Economic costs of using tailwater recovery systems for maintaining water quality and irrigation.

Best management practices (BMPs) are conservation efforts implemented to address environmental challenges associated with agricultural production. One such BMP, a tailwater recovery (TWR) system, has a dual purpose aimed at mitigating solids and nutrient losses from agricultural landscapes and creating an additional surface water source for irrigation. This study analyzes the costs of using five TWR systems to reduce solids, nutrients, and retain water. All systems were located in the Lower Mississippi Alluvial Valley and were used to irrigate crops including rice (Oryza sativa), corn (Zea mays), and soybeans (Glycine max). Costs to reduce solids and nutrients were calculated using annual payments and revenue losses due to lost tillable area from implementation of TWR systems. Similarly, cost to save and irrigate a mega-liter (ML) of water was determined as the annual payment for TWR systems, revenue losses and measured pumping cost. The range of mean total cost to reduce solids using TWR systems was $0 to $0.77 per kg; P was $0.61 to $3315.72 per kg; and N was $0.13 to $396.44 per kg. The range of mean total cost to retain water using TWR systems was $189.73 to $628.23 per ML, compared to a range of mean cost of groundwater of $13.99 to $36.17 per ML. Compared to other BMPs, TWR systems are one of the least expensive ways to reduce solid losses but remain an expensive way to reduce nutrient losses. The costs of using TWR systems to provide an additional irrigation water source range from less expensive than common conservation practices used to improve water use efficiency to more expensive and comparable to practices such as desalination. Therefore, TWR systems may be a prohibitively more expensive BMP to retain nutrients and water on some agricultural landscapes than other solutions.

The management of pressure sores by constant-tension approximation.

The management of pressure sores in medically compromised patients is problematic as they are seldom candidates for major surgical procedures. We treated 52 pressure sores in 49 patients (including three bilateral lesions) by constant-tension approximation. The lesions were distributed as follows: 21 sacral, two ischial, 13 trochanteric and 16 posterior heel. The average age was 75 years and there were 22 males and 27 females. All patients had significant co-morbid conditions that, except for one wheelchair-bound person,confined them to bed. Nine patients were insensate; in two comatose cases this state was temporary. The management regime consisted of excision of the pressure sore and expansion of the skin and subcutaneous tissue using devices that, by means of continuous low-grade tension, approximated the wound edges, together with rigorous wound toilet and the judicious use of sutures. In total, 38 pressure sores healed primarily without recurrence, including three wounds that partially reopened and healed; 11 of these patients died, with healed wounds, at varying times between 2 and 48 months after treatment. Nine patients whose lesions were closed died within a month of treatment, and five patients, three of whose lesions were completely closed and two partially closed, were lost to follow-up; their lesions were not regarded as healed. This minimally invasive technique used to close pressure sores in elderly patients with co-morbid conditions has a satisfactory success rate.

Management of the abdominal wall defect in the prune belly syndrome by muscle transposition: an 18-year follow-up.

Prune belly syndrome (PBS), an uncommon anomaly, consists of genito-urinary abnormalities and a partial or complete absence of abdominal wall musculature. Although the patient's genito-urinary problems are addressed, the attention currently directed toward the abdominal wall deficiency has been mostly aimed at improving the cosmetic appearance of patients and does little to replace the important functions of the musculature. These functions are the support of the viscera and their compression as well as the movement of the trunk. A case report with an 18-year follow-up is presented where thigh muscles were transposed to act as substitutes for the missing musculature. Although this presentation is based on a single case, it is intended to alert patients and physicians to a method of improving the lot of patients with PBS. In this patient, the result was very satisfactory. From being unable to move his trunk as a schoolboy before the surgical procedure, postoperatively he was able to participate in all school activities. As an adult, he is fully active and is a lead guitarist in a band. His excretory functions are normal and the scoliosis, present when first seen, has not progressed. It is suggested that consideration be given to the management of the abdominal wall deficiency in PBS by the transposition of muscle(s), because no alternative effective treatment directed to restoring absent muscle function appears to exist. Because the operative procedure is well tested and successful in adult patients who lose their abdominal wall musculature, the dissemination of this data appears to be necessary.

Transmetatarsal amputation of the toe: an analytic study of ischemic complications.

Transmetatarsal amputations of the toes are very common procedures, particularly involving patients with diabetes mellitus and peripheral vascular disease. A complication of these operations is the onset of gangrene of an adjoining toe, which is usually ascribed to the underlying disease. It is suggested that another explanation may be responsible for this occurrence, namely, a combination of the variability of the bifurcation of the dorsal metatarsal arteries and the operative technique. The former is either not described or has different levels in different texts. The operation in nearly all texts is a classic racquet incision, without mention of the width of the racket. The combination of an incision widely diverging from the handle of the racket is in danger of severing the dorsal metatarsal artery, its bifurcation, or the digital branch to the adjacent toe. A patient with a good blood supply may be able to salvage the situation by way of the plantar vessels, but when the vascular status is parlous, which is the case in many amputations, the adjacent digit is at considerable risk. Clinical, radiological, and anatomic evidence is presented to support this contention. Based on the above, a safer operative technique is suggested to avoid possible complications.

Historical aspects of laparoscopic hernia repair.

The history of the surgical treatment of groin hernias is reviewed with emphasis on the events leading to the introduction and development of the management of these hernias by a laparoscopic approach. The reasons for a shift from an inguinal to an abdominal approach are presented, and the early results of the latter are considered together with the possible advantages and disadvantages. Both methods rely on the use of small or large pieces of mesh that replace the previous bulwark of hernia repairs, namely the rearrangement of tissue layers. Currently, the challenge of the laparoscopic approach is being met by those espousing the inguinal approach.

Anterior compartment syndrome of the leg, a clinical-anatomical perspective: a case report.

Decompression of the fascial compartments of the leg is a fairly common procedure that is carried out therapeutically and prophylactically. It is submitted that the guidance offered by the average surgical texts are unclear and imprecise. A junior surgeon would be led to believe that all four compartments require decompression, whereas it is distinctly uncommon for compartments other than the anterior to suffer compression. Anatomic reasons are offered for this predilection. The incisions advised often extend the full length of the leg; not only is this unnecessary but considerable morbidity may result. A case report is presented which underlines the result of an ill placed incision and unfamiliarity with the detailed anatomy of the anterolateral leg muscles. An incision is suggested which is very unlikely to lead to failure to decompress and which should avoid complications.

The use of external tissue expansion in the management of wounds and ulcers.

A series of 43 wounds and ulcers in 37 patients were treated with the use of constant-tension approximation devices for periods ranging from 7 to 28 days. The etiologies of the lesions were diabetes; posttraumatic, including iatrogenic causes; neuropathic; pressure sores; and collagen disease. The approximation device is described and the technique of applying the device is detailed. The results are presented in tabulated form. The contraindications to the use of this methodology are discussed and the importance of patient selectivity is stressed. Evidence is presented to indicate that constant-tension approximation increases the healing rate as well as provides partial or complete full-thickness coverage, depending on the size of the wound. Such coverage reduces the recurrence rate and is usually only achieved by an operative approach, which is thus avoided. The socioeconomic advantages of this approach are mentioned.

Fecal diversion in management of large infected perianal lesions.

PURPOSE: The purpose of this manuscript is to present a method of temporary fecal diversion. METHODS: A tube was sutured into the anorectum of eight patients with large infected and/or necrotic perianal lesions that were being soiled and infected by the fecal stream. Five patients were diabetic, two had sacral pressure sores, and one suffered from hidradenitis suppurativa. RESULTS: Tubes remained in place from 10 to 14 days, during which time the infective condition was brought under control. There were no complications. CONCLUSIONS: The difficulties and disadvantages of current medical and surgical methods of controlling the fecal stream under these conditions are discussed, and the method presented is suggested as a viable and simple alternative.

Wound management by constant tension approximation.

An ideal result in wound healing is expedited closure with full-thickness skin, as opposed to thin, fragile epithelium prone to future breakdown. To help achieve accelerated healing by full thickness skin, a device has been designed that applies constant tension traction to the wound margins. The device acts by both approximating the wound and by encouraging tissue and skin generation through stimulating angiogenesis and epithelial proliferation. This study includes 31 patients with 36 wounds of varying etiologies treated over 28 days. The wounds were inspected every 3 to 5 days at which time the dressings were changed and new devices applied, as needed. All but five of the wounds healed completely with full thickness skin within the study period (average: 15 days; range: 7-28 days). The longest healing times occurred in the patients with pressure ulcers. Using a formula for determining healing time based on excisional wound dimension, the expected healing time of a 3cm wide foot ulcer with uninterrupted progress is 41 days. The time for such a wound to heal in this study was 21 days. The approximating device accelerated wound healing by full thickness skin for the wounds included in this study. Other considerations when using this method include cost, patient compliance and indications/contraindications.

A clinical trial of wound closure by constant tension approximation.

BACKGROUND: Wounds that heal slowly may pass through a subacute phase and proceed to reach a chronic situation. The latter may heal slowly, if at all. These wounds often heal by secondary intention with a single layer of epithelium that has a tendency to break down. Methods that expedite healing by full-thickness skin usually involve operative procedures. A nonoperative method of achieving coverage of tardy wounds with full-thickness skin, partial or complete depending on the wound, would be valuable. PATIENTS AND METHODS: A device has been designed that approximates the wound margins by applying constant low-grade tension over a period of days or weeks. One or more devices have been applied to the wounds of 25 patients to date. RESULTS: Healing has been obtained in those patients (20) where the devices were used optimally. In 5 patients, optimal use was not possible, mostly for socioeconomic reasons; the latter included noncompliance, insurance problems, economic difficulties, and personal considerations. In these 5 cases, healing was obtained in the 3 that were available for follow-up, full-thickness skin coverage being estimated by grid photography to be in the 80% to 90% range. One patient was lost to follow-up after the wound was 95% covered by full-thickness skin. One patient whose wound reduced in size declined further treatment after 12 days of treatment. CONCLUSIONS: It appears that when constant-tension, low-grade force is applied to subacute and chronic wounds, healing is accelerated and, depending on the wound, a considerable number of ulcers can be closed by full-thickness skin.

Basic surgical training. 4: American and British scenes compared.

This report outlines the surgical residency program in the United States, with special reference to examinations in anatomy. During each of the 5-6 years of the program and in the first part of the surgical board examination, there are written (MCQ) examinations. The final board examination is oral. The anatomic content of each of these examinations is very small. This situation compares unfavorably with that in the UK in the 1940s and 1950s, when the colleges of surgeons demanded a high standard of anatomic knowledge, so that holders of the Fellowship (FRCS) displayed confidence in their diagnostic skills and in the operating room. In the United States today, surgical residents and attending surgeons (British = consultants) alike seldom have a sound overall knowledge of anatomy. They may become proficient in localized regions, but when drawn out of their area of expertise, their anatomic knowledge may be less than expert. It is disappointing to learn that the surgical colleges in the UK and Ireland are making changes in their Basic Surgical Training program that will inevitably result in a decline from their former high standards.

Concurrent right atrial myxoma and malignant lymphoma.

Atrial myxomas are the most common primary tumor of the heart. We report an unusual case where an incidentally found right atrial myxoma was associated with a malignant lymphoma. Surgical management of the concurrent problems is discussed as well as a review of pertinent literature and efficacy of diagnostic modalities.

Of fat and fascia: clinical conundrum corner.

A case report involving a 76-year-old male is presented. The signs and symptoms represent a difficult diagnostic problem. The physical signs are dependent on a knowledge of the distribution of fat and fascia in the region involved. The importance of this distribution, both physiologic and pathologic, is the subject of a brief commentary.

Protection of intestinal anastomoses by biodegradable intraluminal bypass tubes under the condition of general peritonitis: an experimental study on the CLP model in rats.

The purpose of this experimental study was to affirm the protective effect of biodegradable tubes for the intraluminal bypass procedure under the adverse condition of general peritonitis. General peritonitis was induced by means of the cecal ligation and puncture (CLP) model in the rat. The leakage rate in the control group (n = 20) without anastomotic protection was 70 percent (14/20). In three therapeutic groups, each consisting of 20 animals, the intestinal anastomoses were protected by an intraluminal bypass tube of different biodegradable biomaterials (collagen-II, BCL-002, and BCL-004). The best results were noted in the collagen-II and BCL-002 groups, where the leakage rates could be reduced to 10 percent. These highly significant results (P = 0.0001) prove the feasibility of biodegradable biomaterials for the intraluminal bypass procedure in the rat, even in cases with underlying peritonitis.

Management of groin hernias by laparoscopy.

The surgical treatment of groin hernias continues to undergo technical modifications. The introduction of minimally invasive surgery had added a possible new dimension, replacing an inguinal approach by laparoscopy. Conceived some 15 years ago, the thesis was subjected to a clinical trial where coincidental abdominal hernial openings were closed at laparotomy. This study was followed by an experimental study at which time the openings were closed laparoscopically. The satisfactory results led to the development of a stapling instrument that could be passed through a cannula at laparoscopy and used to close the abdominal hernial opening. The clinical trial of treating hernias by laparoscopy was originally directed to the management of indirect inguinal hernias, but its use has since been expanded to include treatment of direct, femoral, obturator, incarcerated, recurrent, and bilateral hernias. The laparoscopic anatomy of the inguinal hernia, different from that seen by an inguinal approach, is briefly reviewed. The details of the operative technique are presented, as are the bases of other laparoscopic techniques that have evolved. Thirty-one hernial orifices have been closed and followed over 18 months. The results appear to be satisfactory in 27 instances. There were early technical failures in 2: One patient developed a recurrence after 5 months, later shown to be due to a sliding hernia; and symptoms of meralgia paresthetica of indeterminate origin appeared in one case. The advantages over the traditional approach are described; the disadvantages of the laparoscopic approach are those of laparoscopy itself and the absence of a long-term follow-up.

Laparoscopic sigmoid colostomy for perianal Crohn's disease.

Fecal stream diversion is not an uncommonly used procedure in the treatment of symptomatic Crohn's disease of the rectum. We present a case report of a patient with documented Crohn's proctitis with multiple rectovaginal and perianal fistulas; an end sigmoid colostomy was performed as part of the management of her disease.