Delayed presentation of iatrogenic ventriculoperitoneal shunt transection following laparoscopic weight loss surgery in a patient with idiopathic intracranial hypertension.

Idiopathic intracranial hypertension is strongly associated with central obesity and consequential raised intra-abdominal pressure. If left untreated it poses significant risk to vision and can eventually cause blindness. Owing to its pathophysiology, this condition is managed by both medical and surgical specialities. When medical management fails neurosurgeons commonly treat idiopathic intracranial hypertension by permanent cerebrospinal fluid peritoneal shunting. Weight reduction surgery provides patients who are obese with a multitude of benefits and it is not uncommon for the general surgeon to be presented with a patient with idiopathic intracranial hypertension and a cerebrospinal fluid peritoneal shunt in place. This provides a potential challenging situation in weight-loss surgical procedures. We describe an interesting case where laparoscopic bariatric surgery resulted in transection of the abdominal catheter with a delayed presentation of recurrent symptoms and an abdominal cerebrospinal fluid collection in a patient with idiopathic intracranial hypertension. We discuss how this could be avoided and its management.

Impact of the Increased Use of Preoperative Imaging and Laparoscopy on Appendicectomy Outcomes.

The diagnosis of appendicitis is based on clinical picture. The aim of this retrospective study was to analyse variation of outcomes and impact of increasing use of radiological investigations and laparoscopy over a 5-year period. A retrospective audit of appendicectomies over the last 5 years (01 January 2007-31 December 2011) was conducted. The negative appendicectomy rate (NAR), perforation rate and complication rate were used as outcome endpoints. A statistical analysis was performed to evaluate the difference in outcomes with surgical approach and use of radiology. One thousand fifty-five appendicectomies were performed in this period. The NAR was 22.65 % (21 % for open and 28 % for laparoscopic) and perforation rate was 14 %. There was no statistically significant difference in NAR with the use of ultrasound (P 0.3814) but there was a significant reduction in NAR with the use of computed tomography (CT) (P <0.0001). Intra-abdominal abscess (2.3 %) and wound infection (1.4 %) were the common complications with the former being higher with laparoscopy and the latter with open appendicectomy. Over 5 years, there were no significant changes in appendicectomy outcomes. The impact of diagnostic imaging on NAR varies with age, gender and the use of CT. CT can significantly reduce the negative appendicectomy rate in equivocal presentations. Complication rates vary with surgical approach.

The pathophysiology of chronic graft failure in the cardiac transplant patient.

Following cardiac transplantation, many patients develop chronic deterioration of graft function, which may lead to a clinical syndrome similar to native chronic heart failure (CHF). This condition of chronic cardiac graft failure (CGF) may also share pathophysiological processes comparable with that of CHF. However, the unique environment following cardiac transplantation may also contribute with a variety of unique mechanisms, deserved of special attention. This review article discusses the complex pathophysiology of CGF after cardiac transplantation, an important yet neglected condition of transplant medicine.

Co-morbid medical and psychiatric illness and substance abuse in HCV-infected and uninfected veterans.

Comorbidities may affect the decision to treat chronic hepatitis C virus (HCV) infection. We undertook this study to determine the prevalence of these conditions in the HCV-infected persons compared with HCV-uninfected controls. Demographic and comorbidity data were retrieved for HCV-infected and -uninfected subjects from the VA National Patient Care Database using ICD-9 codes. Logistic regression was used to determine the odds of comorbid conditions in the HCV-infected subjects. HCV-uninfected controls were identified matched on age, race/ethnicity and sex. We identified 126 926 HCV-infected subjects and 126 926 controls. The HCV-infected subjects had a higher prevalence of diabetes, anaemia, hypertension, chronic obstructive pulmonary disease (COPD)/asthma, cirrhosis, hepatitis B and cancer, but had a lower prevalence of coronary artery disease and stroke. The prevalence of all psychiatric comorbidities and substance abuse was higher in the HCV-infected subjects. In the HCV-infected persons, the odds of being diagnosed with congestive heart failure, diabetes, anaemia, hypertension, COPD/asthma, cirrhosis, hepatitis B and cancer were higher, but lower for coronary artery disease and stroke. After adjusting for alcohol and drug abuse and dependence, the odds of psychiatric illness were not higher in the HCV-infected persons. The prevalence and patterns of comorbidities in HCV-infected veterans are different from those in HCV-uninfected controls. The association between HCV and psychiatric diagnoses is at least partly attributable to alcohol and drug abuse and dependence. These factors should be taken into account when evaluating patients for treatment and designing new intervention strategies.

Offspring sex ratio in smokers.

OBJECTIVE: To assess the ratio of male to female gender in the offspring of smokers and non-smokers. METHOD: The tool used for the survey was a questionnaire. Four hundred subjects were analyzed and were divided into three age groups. RESULTS: Out of 400 subjects 56.5% were smokers and 43.5% were nonsmokers. Overall offspring sex ratio in nonsmokers was 1.53 and 0.61 in smokers. CONCLUSION: The smoking might be a contributing factor to a lower male to female sex ratio of offspring along with Estrogenic pollutants which are everywhere in the environment contaminating food, drinking water and air.

Reduced red-cell folate in mania.

Forty-five hospitalised patients with DSM-III-R diagnosis of mania, were found to have a mean red-cell folate level of 193 nmol/l, as compared to 896 nmol/l in the control group (P < 0.00001). Assessment of serum folate in both groups showed no significant differences in the levels. Furthermore the manic patients and the controls were matched by the socio-economic status. This indicated that the reduced red-cell folate in mania is associated with the illness and not due to reduced absorption or dietary deficiency of folate. Considering previous studies that showed reduced red-cell folate in depression, our findings suggest that reduced red-cell folate occurred in both phases of bipolar disorders.

Belief in supernatural causes of mental illness among Malay patients: impact on treatment.

The concept of aetiology of mental illness in 134 Malay patients was investigated by means of a 20-item checklist. About 53% of the patients attributed their illnesses to supernatural agents. Witchcraft and possession by evil spirits were regarded as common causes of illness. The number of patients who believed in supernatural causes of their mental illness was significantly higher among those who had consulted bomohs (Malay traditional healers) than among those who had not consulted them. The belief that mental illness is caused by supernatural agents is firmly held by bomohs, who reinforce this notion in those who seek their advice. Belief in supernatural causes of mental illness was not significantly associated with age, gender, level of education or occupation of the patients. Patients who believed in supernatural causes of mental illness were also found to show poor drug compliance, and the number of such patients at 6 months follow-up was significantly lower than the corresponding figure for those who did not believe in supernatural causes. The importance of understanding the patients' cultural background when treating psychiatric patients is highlighted.