Preoperative conditioning with oral carbohydrate loading and oral nutritional supplements can be combined with mechanical bowel preparation prior to elective colorectal resection.

OBJECTIVE: Preoperative conditioning with oral fluid and carbohydrate (CHO) loading allows the patient to undergo surgery in the fed state and is associated with reduced postoperative insulin resistance. Further benefit may accrue from oral nutritional supplements (ONS) to counteract the fasting associated with mechanical bowel preparation (MBP). In this study we assess the ability to prescribe, dispense and have patients comply with a protocol combining preoperative ONS and CHO/fluid loading during MBP. METHOD: One hundred and forty-seven patients undergoing elective left colonic or rectal resection were recruited to an Enhanced Recovery after Surgery (ERAS) programme. All patients were prescribed MBP (2 sachets Picolax). On the daytime prior to surgery, eligible patients were prescribed 2 x 200 ml of ONS (Fortijuice, Nutricia) and in the evening 800 ml oral CHO/fluid loading (Preop(R), Nutricia,). Patients were prescribed a further 400 ml of oral/CHO/fluid on the morning of surgery 2 h prior to induction of anaesthesia. Protocol compliance was audited prospectively. RESULTS: One hundred and forty-seven patients received MBP. Twenty-three patients were ineligible for oral CHO/fluid loading [diabetes (n = 22), allergy to lemon flavoured drinks (n = 1)]. Fourteen patients did not receive the preoperative CHO drinks due to failure to prescribe (n = 8) or dispense (n = 6). One hundred and ten patients were dispensed the combined ONS and CHO/fluid loading regimen, compliance rates were 83% with ONS, 80% with CHO/fluid loading and 74% with both. CONCLUSION: Approximately 74% of patients undergoing MBP can comply with preoperative conditioning with ONS and CHO/fluid loading. Prescription and dispensing requires close attention to detail.

Basic surgical training in the era of the European Working Time Directive: what are the problems and solutions?

BACKGROUND AND AIMS: Imposed reductions in working hours will impact significantly on the ability of surgical trainees to achieve competency. The objective of this study was to obtain the opinions of Scottish surgical trainees concerning the training they receive, in order to inform and guide the development of future, high-standard training programmes. METHODS: An anonymous questionnaire was sent to basic surgical trainees on the Edinburgh, Aberdeen and Dundee Basic Surgical Rotations commencing after August 2002. RESULTS: Thirty six questionnaire responses were analysed. Very few of the returned comments were complimentary to the existing training structure; indeed, most comments demonstrated significant trainee disappointment. Despite "regular" exposure to operative sessions, training tutorials and named consultant trainers, the most common concern was a perceived lack of high-quality, structured, operative exposure and responsibility. Textbooks and journals remain the most frequently utilised learning tools, with high-tech systems such as teleconferencing, videos, CD-ROMS, and DVDs being poorly exploited. CONCLUSIONS: Current surgical training is not meeting the expectation of the majority of its trainees. To solve this problem will require extensive revision of attitudes and current educational format. A greater emphasis on the integration of 21st century learning tools in the training programme may help bridge this gap.

Secondary perineal hernia following open abdominoperineal excision of the rectum: report of a case and review of the literature.

This is a case report of a 46-year-old man who presented with a painful perineal lump four months after abdominoperineal excision of the rectum (APER) with pre-operative radiotherapy and adjuvant chemotherapy. Perineal hernia (suspected clinically) was confirmed by magnetic resonance imaging, and the patient underwent open Permacol mesh repair via a perineal approach. Symptomatic perineal herniation after surgical resection is a rare phenomenon, and the approach to management remains challenging. Several different surgical approaches and techniques of repair have been described. In this report, we review the literature surrounding the presentation, aetiology and repair of this unusual post-operative complication. Furthermore, our case confirms that closure of the hernial orifice with mesh via a perineal approach is a satisfactory technique.

Red herring: a rare cause of small bowel obstruction.

This is a case report of a 73-year-old man with a small bowel obstruction secondary to an incarcerated paracaecal hernia. His large right inguinal hernia, initially suspected as a potential source of obstruction, turned out to be a red herring. Congenital internal hernias are a very rare cause of bowel obstruction. In this report we review the literature and embryology behind these uncommon occurrences.

Internal hernia and small bowel obstruction following open ileoanal pouch formation: A case report.

INTRODUCTION: Internal herniae, although rare, can give rise to potentially serious morbidity and mortality. The protrusion and entrapment of the small bowel through an embryological or iatrogenic mesenteric aperture within the confines of the peritoneal cavity can be difficult to diagnose, and delay treatment (operative). Timely intervention must be achieved to minimize small bowel ischemia and infarction. CASE PRESENTATION: In this case, a young lady who had a previous laparoscopic total colectomy and ileostomy developed an unusual internal hernia. Small bowel was passing behind the lesser curvature of the stomach causing the stomach to be rotated to form of a tight "band" trapping bowel. The herniated small bowel was reduced, hence, avoiding resection; the defect closed by interupted 4-0 PDS. "Prompt" surgery avoided small bowel length resection and sacrifice of the ileoanal pouch reconstruction. DISCUSSION: It is theorized that a laparoscopic approach results in a more advanced mobilization of the mesentery right up to the small bowel origin, and with less adhesion formation may in fact promote unusual internal hernia and volvulus. CONCLUSION: The case presented highlights the difficulty in making the diagnosis, and the pictures clearly indicate an unusual hernia passing directly behind the stomach and involving a large section of the small bowel. The lead up history of several admissions with sub acute small bowel obstruction suggested the underlying problem was adhesional but quite clearly there was a well defined internal hernia. Without timely surgery she would have been at high risk of losing her pouch.

The role of pterins in depression and the effects of antidepressive therapy.

Urinary excretion of neopterins (N) and biopterins (B) was measured in 48 patients with depression before and after treatment with placebo, antidepressants, or electroconvulsive therapy (ECT), and in 26 healthy control subjects. Patients prior to and after treatment had a significantly greater neopterin/biopterin (N:B) ratio than control subjects. There was a significant correlation between N:B ratios and the severity of depression and plasma cortisol. As a raised N:B ratio implies failure to convert neopterin to biopterin, it is possible that reduced availability of tetrahydrobiopterin, the essential cofactor for the formation of noradrenaline, serotonin and dopamine, may exert rate-limiting control over the synthesis of monoamines implicated in the pathogenesis of depressive illness.

The role of pterins and related factors in the biology of early postpartum depression.

Plasma tryptophan and other putative amino acids, cortisol, folate and vitamin B12 and urinary biopterin (B) and neopterins (N) were measured in three groups of women: 62 women in the early postpartum period, 23 pregnant and 38 non-gravid controls. Sixty-two postpartum women were screened for depression by the Edinburgh postnatal depression scale (EPDS) on day 7 after delivery. Postpartum women had significantly lower tryptophan, vitamin B12 and significantly greater levels of cortisol, folate, neopterins and biopterins than controls. Comparisons between women who were classified on the EPDS as cases and non-cases revealed only a statistically significant difference for lower N:B (P<0.01) and lower folate (P<0.01) ratio in cases than non-cases. Multiple regression analysis showed a significant contribution for low tryptophan to increased EPDS which also showed significant correlations with low methionine, low tyrosine, low N:B ratio and high vitamin B12.

5-Methyltetrahydrofolate level in the serum of depressed subjects and its relationship to the outcome of ECT.

Serum 5-MeTHF levels are reported in 26 subjects, before and after completing a course of ECT, and compared to 21 healthy volunteers. 5-MeTHF levels of depressed subjects were significantly lower than controls before and after ECT. There was no difference in 5-MeTHF levels between ECT responders and non-responders but folate deficiency was related to severity of depression before ECT. Serum 5-MeTHF was not related to treatment response and values remained markedly low even after a good response to treatment.

Colonic perforation following prolonged hypovolaemia in a major burns injury.

Perforation of the lower gastrointestinal tract is rare in burns patients. A 41-year-old male, who sustained 40% total body surface area burns and subsequently developed an acute abdomen on day 15 postburn, is presented. Emergency management included a subtotal colectomy and ileostomy formation performed to repair a perforated transverse colon found at laparotomy. The burns were debrided and grafted and the patient required cardiac, renal and respiratory support initially in the ITU setting before making a complete recovery. It is suggested that ischaemia caused the perforated transverse colon due to a prolonged low flow state. This was not detected until invasive cardiovascular catheterisation was performed and revealed a hypovolaemic state, which was corrected by fluids and noradrenaline. Both the previous cardiac history of the patient (Fallot's Tetralogy repair) and the noradrenaline may have exacerbated the low flow state within the mesenteric circulation leading to ultimate perforation. This case highlights the difficulties that may arise in resuscitating a patient who has previously had a cardiac defect repaired. Despite repair, abnormal physiology may persist resulting in misleading observations that produce undetected hypovolaemia with subsequent adverse events, as in this case. In such patients, early invasive cardiovascular monitoring should be considered.

Chicken or the leg: Sigmoid colon perforation by ingested poultry fibula proximal to an occult malignancy.

INTRODUCTION: Colonic perforation by ingested foreign bodies is exceedingly rare, with the diagnosis made more challenging by patients infrequently recalling any inadvertent ingestion and the poor sensitivity of plain radiography. PRESENTATION OF CASE: The presented case demonstrates that bony perforation of the large bowel might occur immediately proximal to an otherwise occult colonic malignancy. DISCUSSION: Ingestion of foreign bodies is common and rarely results in colonic perforation. However, bony ingestion is not usually remembered and can be missed even with cross-sectional imaging. If present, consideration should be given to the presence of an adjacent concealed colon cancer. CONCLUSION: The co-existence of separate pathology should be carefully assessed in these patients, since this has important implications for relevant investigations and appropriate surgical management.

New data on some species of Monogenea and Digenea parasites of marine fish from the coast of the State of Rio de Janeiro, Brazil.

Fifty four specimens of marine fish belonging to seven species collected from the coast of the State of Rio de Janeiro, Brazil were examined for helminths, and results relating to Monogenea and Digenea are presented. The monogeneans Metamicrocotyla macracantha, Microcotyle pomatomi and Gotocotyla acanthura are reported in new hosts. The digeneans Parahemiurus merus, Lecithochirium microstomum, Gonocercella pacifica, Aponurus laguncula, Gonocerca trematomi and Lampritrema miescheri are reported in new hosts, and the latter two species are also reported for the first time in Brazil.

Paraileostomy recontouring by collagen sealant injection: a novel approach to one aspect of ileostomy morbidity. Report of a case.

INTRODUCTION: Poorly fitting stoma appliances, resulting in stomal leakage and subsequent skin excoriation, remain a significant cause of ileostomy-related morbidity. One cause of ill-fitting stoma bags is the presence of parastomal dermal contour defects/irregularities. These may occur after surgical complications or change in patient weight and body habitus. METHODS: We report the case of a 29-year-old man who, after panproctocolectomy and formation of ileostomy for ulcerative colitis, experienced significant problems with stoma bag application because of dermal contour defects. As a result, he suffered from significant stomal leakage and skin excoriation. After a single treatment of cutaneous parastomal infiltration of porcine collagen (Permacol Injection), applied stoma bags achieved a watertight seal, and the patient experienced complete and sustained resolution of his symptoms. CONCLUSIONS: Porcine collagen is a safe, versatile, and relatively easy method of restoring irregular skin defects surrounding abdominal stomas, thus resolving the significant patient morbidity associated with ill-fitting stomal appliances. Such a technique avoids the need for surgical stoma refashioning, which may be associated with significant morbidity and unsatisfactory outcomes.

A comparison of in-patient and out-patient prescribing.

The prescribing of psychotropic medication to 96 attenders at a lithium clinic was compared with their prescriptions while in-patients. As out-patients, they received fewer psychotropic drugs fewer times a day. This suggests that psychiatrists do not adopt intransigent stances in favour of polypharmacy and irrational psychotropic prescribing, as previous studies have implied. Caution is advised before attributing apparently irrational prescribing to bad clinical practice, or advocating remedial action aimed at changing the habits of prescribers.

The delusion of inanimate doubles. Implications for understanding the Capgras phenomenon.

The Capgras delusion has long been held to be specific for close personal relationships. This paper presents evidence that this is not the case and the implications of this for accepting psychodynamic explanations of the phenomenon are discussed. Parallels are drawn with the condition prosopagnosia and a hypothesis presented that any specificity is apparent rather than real. It is proposed that both prosopagnosia and the Capgras symptom represent abnormalities of visual perception occurring at different stages of this neurophysiological process.

Koro: the genital retraction symptom after stroke.

The complete Koro complex in an elderly male Briton was associated with psychotic depression following a non-dominant temporoparietal stroke. As Koro lacks both cultural and diagnostic specificity, it would be more appropriately renamed the genital retraction symptom.

Treating depression in old age: the reasons to be positive.

Depression affects 10-15% of people over 65 living at home in the United Kingdom. It is the commonest and the most reversible mental health problem in old age. Depression is associated with physical illness and disability, life events, social isolation and loneliness. Depression in old age carries an increased risk of suicide and natural mortality. Recognition and simple intervention can reduce morbidity, demand on health and social services and the cost of community care. Despite a favourable response to treatment, depression remains largely undetected and untreated.

Experimental mycosis in immunosuppressed rabbits. I. Acute and chronic candidosis.

Chronic candidosis was established in rabbits by the injection I.V. of 2 X 10(6) cells of C. albicans. The rabbits were assayed every week for 14 weeks for the appearance of candida antigen and anticandida antibodies in serum and other body fluids. Tests were carried out in double diffusion plates; antigen against hyperimmune rabbit sera and antibody against Candida cell sap antigen preparation. A sensitive specific passive hemagglutination procedure was also developed which used chromate treated cells. In rabbits with chronic candidosis not treated with cyclophosphamide antigen was detected in 4x concentrated serum between the fifth and sixth week. At about the same time antibodies were demonstrable and thereafter antigen was no longer detected. Maximum antibody titer occurred between the eight to 10th week and disappeared thereafter. If cyclophosphamide 30 mg/kg was given at this point, anticandida antibodies reappeared in high titers, persisted from three to four weeks and then disappeared. At autopsy no evidence of candidosis was present. If rabbits were pretreated with cyclophosphamide 60 mg/kg for one week before inoculation and given the drug weekly thereafter no antibody was detectable but antigen and antibody were present in body fluids (not serum) at post mortem.

Experimental mycosis in immunosuppressed rabbits. II. Acute and chronic aspergillosis.

The influence of immunosuppression on the course of experimental aspergillosis was investigated. Rabbits (2.2--2.5 kg) were divided into four groups. Group one received no drugs and was given 10(6) spores intravenously (IV) or intratracheally (IT) on two occasions one week apart. Weight gain or loss, appearance or disappearance of aspergillus antigen and/or antibody, and detection of aspergillosis at autopsy were followed. Group 2 received weekly injections of cyclophosphamide (70 mg/kg) starting two weeks prior and throughout the experiment. Animals in group three received either 1.14 or 2.25 mg/kg/day methyl prednisolone and group four received 2.28 mg/kg/day methyl prednisolone and 70 mg/kg/week cyclophosphamide. In group one, serum antigen levels were detected within a week of infection followed by antibody (I.D.) levels for three months. All animals grew normally and no infection was detected at autopsy. In group 2, animals survived one but not two challenges and had Ag but no Ab. In group 3, animals survived two challenges at the lower drug level but not the higher. All animals in group 4 succumbed to one challenge.

Delusional depression, hyperparathyroidism, and ECT.

A woman with delusional depression and unsuspected primary hyperparathyroid disorders responded completely to electroconvulsive therapy (ECT). Hypercalcemia is a complicating factor in the treatment of delusional depression, but there is little evidence that it is causative and the use of ECT should not be delayed. The case adds to the literature confirming the efficacy and safety of ECT with physically ill patients when it may be a life-saving procedure.