology were carried out in all children. They were treated with antitubercular therapy (WHO regimen), and the clinical response was followed up. RESULTS: Of 142 patients with cutaneous tuberculosis, 68 were children (40 females, 28 males). These children were aged from 9 months to 14 years. The duration of the disease varied from 1 month to 6 years. Family history of tuberculosis was present in 28 (41.2%) of the patients. Scrofuloderma was the most common presentation encountered in 30 (44.1%) patients with preferential involvement of the cervical (56.2%) and inguinal (20%) regions. Fifteen (22.1%) patients had lupus vulgaris, of which the keratotic type was the most common (46.7%), 16 had lichen scrofulosorum, three had tuberculosis verrucosa cutis, and four had more than one type of tuberculosis. Involvement of the lung in 14 (20.6%), bone in seven (10.2%), and both in four (5.9%) was found. Histopathology corroborated the clinical diagnosis in 54 (80.6%), culture was positive in six (8.8%). Fifty (73.5%) patients completed the treatment with an excellent response, no multidrug resistant cases were seen. CONCLUSIONS: Cutaneous tuberculosis in children continues to be an important cause of morbidity, there is a high likelihood of internal involvement, especially in patients with scrofuloderma. A search is required for more sensitive, economic diagnostic tools. Response to treatment at 4 weeks often helps in substantiating the diagnosis of tuberculosis in doubtful cases.

Sturge Weber syndrome.

A variant of hemangioma and an uncommon congenital condition, the Sturge Weber syndrome (SWS), also called encephalo trigeminal angiomatosis, is a neurocutaneous disorder with angiomas involving the skin of the face (cutaneous angioma) and pia arachnoid (leptomeningeal angioma). It occurs typically in the ophthalmic and maxillary distributions of the trigeminal nerve (1,2). Here we present a case of a 14 year old girl.

Congenital erythropoietic porphyria complicated by squamous cell carcinoma.

We report two sisters, ages 12 and 8 years, with the characteristic clinical and biochemical profile of congenital erythropoietic porphyria (CEP). The disease is inherited as an autosomal recessive. The elder sibling had squamous cell carcinoma arising from the stump of the amputated left arm with metastases to lymph nodes, adrenals, and bone. To our knowledge, this feature has not been described in the English language literature, making our patient the first documented report of CEP with squamous cell carcinoma.