Incisional pubic hernia: treatment of a case with congenital malformation of the pelvis.

Parapubic hernia is a rare entity, the aetiology of which is usually associated with pelvic surgery, traumatisms and bone malformations. Treatment is difficult because the defect is usually limited by altered fibrotic anatomical planes. We present a case of incisional pubic hernia in a patient with congenital bladder exstrophy and multiple surgeries for pelvic reconstruction, who was treated using a plasty combined with a double intra-abdominal/supra-aponeurotic mesh. The therapeutic possibilities are described for the laparoscopic and open approaches in the management of these complex hernias.

Open vs laparoscopic repair of secondary lumbar hernias: a prospective nonrandomized study.

BACKGROUND: Lumbar hernias are uncommon defects of the posterior abdominal wall. Surgical treatment is still controversial in these cases. The aim of this study was to compare outcome and costs of the laparoscopic approach vs the open method. METHODS: We conducted a prospective nonrandomized study of 16 patients who underwent operation for secondary lumbar hernia between January 1997 and January 2003. Nine were treated via the laparoscopic approach and seven with an open technique. The following variables were analyzed: clinical data, hospital data (operating time and length of stay), patient comfort (consumption of analgesics and time to return to normal activities), and recurrences. Hospital costs were also analyzed. RESULTS: There were no differences between the two groups in terms of age and history, although the defects of the patients in the laparoscopic group were smaller. Mean operating time, postoperative morbidity, mean hospital stay, consumption of analgesics, and time to return to normal activities were significantly lower in the laparoscopic group (p < 0. 01). No were there any statistical differences between the two types of surgical procedure in terms of hospital costs. However, the final cost did show differences when expenses for readmissions and recurrences were taken into account (p < 0.01). CONCLUSION: The laparoscopic approach to secondary lumbar hernia repair is more efficient and more profitable than the traditional open technique.

Indisputable double paternity in dizygous twins.

OBJECTIVE: To report a case of heteropaternal superfecundation. DESIGN: Case report. SETTING: University paternity laboratory. PATIENT(S): Father, mother, and a set of twins. INTERVENTION(S): Blood typing conventional markers, as well as polymerase chain reaction loci and restriction fragment length polymorphism loci of DNA. MAIN OUTCOME MEASURE(S): Heteropaternal superfecundation was demonstrated after paternity investigation. RESULT(S): The probability of paternity for twin 1 was 99.9999998%, whereas that for twin 2 was excluded on the basis of the following tests: Fy, Pi, human leukocyte antigen (HLA)-DQA1, D1S80, D17S5, HBGG, D5S110, D2S44, and D10S28. CONCLUSION(S): Dizygous twins can have different biologic fathers, as demonstrated in this case. According to published data, the frequency of twins with different fathers is probably underestimated, at least in small selected populations such as those of paternity suits.

Treatment of spigelian hernia using totally extraperitoneal laparoscopy ambulatory surgery.

Spigelian hernia is an uncommon hernia of the abdominal wall. Diagnosis and treatment are controversial because it is frequently an emergency pathology. We report two patients with preoperative diagnosis and treatment using totally extraperitoneal laparoscopy under regional anesthesia in a day surgery department.

Post mortem markers of chronic alcoholism.

We compared the post mortem diagnostic value of gamma-glutamyltransferase (GGT), carbohydrate-deficient transferrin (CDT), alcoholic liver disease (ALD), blood alcohol concentration (BAC), the presence of multiple bruises and poor hygiene of the feet as markers of chronic alcoholism (heavy continuous drinking) in 32 alcoholics with 32 age-sex matched controls drawn from a forensic autopsy population. Alcoholics and controls were selected on the basis of positive and negative medical history but controls were excluded if BAC exceeded 70 mg%. Femoral venous blood, urine and vitreous humour alcohol concentrations were determined by headspace gas chromatography (GC). BAC was positive in 19 alcoholics (mean 234 mg%, range 2-570 mg%) and six controls (mean 32 mg%, range 2-52 mg%). Serum GGT was measured by a kinetic photometric method, and CDT by both isoelectric focusing/laser densitometry and by a commercial radioimmunoassay kit (CDTect). Features of alcoholic liver disease were graded histologically using two weighted scoring systems. Eleven alcoholics tested positive for GGT, CDTq and ALD, nine were positive for two tests, five for one test and three were negative for all three tests. No controls were positive for all three tests but six were positive for two tests and nine for only one test; 17 were negative for all three tests. Using the normal clinical cut-off values GGT, CDTq and CDTect gave poor specificity which was improved at moderate cost to sensitivity by raising cut off values for each test. Comparison of receiver operating characteristic curves, likelihood ratios and post-test odds showed CDT to be the best individual test, followed by ALD and GGT. Quantitation of CDT by IEF/laser densitometry performed slightly better than MAEC/RIA by CDTect. CDT shows considerable promise as a post mortem marker of chronic alcoholism.

Postmortem stability of some markers of intra-vital wounds.

We have studied the diagnostic value of several markers of the intra-vital nature of wounds - cathepsin D (EC 3.4.23.5) and ions (Ca, Mg, Cu, Zn and Fe) - after the influence of putrefaction. For this purpose, we have inflicted vital wounds to six pigs, which were killed 20 min later. Ten minutes after death, wounds were excised with 5-6 cm of skin around the incision and maintained at three different temperatures (4, 18 and 28.5 +/- 13.4 degrees C). After varying periods of postmortem interval from 0 to 48 h, aliquots of each wound were taken and analyzed with atomic absorption spectrophotometry for ions and with UV-spectrophotometry for cathepsin D. Our results demonstrate that ions conserve their diagnostic ability to differentiate vital from postmortem wounds after the influence of putrefaction. Nevertheless, cathepsin D does not show this ability in these experimental conditions.

Diagnostic ability of D-dimer in the establishment of the vitality of wounds.

The potential of skin measurements of D-dimer (DD), a specific derivative of crosslinked fibrin, for the diagnosis of the vital origin of wounds was investigated in 67 human vital skin wounds and homolateral control pieces of skin from 53 autopsies performed at the Institute of Legal Medicine of Coimbra (Portugal) during 1992. Our results demonstrate that DD levels for the incised vital skin wounds (n = 50) were much higher on average than their controls (P < 0.01) which were actually incised injuries produced postmortem at the autopsy. We did not find any statistical difference in average DD levels among the remaining injuries (seven abrasions and ten contusions) in comparison to their respective controls. DD may be used, with certain limitations, as a marker of the vitality of incised wounds. The authors believe this is the first time this marker has been applied in forensic pathology. It is an example of an easy and quick application technique, with the added advantage of low cost.

Spigelian hernia: bibliographical study and presentation of a series of 28 patients.

Spigelian hernias are rare defects of the abdominal wall. Our aim is to analyse the bibliography and present a series of 28 patients. A Medline bibliographical study was performed between 1970 and 2000 with analysis of the number of cases, series, ratio of cases to year and type of journal. We also present a personal study and analyse epidemiological, diagnostic, and treatment factors. There are 159 articles, 479 cases, and 19 series of more than five patients published in 85 journals (42.3% medical). Our diagnosis was preoperative in 75%, and programmed surgery was 3.6 times more common than emergency surgery. We found a significant relationship between hospital stay and type of surgery (P < 0.02) and surgical technique used (P < 0.001). We found that spigelian hernias have a multidisciplinary interest; they are given almost equal treatment in medical and surgical journals; preoperative diagnosis can be established in 75% of cases; and the best results are offered by the extraperitoneal laparoscopic approach.

Laparoscopic repair of ventral and incisional hernias using a new composite mesh (Parietex): initial experience.

Ventral hernia repair is still a difficult problem for surgeons because of the high recurrence rate and possible postoperative complications. Repairs with a prosthesis have reduced the recurrence rate, but the anterior approach still involves high morbidity and a long hospital stay. The purpose of this article was to evaluate the results of laparoscopic surgery on ventral hernias using a new double-layer mesh in an intra-abdominal position. A retrospective analysis was performed of the first 20 patients undergoing laparoscopic surgery for ventral hernia (75% incisional and 25% umbilical) with intra-abdominal prosthetic repair using a double-layer mesh consisting of three-dimensional multifiber polyester on one side and a hydrophilic resorbable nonstick collagen membrane on the other (Parietex composite, Sofradim, Villefranche sur Saone, France). The procedure was done on an outpatient basis in 85% of the cases. There was no morbidity or mortality. During a mean follow-up period of 10 months we found no infections, rejections, fistulas, recurrences, or alterations in bowel function. Laparoscopic repair of ventral hernias is an efficient alternative to open repair, with a low morbidity rate and short hospital stay. The double-layer mesh is safe for intra-abdominal use.

Study of coercive measures in prisons and secure psychiatric hospitals: the views of inmates and caregivers.

AIM: The aim of the study was to ascertain the opinions of both inmates and staff of prison establishments about the use of coercive measures justified for clinical reasons for people with mental health problems and about the need to create protocols to regulate the application of these measures. METHOD: These opinions were gathered in a Qualitative Study with Focus Groups (prison inmates and prison staff) from the Granada Penitentiary Centre and the Alicante Penitentiary Psychiatric Hospital, both in Spain. RESULTS: The results showed that forced medication is the most commonly used coercive measure in these institutions. The inmates did not understand and rejected the use of this measure, above all because they were poorly informed about their illness and the medication required to treat it. The staff however defended the benefits of psychiatric medicine, even when administered without the patient's consent. CONCLUSIONS: Both inmates and staff agreed that it would be useful to have a protocol regulating the use of coercive measures. The study has also identified a number of important factors that could help to reduce the need for coercive measures or make their use unnecessary.

Variables associated with the use of coercive measures on psychiatric patients in Spanish penitentiary centers.

We have studied the use of coercive medical measures (forced medication, isolation, and mechanical restraint) in mentally ill inmates within two secure psychiatric hospitals (SPH) and three regular prisons (RP) in Spain. Variables related to adopted coercive measures were analyzed, such as type of measure, causes of indication, opinion of patient inmate, opinion of medical staff, and more frequent morbidity. A total of 209 patients (108 from SPH and 101 from RP) were studied. Isolation (41.35%) was the most frequent coercive measure, followed by mechanical restraint (33.17%) and forced medication (25.48%). The type of center has some influence; specifically in RP there is less risk of isolation and restraint than in SPH. Not having had any previous imprisonment reduces isolation and restraint risk while increases the risk of forced medication, as well as previous admissions to psychiatric inpatient units does. Finally, the fact of having lived with a partner before imprisonment reduces the risk of forced medication and communication with the family decreases the risk of isolation. Patients subjected to a coercive measure exhibited a pronounced psychopathology and most of them had been subjected to such measures on previous occasions. The mere fact of external assessment of compliance with human rights slows down the incidence of coercive measures.

[Ethical questions related to nutrition and hidration: basic aspects]. / Problemas éticos en relación a la nutrición y a la hidratación: aspectos básicos.

Conditions that pose ethical problems related to nutrition and hydration are very common nowdays, particularly within Hospitals among terminally ill patients and other patients who require nutrition and hydration. In this article we intend to analyze some circumstances, according to widely accepted ethical values, in order to outline a clear action model to help clinicians in making such difficult decisions. The problematic situations analyzed include: should hydration and nutrition be considered basic care or therapeutic measures?, and the ethical aspects of enteral versus parenteral nutrition.

Estudio de las medidas coercitivas en centros penitenciarios y hospitales psiquiátricos penitenciarios: opiniones de internos y profesionales / Study of coercive measures in prisons and secure psychiatric hospitals: the views of inmates and caregivers

Objetivos: El estudio ha pretendido conocer por un lado la opinión de personas internas en establecimientos penitenciarios, y por otro lado, la opinión de los funcionarios de estas instituciones sobre el uso de medidas coercitivas por indicación clínica en personas con problemas de salud mental y sobre la necesidad de creación de protocolos de actuación para la aplicación de estas medidas. Metodología: Estudio cualitativo que ha utilizado la técnica de Grupos Focales llevados a cabo con internos y funcionarios del Centro Penitenciario de Granada y del Hospital Psiquiátrico Penitenciario de Alicante, España. Resultados: Los resultados demuestran que la medida coercitiva más utilizada en estas instituciones es la medicación forzosa. Las personas internas no comprenden y rechazan la utilización de esta medida, sobre todo porque están mal informadas sobre su enfermedad y su tratamiento farmacológico, pero los profesionales abogan por los beneficios de la medicación psiquiátrica, aunque sea de forma involuntaria. Conclusiones: Tanto usuarios como profesionales están de acuerdo con la utilidad de la existencia de un protocolo de actuación para la aplicación de medidas coercitivas. Este estudio ha hallado importantes factores que podrían ayudar a disminuir la utilización de medidas coercitivas o incluso evitarlas (AU)

Aim: The aim of the study was to ascertain the opinions of both inmates and staff of prison establishments about the use of coercive measures justified for clinical reasons for people with mental health problems and about the need to create protocols to regulate the application of these measures. Method: These opinions were gathered in a Qualitative Study with Focus Groups (prison inmates and prison staff) from the Granada Penitentiary Centre and the Alicante Penitentiary Psychiatric Hospital, both in Spain. Results: The results showed that forced medication is the most commonly used coercive measure in these institutions. The inmates did not understand and rejected the use of this measure, above all because they were poorly informed about their illness and the medication required to treat it. The staff however defended the benefits of psychiatric medicine, even when administered without the patient's consent. Conclusions: Both inmates and staff agreed that it would be useful to have a protocol regulating the use of coercive measures. The study has also identified a number of important factors that could help to reduce the need for coercive measures or make their use unnecessary (AU)

Problemas éticos en relación a la nutrición y a la hidratación: aspectos básicos / Ethical questions related to nutrition and hidration: basic aspects

Las situaciones que plantean problemas éticos en relación con la nutrición y la hidratación son muy frecuentes hoy día, principalmente a nivel hospitalario tanto en pacientes terminales como en otro tipo de pacientes que precisen de hidronutrición. En este artículo se pretende analizar las sencillas en sus fundamentos, a la luz de valores éticos ampliamente aceptados, para intentar enunciar un modo de actuación claro que ayude en su resolución a los clínicos que han de tomar estas difíciles decisiones. Las situaciones problema analizadas incluyen, entre otras, si la hidratación y la nutrición deben considerarse medidas terapéuticas o cuidados básicos, y si presentan iguales aspectos éticos la nutrición enteral y la parenteral (AU)

Conditions that pose ethical problems related to nutrition and hydration are very common now days, particularly within Hospitals among terminally ill patients and other patients who require nutrition and hydration. In this article we intend to analyze some circumstances, according to widely accepted ethical values, in order to outline a clear action model to help clinicians in making such difficult decisions. The problematic situations analyzed include: should hydration and nutrition be considered basic care or therapeutic measures?, and the ethical aspects of enteral versus parenteral nutrition (AU)

Advances in the diagnosis of wound vitality: a review.

The diagnosis of the vital origin of wounds in many cases remains an unsolved problem for the forensic pathologist. Practical experience enables the expert to diagnose the vital or postmortem origin of wounds on the basis of macroscopic examination. In some cases, optic microscopy is used to confirm the diagnosis. In many other cases, additional more sensitive and specific markers of vitality are required. In the past 50 years, comprehensive research on this topic has resulted in a better understanding of the acute inflammatory reaction. The development and application of sensitive and specific markers through research in the areas of histochemistry, enzymology, and biochemistry has provided a partial solution to the problems involved in wound vitality diagnosis. A review of this challenging area of forensic pathology, including an explanation of these methods and markers, is presented in this paper.

Comparison of the CAGE questionnaire versus some biochemical markers in the diagnosis of alcoholism.

We have compared the individual sensitivity, specificity and predictive value of the CAGE questionnaire, plasma levels of ethanol and acetate, mean corpuscular volume (MCV), gamma glutamyl transferase (GGT), and glycosylated haemoglobin (Hb A1c) in a group of 50 healthy non-alcoholic controls and 31 patients with non-alcoholic liver disease (Group I), and in a second group of 40 alcoholic patients (Group II). Taken individually, the CAGE questionnaire was the most efficient (96% sensitive and 92% specific), followed by plasma levels of acetate (74% sensitive and 85% specific), MCV (64% sensitive and 91% specific) and GGT (72% sensitive and 80% specific). Hb A1c did not show any statistically significant difference between alcoholics and non-alcoholics and thus is of no use as a screening test for the diagnosis of alcoholism. Furthermore, we attempted to design a discrimination procedure to separate alcoholics from controls and patients with non-alcoholic hepatic diseases using a combination of the most promising tests. The most powerful discrimination model was constructed with the four questions of the CAGE questionnaire. The percentage of correct classifications using this model was 99% from Group I (specificity) and 90% from Group II (sensitivity). The CAGE questionnaire was itself so useful as a discriminant in our sample that no increased diagnostic efficacy was noticed on adding any of the other tests. Using objective variables (MCV, acetate and GGT) as discriminants, we could correctly classify 96% of subjects from Group I (specificity) and only 64% from Group II (sensitivity).

[Acetate metabolism: experimental study]. / Metabolismo del acetato: estudio experimental.

Plasma levels of ethanol and acetate, which is the end product of hepatic ethanol oxidation, have been studied in 60 rats. Animals were divided into two groups: 1) Control rats, and 2) Alcohol-treated rats. Ethanol and acetate were measured without any previous handling (endogenous levels) and after intraperitoneal injection of a single dose of ethanol. Blood specimens were taken at 30, 60, 120, 180 and 240 minutes after ethanol injection. Plasma levels of ethanol and acetate were performed by Head Space Gas Chromatography. Alcohol-treated animals had higher plasma acetate levels than control ones. There were statistically significant differences for acetate between both groups of rats at 0, 30, 120 and 180 minutes.

Cathepsin D as a vitality marker in human skin wounds.

This paper shows the results obtained by studying the lysosomal enzyme Cathepsin D as a potential marker for the vitality of wounds in human specimens. We have analyzed 53 samples using enzymological and histological techniques. Our results show the ability of Cathepsin D to establish the vital origin of wounds inflicted 5 minutes or less before death, where the specific activity of cathepsin D reached 0.055 units at the wound edge and 0.01 units in their respective controls (P < 0.001). As previously demonstrated in an experimental series, Cathepsin D seems to be a very useful marker of high forensic interest in especially difficult cases. Further studies are in progress to check the influence of different factors such as drugs intake and clinical conditions on Cathepsin D activity.

Prostaglandin F2a (PGF2a): an inadequate marker of the vitality of wounds?

We have studied the viability of PGF2a as a vitality marker in skin wounds. Incised vital skin wounds and homolateral control pieces of skin were obtained from 20 autopsies performed at the Institute of Legal Medicine of Coimbra University (Portugal). We have also studied 10 fresh skin samples from the Department of Dermatology of the University Hospital (Granada). Our results show that PGF2a is not suitable for the diagnosis of the vitality of wounds because of its irregular behaviour.