Ventral hernia repair in India: a Delphi consensus.

PURPOSE: While research on inguinal hernias is well-documented, ventral/incisional hernias still require investigation. In India, opinions on laparoscopic ventral hernia repair (LVHR) techniques are contested. The current consensus aims to standardize LVHR practice and identify gaps and unfulfilled demands that compromise patient safety and therapeutic outcomes. METHODS: Using the modified Delphi technique, panel of 14 experts (general surgeons) came to a consensus. Two rounds of consensus were conducted online. An advisory board meeting was held for the third round, wherein survey results were discussed and the final statements were decided with supporting clinical evidence. RESULTS: Experts recommended intraperitoneal onlay mesh (IPOM) plus/trans-abdominal retromuscular/extended totally extraperitoneal/mini- or less-open sublay operation/transabdominal preperitoneal/trans-abdominal partial extra-peritoneal/subcutaneous onlay laparoscopic approach/laparoscopic intracorporeal rectus aponeuroplasty as valid minimal access surgery (MAS) options for ventral hernia (VH). Intraperitoneal repair technique is the preferred MAS procedure for primary umbilical hernia < 4 cm without diastasis; incisional hernia in the presence of a vertical single midline incision; symptomatic hernia, BMI > 40 kg/m2, and defect up to 4 cm; and for MAS VH surgery with grade 3/4 American Society of Anaesthesiologists. IPOM plus is the preferred MAS procedure for midline incisional hernia of width < 4 cm in patients with a previous laparotomy. Extraperitoneal repair technique is the preferred MAS procedure for L3 hernia < 4 cm; midline hernias < 4 cm with diastasis; and M5 hernia. CONCLUSION: The consensus statements will help standardize LVHR practices, improve decision-making, and provide guidance on MAS in VHR in the Indian scenario.

Spontaneous Cerebrospinal Fluid Rhinorrhea in End Stage Renal Disease.

We report a case of spontaneous cerebrospinal fluid (CSF) rhinorrhea in a patient on maintenance hemodialysis. There was no previous history of trauma or surgery. Secondary hyperparathyroidism due to progression of chronic kidney disease (CKD) and a rise in intracranial pressure resulted in spontaneous cerebrospinal fluid rhinorrhea. He underwent endoscopic endonasal repair with theco-peritoneal shunt; CSF leak stopped completely and the patient is doing well on one year follow up.

Three-dimensional imaging of vortex structure in a ferroelectric nanoparticle driven by an electric field.

Topological defects of spontaneous polarization are extensively studied as templates for unique physical phenomena and in the design of reconfigurable electronic devices. Experimental investigations of the complex topologies of polarization have been limited to surface phenomena, which has restricted the probing of the dynamic volumetric domain morphology in operando. Here, we utilize Bragg coherent diffractive imaging of a single BaTiO3 nanoparticle in a composite polymer/ferroelectric capacitor to study the behavior of a three-dimensional vortex formed due to competing interactions involving ferroelectric domains. Our investigation of the structural phase transitions under the influence of an external electric field shows a mobile vortex core exhibiting a reversible hysteretic transformation path. We also study the toroidal moment of the vortex under the action of the field. Our results open avenues for the study of the structure and evolution of polar vortices and other topological structures in operando in functional materials under cross field configurations.Imaging of topological states of matter such as vortex configurations has generally been limited to 2D surface effects. Here Karpov et al. study the volumetric structure and dynamics of a vortex core mediated by electric-field induced structural phase transition in a ferroelectric BaTiO3 nanoparticle.

A clinical study of cutaneous changes in pregnancy.

BACKGROUND/OBJECTIVE: Pregnant women experience a myriad of physiological and metabolic changes that affect different organ systems in the body. Cutaneous and appendageal alterations that manifest during pregnancy are largely modulated by hormonal, immunologic, and metabolic factors. Detailed reports encompassing physiological changes and specific dermatoses of pregnancy and effects of various dermatoses on pregnant women are scanty in literature. This study was conducted to examine in detail both physiological changes and specific dermatoses. The cutaneous changes are divided into physiological changes, skin diseases aggravated by pregnancy, and specific dermatoses of pregnancy. The objectives were to study the various cutaneous changes of pregnancy and to know the proportion of these cutaneous manifestations in pregnant women. METHODS: This study included 600 pregnant women attending the Obstetrics and Gynecology Department of a tertiary teaching hospital in Northern Kerala, India. Detailed history elicitation and complete physical and dermatological examination were performed. Skin biopsy was performed in relevant cases. RESULTS: Cutaneous changes were seen in a majority of patients, of which physiological changes were the most common (99%). The most common cutaneous manifestation was hyperpigmentation (526; 87.6%), followed by striae gravidarum (72.8%). Other changes were vascular, including pedal edema (10%), pregnancy gingivitis (1.8%), and varicose veins (1%). Infections were the common dermatological problem in this study group. The most common infections were vulvovaginal candidiasis (21%), Tinea versicolor (6%), scabies (2.8%), dermatophytosis (1.5%), and sexually transmitted infection (0.5%). Specific dermatoses were seen in 12 cases (2%), with the most common being pruritic urticarial papules and plaques of pregnancy (1.3%). CONCLUSION: Pregnant women are prone to suffer from a wide range of dermatological problems apart from specific dermatoses of pregnancy. The study emphasizes the need for a detailed and meticulous examination of these patients to detect these various disorders.

Classification of ABO3 perovskite solids: a machine learning study.

We explored the use of machine learning methods for classifying whether a particular ABO3 chemistry forms a perovskite or non-perovskite structured solid. Starting with three sets of feature pairs (the tolerance and octahedral factors, the A and B ionic radii relative to the radius of O, and the bond valence distances between the A and B ions from the O atoms), we used machine learning to create a hyper-dimensional partial dependency structure plot using all three feature pairs or any two of them. Doing so increased the accuracy of our predictions by 2-3 percentage points over using any one pair. We also included the Mendeleev numbers of the A and B atoms to this set of feature pairs. Doing this and using the capabilities of our machine learning algorithm, the gradient tree boosting classifier, enabled us to generate a new type of structure plot that has the simplicity of one based on using just the Mendeleev numbers, but with the added advantages of having a higher accuracy and providing a measure of likelihood of the predicted structure.

Effect of interfacial octahedral behavior in ultrathin manganite films.

We investigate structural coupling of the MnO6 octahedra across a film/substrate interface and the resultant changes of the physical properties of ultrathin La2/3Sr1/3MnO3 (LSMO) films. In order to isolate the effect of interfacial MnO6 octahedral behavior from that of epitaxial strain, LSMO films are grown on substrates with different symmetry and similar lattice parameters. Ultrathin LSMO films show an increased magnetization and electrical conductivity on cubic (LaAlO3)0.3(Sr2AlTaO6)0.7 (LSAT) compared to those grown on orthorhombic NdGaO3 (NGO) substrates, an effect that subsides as the thickness of the films is increased. This study demonstrates that interfacial structural coupling can play a critical role in the functional properties of oxide heterostructures.

Prevalence and etiology of subclinical mastitis among buffaloes (Bubalus bubalus) in Namakkal, India.

Milk samples from 206 apparently healthy buffaloes of marginal farmers maintained under the prevailing field conditions were screened for Subclinical Mastitis (SCM) to determine its prevalence and etiology by White Side Test (WST), California Mastitis Test (CMT), Somatic Cell Count (SCC) and Bacteriological examination. 26.20% of animals were positive for SCM in SCC and bacteriological examination. Prevalence in graded Murrah buffaloes were found to be higher compared to graded Surti and Non-descript breeds. The prevalence of SCM was highest in above 6th stage of lactation. Single quarter infection (51.85%) was more common compared to multiple quarter infection. Hind (83.34%) and left side (57.41%) quarters were more prone to SCM. The indirect tests such as WST and CMT were found to be closely agreement with SCC and bacteriological examination. Due to their efficacious, easy to perform and interpret, these tests can effectively be employed to detect SCM under field conditions. Somatic cell count of = 3,00,000/mL of milk was regarded as the upper limit for normal buffaloes. The SCC of = 3,00,000/mL of milk with positive bacterial growth were used to diagnose SCM in the present study. Staphylococcus sp. 25 (46.30%) was the most common pathogens isolated from SCM followed by Streptococcus sp. 11 (20.37%) and E. coli 06 (11.11%) of the 54 bacterial isolates. Monobacterial and mixed bacterial infections were observed in 47 (87.04%) and 7 (12.96%) cases respectively.

An audit of postoperative radiotherapy after non-curative resection for cancer of the oesophagus.

AIMS: The role of postoperative radiotherapy (PORT) after non-curative resections for cancer oesophagus is not well defined. A policy of offering PORT after non-curative resections for cancer oesophagus has been followed at our institution, and we report an audit of our experience. MATERIAL AND METHODS: Between March 1990 and September 2002, 139 patients underwent resections for cancer oesophagus. Of these, 86 patients received PORT to a dose of 45-50.4 Gy/25-28 fractions. Eleven of these patients also received concurrent and adjuvant 5-fluorouracil (5-FU). Disease-free survival and overall survival were computed from the day of surgery using the Kaplan-Meier method. RESULTS: Seventy-six per cent (65/86) of patients had squamous cell carcinoma and 69% (59/86) of patients had tumours in the lower-third of the oesophagus. The median interval between surgery and PORT was 41 days, and 93% of patients received doses as planned. Strictures at the anastomotic site and ulcerations in the stomach mucosa were seen in 17% and 5% of patients, respectively. The median and 5-year disease-free survival was 12 months (95% CI 9.9-14.1) and 14%; whereas the median and 5-year overall survival was 17 months (95% CI 12.4-21.6) and 17%, respectively. Local and distant failures were seen in 29% and 45% of patients, respectively. CONCLUSIONS: PORT, after a non-curative resection of cancer oesophagus, is well tolerated with acceptable morbidity and survival.

Adjuvant chemo-radiotherapy in ampullary cancers.

PURPOSE: Patterns of failure following surgical treatment of ampullary cancers indicate that up to 45% of patients develop loco-regional recurrence. The effect of adjuvant chemo-radiotherapy on survival and loco-regional control is not yet established in this malignancy. PATIENTS AND METHODS: From January 1989 to December 2000, 113 patients underwent pancreatico-duodenectomy for ampullary cancer. One hundred and four patients who survived the operation were available for analysis to study the effect of adjuvant chemo-radiotherapy on survival and loco-regional control. Forty-nine patients received adjuvant chemo-radiotherapy (median dose 50.4 Gy with concurrent 5-Flurouracil) and long-term outcome in these patients was compared with those 55 who did not receive adjuvant therapy. RESULTS: The overall median survival was 30.1 (range 1.6-140.0) months with actuarial 1, 3 and 5-year survival rates of 79, 43 and 33%, respectively. No significant difference in median survival (34.6 vs 24.5 months; P=0.3) and actuarial 5-year survival rates (38 vs 28%) was seen between those who received and those who did not receive adjuvant therapy. Adjuvant chemo-radiotherapy did not influence the survival in high-risk patients (P=0.84), in various T and N stages and had no impact on loco-regional recurrence (P=0.6). CONCLUSIONS: Adjuvant chemo-radiotherapy did not improve the long-term survival or decrease recurrence rates in patients with ampullary cancers who had undergone pancreatico-duodenectomy.

The ADP ribosyltransferase domain of Pseudomonas aeruginosa ExoT contributes to its biological activities.

ExoT is a type III secreted effector protein found in almost all strains of Pseudomonas aeruginosa and is required for full virulence in an animal model of acute pneumonia. It is comprised of an N-terminal domain with GTPase activating protein (GAP) activity towards Rho family GTPases and a C-terminal ADP ribosyltransferase (ADPRT) domain with minimal activity towards a synthetic substrate in vitro. Consistent with its activity as a Rho family GTPase, ExoT has been shown to inhibit P. aeruginosa internalization into epithelial cells and macrophages, disrupt the actin cytoskeleton through a Rho-dependent pathway, and inhibit wound repair in a scrape model of injured epithelium. We have previously shown that mutation of the invariant arginine of the GAP domain to lysine (R149K) results in complete loss of GAP activity in vitro but only partially inhibits ExoT anti-internalization and cell rounding activity. We have constructed in-frame deletions and point mutations within the ADPRT domain in order to test whether this domain might account for the residual activity observed in ExoT GAP mutants. Deletion of a majority of the ADPRT domain (residues 234 to 438) or point mutations of the ADPRT catalytic site (residues 383 to 385) led to distinct changes in host cell morphology and substantially reduced the ability of ExoT to inhibit in vitro epithelial wound healing over a 24-h period. In contrast, only subtle effects on the efficiency of ExoT-induced bacterial internalization were observed in the ADPRT mutant forms. Expression of each domain individually in Saccharomyces cerevisiae was toxic, whereas expression of each of the catalytically inactive mutant domains was not. Collectively, these data demonstrate that the ADPRT domain of ExoT is active in vivo and contributes to the pathogenesis of P. aeruginosa infections.

The autolytic enzyme LytA of Streptococcus pneumoniae is not responsible for releasing pneumolysin.

It was previously proposed that autolysin's primary role in the virulence of pneumococci was to release pneumolysin to an extracellular location. This interpretation came into question when pneumolysin was observed to be released in significant amounts from some pneumococci during log-phase growth, because autolysis was not believed to occur at this time. We have reexamined this phenomenon in detail for one such strain, WU2. This study found that the extracellular release of pneumolysin from WU2 was not dependent on autolysin action. A mutant lacking autolysin showed the same pattern of pneumolysin release as the wild-type strain. Addition of mitomycin C to a growing WU2 culture did not induce lysis, indicating the absence of resident bacteriophages that could potentially harbor lytA-like genes. Furthermore, release of pneumolysin was unaltered by growth in 2% choline, a condition which is reported to inactivate autolysin, as well as most known pneumococcal phage lysins. Profiles of total proteins in the cytoplasm and in the supernatant media supported the hypothesis that release of pneumolysin is independent of pneumococcal lysis. Finally, under some infection conditions, mutations in pneumolysin and autolysin had different effects on virulence.

Managing morphine-induced constipation: a controlled comparison of an Ayurvedic formulation and senna.

Constipation is a frequent cause of distress in advanced cancer. A palliative care unit in Kerala, a southern state of India, conducted a controlled trial comparing a liquid Ayurvedic (herbal) preparation (Misrakasneham) with a conventional laxative tablet (Sofsena) in the management of opioid-induced constipation in patients with advanced cancer. Although there was no statistically significant difference in the apparent degree of laxative action between the two, the results indicate that the small volume of the drug required for effective laxative action, the tolerable taste, the once-daily dose, the acceptable side effect profile, and the low cost make Misrakasneham a good choice for prophylaxis in opioid-induced constipation. There is a need for further studies of Ayurvedic medicines in palliative care.

Autoradiographic analysis of FSH binding during follicular atresia.

Binding of FSH to ovarian cells was studied in PMSG primed immature Swiss mice, 48 h after PMSG treatment, FSH-binding was higher in the periphery than in the cumulus cells of the antral follicles. Binding of FSH to granulosa cells of normal follicles was observed to be specific, 48 h after PMSG injection. No localization in the atretic follicles could be seen by autoradiography 72 h after priming.

Prognostic significance of chronic versus acute bundle branch block in acute myocardial infarction.

Of 1125 patients with acute myocardial infarction admitted to Mount Sinai Medical Center in 1971 and 1972, 292 (28.8 percent) had intraventricular conduction defects. In 210 of the 292 patients with intraventricular conduction defect, it was possible to determine if the conduction defect, was present before the infarction (Group 1, 123 patients) or developed acutely with the infarction (Group 2, 87 patients). Of the 210 patients, 52.8 percent died (mean age 72.1 years). Fifty-three patients in Group 1 and 18 patients in Group 2 had isolated left axis deviation (LAD). The mortality was 35 percent and 28 percent respectively. This difference was not significant (p greater than 0.60). Sixty-four of the 210 patients presented with a left bundle branch block (LBBB) pattern. The overall mortality of 54 percent was the same in both groups. Right bundle branch block(RBBB), with either normal axis, left (LAD) or right axis deviation (RAD), was found in 74 patients. Of 40 patients in Group 1, 62 percent died, and of 35 patients in Group 2, 80 percent expired. Again this difference was not significant (p greater than 0.10). In 13 of 25 patients with RBBB in Group 1, death was possible related to progression of the conduction defect. The use of prophylactic temporary pacing is suggested for these patients.

Echocardiographic observations on ventricular septal rupture complicating acute myocardial infarction.

Echocardiograms were performed on three patients with ventricular septal rupture complicating myocardial infarction. The pulmonary artery mean pressure was 30 mm Hg or more in all three patients. The size of the ventricular septal defect, determined at operation or autopsy, was 2 cm or greater in each patient. The salient echocardiographic abnormality was dilatation of the right ventricle. The direction of septal motion was normal in all the patients. The left atrial diameter was slightly increased in one patient and was normal in the other two. In one patient, and unusual pattern of mitral valve motion was seen. Complete closure of the reopening of the valve. This pattern was suggestive of increased blood flow through the mitral valve. Although some of these findings are nosspecific, the combination of echocardiographic findings may provide useful clues to the diagnosis of septal perforation.