Incisional hernia following closure of loop ileostomy: The main predictor is the patient, not the surgeon.

BACKGROUND: Incisional hernia at the ileostomy site occurs in 0-48% of patients undergoing loop ileostomy closure. Risk factors for ileostomy-site hernia are not currently well understood. We explored the predictive value of patient and clinical factors for ileostomy-site hernias. METHOD: Loop ileostomy reversals undertaken between 1st January 2009 and 31st December 2013 were retrospectively evaluated. Preoperative patient data (BMI, age, gender, blood pressure, diabetes), surgical variables (preoperative ileostomy marking, intraoperative management (suture type, closure method), postoperative complications (≤30 days), approach, urgency, and chemotherapy, hospital stay, stoma closure interval, follow-up duration) were collected. Patients were followed up by clinical examination and postoperative imaging. RESULTS: 193 loop ileostomy reversals were identified. Operative indications included: colorectal cancer (n = 102, 52.8%); inflammatory bowel disease (n = 47, 24.3%); diverticulosis (n = 20, 10.4%); assorted indications (n = 19, 9.8%); and inflammatory fistulae (n = 5, 2.6%). Median duration of clinical follow-up was 20.5 months (0-69). Hernia occurred in 26 patients (13.5%), detected at a median of eight months post-reversal. Radiological follow-up occurred in 72% of patients and, as a reference standard, in 100% of patients diagnosed with a hernia. Concordance between clinical and radiological findings was 88.5%. Postoperative complications predicted higher hernia risk. BMI and preoperative blood pressure were significant hernia predictors. Differences in the type of suture material to close the defect (absorbable vs. non-absorbable) and stoma skin closure method (primary vs. secondary intention healing) were non-predictive of hernia. CONCLUSION: Whilst BMI and patient comorbidity are the major hernia predictors, variability in surgical practice does not constitute a significant risk factor for ileostomy-site incisional hernia.

Management of sulfonylurea-treated monogenic diabetes in pregnancy: implications of placental glibenclamide transfer.

The optimum treatment for HNF1A/HNF4A maturity-onset diabetes of the young and ATP-sensitive potassium (KATP ) channel neonatal diabetes, outside pregnancy, is sulfonylureas, but there is little evidence regarding the most appropriate treatment during pregnancy. Glibenclamide has been widely used in the treatment of gestational diabetes, but recent data have established that glibenclamide crosses the placenta and increases risk of macrosomia and neonatal hypoglycaemia. This raises questions about its use in pregnancy. We review the available evidence and make recommendations for the management of monogenic diabetes in pregnancy. Due to the risk of stimulating increased insulin secretion in utero, we recommend that in women with HNF1A/ HNF4A maturity-onset diabetes of the young, those with good glycaemic control who are on a sulfonylurea per conception either transfer to insulin before conception (at the risk of a short-term deterioration of glycaemic control) or continue with sulfonylurea (glibenclamide) treatment in the first trimester and transfer to insulin in the second trimester. Early delivery is needed if the fetus inherits an HNF4A mutation from either parent because increased insulin secretion results in ~800-g weight gain in utero, and prolonged severe neonatal hypoglycaemia can occur post-delivery. If the fetus inherits a KATP neonatal diabetes mutation from their mother they have greatly reduced insulin secretion in utero that reduces fetal growth by ~900 g. Treating the mother with glibenclamide in the third trimester treats the affected fetus in utero, normalising fetal growth, but is not desirable, especially in the high doses used in this condition, if the fetus is unaffected. Prospective studies of pregnancy in monogenic diabetes are needed.

Chlorination at power plants: impact on phytoplankton productivity.

Studies of the eflects of passage through a power plant on river phytoplankton have shown that chlorination depresses rates of photosynthesis and respiration to a much greater extent than does heating.

Contrasting success in the restoration of plant and phytophagous beetle assemblages of species-rich mesotrophic grasslands.

Over the last 60 years changes to the management of species-rich mesotrophic grasslands have resulted in the large-scale loss and degradation of this habitat across Europe. Restoration of such grasslands on agriculturally improved pastures provides a potentially valuable approach to the conservation of these threatened areas. Over a four-year period a replicated block design was used to test the effects of seed addition (green hay spreading and brush harvest collection) and soil disturbance on the restoration of phytophagous beetle and plant communities. Patterns of increasing restoration success, particularly where hay spreading and soil disturbance were used in combination, were identified for the phytophagous beetles. In the case of the plants, however, initial differences in restoration success in response to these same treatments were not followed by subsequent temporal changes in plant community similarity to target mesotrophic grassland. It is possible that the long-term consequences of the management treatments would not be the establishment of beetle and plant communities characteristic of the targets for restoration. Restoration management to enhance plant establishment using hay spreading and soil disturbance techniques would, however, still increase community similarity in both taxa to that of species-rich mesotrophic grasslands, and so raise their conservation value.

THE DISCOLORATION OF ROOFS IN THE UNITED STATES AND CANADA BY ALGAE(1).

Roof shingles are often colonized and discolored by blue-green and green algae. The former are mostly subaerial species and the latter are soil algae most frequently recovered from the atmosphere.

A POPULATION OF STAURASTRUM FREEMANII FROM THE CENTRAL HIGHLANDS OF NEW GUINEA.

An abundant gathering of the desmid Staurastrum freemanii has been collected from a pond located in the highlands of New Guinea. This material shows considerable polymorphism and contains a number of significant dichotypic forms. Examination of this material questions the validity of the varietal rank conferred by earlier investigators to many of the forms of this species. Consequently, a taxonomic revision of these varieties is proposed.