Peritoneal flap technique for abdominal wall expansion in the management of complex ventral hernias: a multicentre study from India.

INTRODUCTION: Large abdominal wall hernias often require techniques for wall expansion to improve surgical outcomes. The peritoneal flap hernioplasty (PF) is one such technique that utilizes the hernia sac to reconstruct the abdominal wall, however, with limited published data. It is a modification of the Rives-Stoppa mesh repair where a part of the bisected hernia sac is utilized to reconstruct the anterior fascia and the other part for the posterior fascia. We present a collated retrospective analysis of the outcomes from three centers performing PF with or without transverse abdominis release (TAR) in patients with complex ventral hernias. METHODS: The PF was performed in patients with incisional hernias, both midline and lateral. The primary outcome measured was hernia recurrence. The secondary outcomes were to evaluate pain, surgical site infection, seroma, hematoma, wound dehiscence, pseudo-recurrence, Clavien-Dindo score for complications, and the patient's reported quality of life. The quality of life was assessed by oral questionnaires in the follow-up period. RESULTS: We analyzed 63 patients (38 female, 25 male) with a mean width of hernia defect of 11 cm SD 4. Based on the European Hernia Society (EHS) classification 42 patients were W3 and 21 were W2 hernias. Fifty patients had a midline hernia, while the rest of the patients included transverse, subcostal, and rooftop incision hernias. The classical peritoneal flap procedure was done in 29 (46%) patients, while the peritoneal flap with TAR was done in 34 (54%) patients. Four patients had symptomatic seroma (6%), seven superficial surgical site infection (SSI) (11%), one deep SSI (1.5%), one skin necrosis (1.5%), and one anterior peritoneal flap necrosis (1.5%). No patient required postoperative ventilatory support. The mean pain score on day one was 3/10. There was no recurrence in the mean follow-up of 17 months (range 5 to 49 months). Overall, 58 of 63 (92%) patients reported being satisfied with their surgery. CONCLUSION: In our multicentre study, we found the PF technique with or without TAR for midline and non-midline ventral hernia leads to satisfactory outcomes in terms of low recurrence, low rate of complications, and a good quality of life in the medium to long term. It appears to be a useful technique in the surgeon's armamentarium to repair W2 and W3 hernias needing expansion of abdominal domain.

Delphi consensus statement for understanding and managing the subcostal hernia: subcostal hernias collaborative report (scholar study).

INTRODUCTION: Subcostal hernias are categorized as L1 based on the European Hernia Society (EHS) classification and frequently involve M1, M2, and L2 sites. These are common after hepatopancreatic and biliary surgeries. The literature on subcostal hernias mostly comprises of retrospective reviews of small heterogenous cohorts, unsurprisingly leading to no consensus or guidelines. Given the limited literature and lack of consensus or guidelines for dealing with these hernias, we planned for a Delphi consensus to aid in decision making to repair subcostal hernias. METHODS: We adopted a modified Delphi technique to establish consensus regarding the definition, characteristics, and surgical aspects of managing subcostal hernias (SCH). It was a four-phase Delphi study reflecting the widely accepted model, consisting of: 1. Creating a query. 2. Building an expert panel. 3. Executing the Delphi rounds. 4. Analysing, presenting, and reporting the Delphi results. More than 70% of agreement was defined as a consensus statement. RESULTS: The 22 experts who agreed to participate in this Delphi process for Subcostal Hernias (SCH) comprised 7 UK surgeons, 6 mainland European surgeons, 4 Indians, 3 from the USA, and 2 from Southeast Asia. This Delphi study on subcostal hernias achieved consensus on the following areas-use of mesh in elective cases; the retromuscular position with strong discouragement for onlay mesh; use of macroporous medium-weight polypropylene mesh; use of the subcostal incision over midline incision if there is no previous midline incision; TAR over ACST; defect closure where MAS is used; transverse suturing over vertical suturing for closure of circular defects; and use of peritoneal flap when necessary. CONCLUSION: This Delphi consensus defines subcostal hernias and gives insight into the consensus for incision, dissection plane, mesh placement, mesh type, and mesh fixation for these hernias.

Retrospective analysis of EMR database to assess the effectiveness of Saccharomyces boulardii CNCM I-745 in children with acute diarrhoea during routine clinical practice.

This study aimed to assess the efficacy of Saccharomyces boulardii, a yeast probiotic, in the management of acute diarrhoeal disorders in the paediatric population in outpatient settings. It was a multicentre retrospective analysis of medical records of children who were treated for acute diarrhoea by routine treatment (oral rehydration solution and zinc) with or without S. boulardii. Overall, 160 children presenting with acute diarrhoea at seven different outpatient paediatric settings were included in the study. Children were divided into two categories based on their treatment with S. boulardii (SB group) or without S. boulardii (Non-SB group). Baseline demographic, anthropometric and clinical variables were compared between the two groups. The median duration of diarrhoea post-treatment was significantly shorter in the S. boulardii group (3 days) than in the non-SB group (4 days). A significant reduction in the frequency of stools was observed post-treatment in the S. boulardii group (1.7 versus 2.5 in the non-SB group). There was a significant weight gain in the S. boulardii group post-treatment (300 g) in comparison with the non-SB group (mean loss of 400 g). This study established the positive role of S. boulardii in the management of acute diarrhoeal diseases in children. Moreover, the S. boulardii probiotic was seen to be effective in diarrhoeal diseases in children with dehydration.

Meiotic abnormalities affect genetic constitution and pollen viability in dicots from Indian cold deserts.

BACKGROUND: Meiotic abnormalities lead to morphological and genetic variations which caused not only to evolution but also intraspecific reproductive barriers. During present study of detailed meiotic course in dicotyledonous plants sampled from Indian cold deserts, various meiotic abnormalities have been detected. For this, the plant materials fixed in Carnoy's fixative and studied detailed meiotic course by standard squash method in 1% acetocarmine. RESULTS: Meiotic abnormalities have been presently detected in 71 species which include multiple associations in diploids (Achillea millefolium L.), multivalents and univalents in polyploids (4 species), cytomixis (40 species), chromosome stickiness (20 species), nonsynchronous disjunction of bivalents (32 species), interbivalent connections (15 species), synaptic mutants (2 species), syncyte meiocytes (2 species), abnormal spindles (7 species), and fusion of pollen grains (1 species), laggards and chromatin bridges, hypo-, hyperploid PMCs, monads, dyads, triads, tetrads with micronuclei and polyads. CONCLUSIONS: Consequently, variable sized apparently fertile pollen grains and considerable amount of sterile pollen grains are resulted as end products which lead to different genetic constitution (aneuploids and polyploids) and curtailed sexual reproductive success in these species.

A convenient way to do valgus osteotomy for neglected fracture neck of femur.

BACKGROUND: Neglected fracture of neck of femur in young adults is a major problem in developing countries. Existing treatment options varies from osteotomy to various graft techniques (muscle pedicle, vascularized and nonvascularized fibula etc.). There is paucity of literature regarding the use of double angle barrel plate and hip screw in such cases. We conducted a prospective longitudinal observational study with displaced, neglected fracture neck of femur in young adults and compared the results with literature. OBJECTIVES: The aim of this study was to determine feasibility and effectiveness of 120° double angle barrel plate and hip screw fixation in neglected fracture neck of femur. Effectiveness of fixed 30 degree closed wedge osteotomy in neglected fracture neck of femur. METHODS: Thirty cases of neglected (more than three weeks) femoral neck fracture (Pauwel II and III) of age 20-60 years were included in the study conducted at Postgraduate Institute Of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India in year 2004-06. Average age of the patient was 35.4 years (range, 22yrs-55yrs). In all cases internal fixation was done by 120° double angle barrel plate and hip Screw. At the end of follow-up, results were evaluated according to Askin Bryan Criteria and Harris-hip score. RESULTS: Union was achieved in 28 of 30 patients. Two patients that went into nonunion were later treated with hemireplacement arthroplasty. According to Askin Bryan Criteria at the end of study, 35% patients had excellent results, 50% patients had good results. Minimum follow-up in our study was 12 months and maximum was five years. CONCLUSION: This study validates the use of double angled screw plate configuration for successful outcome in patients with neglected fracture neck of femur. Valgus osteotomy is also technically easy operation in hands of average trauma surgeon with the use of a fixed angle plate and hip screw.

Chromosome number and secondary chromosomal associations in wild populations of Geranium pratense L. from the cold deserts of Lahaul-Spiti (India).

In this work we studied the meiotic chromosome number and details of secondary chromosomal associations recorded for the first time in Geranium pratense L. from the alpine environments in the cold deserts of Lahaul-Spiti (India). All the presently studied individuals of the species existed at 4x level (x = 14). The present chromosome count of n = 28 in the species adds a new cytotype to the already existing diploid chromosome count of 2n = 28 from the Eastern Himalayas and outside of India. Out of the six accessions scored presently four showed normal meiotic course. However, two accessions investigated from Mud, 3800 m and Koksar, 3140 m depicted abnormal meiotic course due to the presence of multivalents and univalents, and secondary associations of bivalents/chromosomes. The secondary chromosomal associations in the species existed among bivalents/chromosomes were noticed in the PMCs at prophase-1 (diakinesis) and persisted till the separation of sister chromatids at M-II. The variation in the number of bivalents/chromosomes involved in the secondary associations at M-I (2-8) and A-I/M-II (2-12) has also been recorded. The occurrence of such secondary associations of bivalents/chromosomes in G. pratense which existed at 4x level indicated the secondary polyploid nature of the species.

Impact of cytomixis on meiosis, pollen viability and pollen size in wild populations of Himalayan poppy (Meconopsis aculeata Royle).

We report the occurrence of cytomixis in wild populations of Himalayan poppy (Meconopsis aculeata Royle),which is considered to be an important and threatened medicinal plant growing in the high hills of the Himalayas. The impact of cytomixis on meiotic behaviour, reduced pollen viability and heterogeneous-sized pollen grains was also studied. Cytological studies in the seven wild populations from the high hills of Himachal Pradesh revealed that all the Himalayan populations exist uniformly at the tetraploid level (2n=56) on x=14. The phenomenon of chromatin transfer among the proximate pollen mother cells (PMCs) in six populations caused various meiotic abnormalities. Chromatin transfer also resulted in the formation of coenocytes, aneuploid, polyploid and anucleated PMCs. Among individuals that showed chromatin transfer, chromosome stickiness and interbivalent connections were frequently observed in some PMCs. The phenomenon of cytomixis in the species seems to be directly under genetic control; it affects the meiotic course considerably and results in reduced pollen viability.

Acute appendicitis: are we over diagnosing it?

INTRODUCTION: Appendicectomy is by far the commonest major emergency general surgical operation and laparoscopic appendicectomy is now becoming common. The question of whether a normal-looking appendix should be removed laparoscopically is more pertinent than ever before. PATIENTS AND METHODS: A retrospective study was undertaken to review the histopathology results and compare macroscopic with microscopic descriptions of all patients who underwent an appendicectomy, either by open surgery or laparoscopically, over a 1-year period from 1 September 2004 to 31 August 2005. RESULTS: A total of 199 appendicectomies were carried out in the year of which histopathology results for 190 could be retrieved. Of the 190 who had an appendicectomy, 110 (57.9%) were female and 80 (42.1%) were male. While appendicitis was confirmed histologically in 65 of 80 (81.2%) male patients, it could only be confirmed histologically in 57 of 110 (51.8%) female patients. However, in a large number of female patients in whom macroscopically normal appendices had been removed, other findings were noted including fibro-obliterative changes in 10, luminal inflammation in 6, serositis in 5, lymphoid hyperplasia in 3, feacoliths in 2, and pinworm in 1, making another abdominal pathology a possibility. CONCLUSIONS: The number of macroscopically normal appendices removed was much larger in female patients. However in 27 of 49 normal looking appendices in females, findings such as serositis, luminal inflammation, lymphoid hyperplasia, etc. were noted on histology, suggesting that another abdominal pathology may have been missed or the appendix may still have been the cause for pain. On the basis of these findings, we suggest that diagnostic laparoscopy should be performed at least in all female patients before an appendicectomy; if no other findings are noted on laparoscopy, it is likely to be worthwhile to remove the appendix.

Evaluation of a diclofenac transdermal patch for the attenuation of venous cannulation pain: a prospective, randomised, double-blind, placebo-controlled study.

Venous cannulation, although a minor procedure, is often painful. The present study was planned to evaluate the efficacy of a diclofenac transdermal patch placed over the venepuncture site in decreasing the pain of cannulation. Seventy-two adults undergoing elective surgery were included in this randomised, prospective, double-blind, placebo-controlled study. Patients were divided into three equal groups. The Control group had a placebo adhesive patch placed on the both the dorsum of hand and the buttock; the Diclofenac-Buttock group had a placebo patch placed on the dorsum of the hand and a diclofenac transdermal patch on the buttock; the Diclofenac-Hand group had a diclofenac transdermal patch placed on the dorsum of hand and a placebo patch on the buttock. The patches were applied 1 h before cannulation. An 18G cannula was used for all venous cannulations. Pain during cannulation was assessed on a non-graduated 10-cm visual analogue scale. Median [interquartile range] pain scores were 3.0 [2.0-4.0] in the Diclofenac-Hand group, 5.0 [4.3-7.8] in the Diclofenac-Buttock group and 6.5 [4.5-7.0] in the Control group, p < 0.05. The numbers needed to treat were six and two in the Diclofenac-Buttock and Diclofenac-Hand groups, respectively. The application of a diclofenac transdermal patch at the cannulation site appears to be effective in decreasing cannulation pain.

Comparison of efficacy of oxybutynin and tolterodine for prevention of catheter related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study.

BACKGROUND: Bladder discomfort related to intraoperative catheterization of urinary bladder is a distressing symptom and more so in patients awakening from anaesthesia. These symptoms are similar to symptoms of overactive bladder. Muscarinic receptor antagonists have been reported to be effective in the treatment of overactive bladder. This study was therefore undertaken to evaluate the efficacy of oxybutynin and tolterodine in preventing catheter related bladder discomfort. METHODS: Two hundred and thirty-four consecutive adult patients, ASA I and II, of either sex, undergoing elective percutaneous nephrolithotomy surgery requiring urinary bladder catheterization were randomized into three equal groups of 78 each. Group C (control) received placebo, Group O (oxybutynin) received oxybutynin 5 mg and Group T (tolterodine) received tolterodine 2 mg orally 1 h before surgery. After induction of anaesthesia patients were catheterized with a 16 Fr Foley's catheter and the balloon was inflated with 10 ml distilled water. The bladder discomfort was assessed at 0, 1, 2 and 6 h after patient's arrival in the post-anaesthesia care unit. Severity of bladder discomfort was graded as mild, moderate and severe. RESULTS: Incidence of bladder discomfort observed in the control group was higher, i.e. 58% (45/78), compared with oxybutynin and tolterodine groups where it was 35% (28/78) and 33% (26/78), respectively (P<0.05). Significant reduction in the severity of bladder discomfort was also observed after oxybutynin and tolterodine therapy compared with control (P<0.05). CONCLUSION: Pretreatment with either oxybutynin or tolterodine reduces the incidence and severity of catheter related bladder discomfort.

Bioremediation of pulp and paper mill effluent with Phanerochaete chrysosporium.

The present study reports on the treatment of pulp and paper mill effluent by Phanerochaete chlysosporium and the same has been compared at two different pH, 5.5 and 8.5. At both the pH, colour, COD, lignin content and total phenols of the effluent significantly declined after bioremediation. However, greater decolourisation and reduction in COD, lignin content and total phenols were observed at pH 5.5. Such bioremediated effluent of pulp and paper mill could gainfully be utilized for crop irrigation.

Pain during injection of propofol: the effect of prior administration of ephedrine.

Propofol causes pain on intravenous injection in 28 to 90% of patients. A number of techniques have been tried to minimize propofol-induced pain, with variable results. In a randomized, double-blind, placebo-controlled trial, we compared the efficacy of ephedrine 30 microg/kg pretreatment to lignocaine 40 mg for prevention of propofol-induced pain. Ninety-three adult patients, ASA 1 and 2, undergoing elective laparoscopic cholecystectomy were randomly assigned to three groups of 31 each. Group 1 received normal saline, group 2 received lignocaine 2% (40 mg) and group 3 received 30 microg/kg ephedrine. All pretreatment drugs were made up to 2 ml. Pain at the time of propofol injection was assessed on a four-point scale: 0=no pain, 1 =mild pain, 2=moderate pain, and 3=severe pain. Twenty-seven patients (87%) of ephedrine pretreatment patients had pain during intravenous injection of propofol as compared to 24 (77%) in the normal saline group. In the lignocaine group, propofol-induced pain was observed in only 13 (42%) when compared with other study groups (P<0.05). Pretreatment with ephedrine 30 microg/kg did not attenuate pain associated with intravenous injection of propofol, nor did it improve haemodynamic stability during induction. However, pretreatment with 2% lignocaine (40 mg) was effective in attenuating propofol-associated pain.

Biogas production from water hyacinth and channel grass used for phytoremediation of industrial effluents.

The paper reports on the biogas production from water hyacinth (Eichhornia crassipes) and channel grass (Vallisneria spiralis) employed separately for phytoremediation of lignin and metal-rich pulp and paper mill and highly acidic distillery effluents. These plants eventually grow well in diluted effluent up to 40% (i.e., 2.5-times dilution with deionized water) and often take up metals and toxic materials from wastewater for their metabolic use. Slurry of the two plants used for phytoremediation produced significantly more biogas than that produced by the plants grown in deionized water; the effect being more marked with plants used for phytoremediation of 20% pulp and paper mill effluent. Biogas production from channel grass was relatively greater and quicker (maximum in 6-9 days) than that from water hyacinth (in 9-12 days). Such variation in biogas production by the two macrophytes has been correlated with the changes in C, N and C/N ratio of their slurry brought by phytoremediation.

A comparison of the laryngeal mask airway and PA(Xpress) for short surgical procedures.

Sixty adult patients undergoing minor peripheral surgery under general anaesthesia were randomly allocated to receive either the laryngeal mask airway (laryngeal mask airway; size 4 for females and size 5 for males) or the PAXpress (adult size), inserted by a single operator with experience of > 50 insertions of each device. The laryngeal mask airway was correctly placed on the first attempt in 27 patients (90%) compared with 20 patients (67%) when using the PAXpress (p < 0.01). No patient required more than two attempts at insertion and there were no failures with the laryngeal mask airway, compared with four (13%) who needed three attempts and two failures (7%) with the PAXpress (p < 0.001 and p < 0.01, respectively). Mean (SD) total placement time was shorter with the laryngeal mask airway [24.6 (3.1) s] than with the PAXpress[35.4 (2.5) s; p < 0.01]. The most common complication was sore throat, which occurred less frequently with the laryngeal mask airway (8 patients; 26%) than with the PAXpress (15 patients; 53.5%; p < 0.001).

The effects of lactation education and a prosthetic obturator appliance on feeding efficiency in infants with cleft lip and palate.

OBJECTIVE: This prospective study examined the effect of lactation instruction and palatal obturation in decreasing time to feed, increasing intake, and on growth in eight breast milk bottle-fed newborn infants with cleft lip, cleft palate, or both. DESIGN: An A, B1, C1, B2, and C2 reversal design was used with eight mothers. In A, baseline data on minutes fed by breast were recorded. In B1, baseline on minutes fed with a Haberman bottle was recorded. In C1, minutes fed following lactation education and palatal obturation were documented. Lactation education was information given to mothers to recognize infant feeding cues and to have infant-led feedings. The palatal obturator was a passive molding appliance. In B2, the obturator was removed and minutes fed noted. In C2, the obturator was returned and lactation support provided. Mothers kept feeding logs, satisfaction was assessed, and infant breast milk intake and flow rate were recorded during each study phase. Routine nutrition evaluation of weight, height, weight for height, and feed volume was completed by a registered dietitian during and following completion of the study. RESULTS: Feeding times decreased with all infants, volume consumed increased with seven of eight infants, and flow rate increased with all infants. Mean feeding times during B1 and B2 phases (Haberman bottle only) were 34.4 and 32.3 minutes, respectively. Mean feeding times during C1 and C2 phases (obturation and lactation education) were 15.1 and 15.6 minutes. Volume of milk consumed during B1 and B2 feedings averaged 36.5 and 37 mL, compared with 67 mL and 76 mL during C1 and C2 phases. Growth as measured by height, weight gain, and weight for height during the study and the first 2 years of life compared favorably with that of children born without clefts. CONCLUSIONS: The combined use of a palatal obturator and lactation education reduced feeding time and increased volume intake and was associated with good growth. Mothers who had desired to breast-feed elected to use the obturator to support high-volume intake, decrease infant fatigue, and provide breast milk for nutrition.