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.

Prolactin-Releasing Peptide Contributes to Stress-Related Mood Disorders and Inhibits Sleep/Mood Regulatory Melanin-Concentrating Hormone Neurons in Rats.

Stress disorders impair sleep and quality of life; however, their pathomechanisms are unknown. Prolactin-releasing peptide (PrRP) is a stress mediator; we therefore hypothesized that PrRP may be involved in the development of stress disorders. PrRP is produced by the medullary A1/A2 noradrenaline (NA) cells, which transmit stress signals to forebrain centers, and by non-NA cells in the hypothalamic dorsomedial nucleus. We found in male rats that both PrRP and PrRP-NA cells innervate melanin-concentrating hormone (MCH) producing neurons in the dorsolateral hypothalamus (DLH). These cells serve as a key hub for regulating sleep and affective states. Ex vivo, PrRP hyperpolarized MCH neurons and further increased the hyperpolarization caused by NA. Following sleep deprivation, intracerebroventricular PrRP injection reduced the number of REM sleep-active MCH cells. PrRP expression in the dorsomedial nucleus was upregulated by sleep deprivation, while downregulated by REM sleep rebound. Both in learned helplessness paradigm and after peripheral inflammation, impaired coping with sustained stress was associated with (1) overactivation of PrRP cells, (2) PrRP protein and receptor depletion in the DLH, and (3) dysregulation of MCH expression. Exposure to stress in the PrRP-insensitive period led to increased passive coping with stress. Normal PrRP signaling, therefore, seems to protect animals against stress-related disorders. PrRP signaling in the DLH is an important component of the PrRP's action, which may be mediated by MCH neurons. Moreover, PrRP receptors were downregulated in the DLH of human suicidal victims. As stress-related mental disorders are the leading cause of suicide, our findings may have particular translational relevance.SIGNIFICANCE STATEMENT Treatment resistance to monoaminergic antidepressants is a major problem. Neuropeptides that modulate the central monoaminergic signaling are promising targets for developing alternative therapeutic strategies. We found that stress-responsive prolactin-releasing peptide (PrRP) cells innervated melanin-concentrating hormone (MCH) neurons that are crucial in the regulation of sleep and mood. PrRP inhibited MCH cell activity and enhanced the inhibitory effect evoked by noradrenaline, a classic monoamine, on MCH neurons. We observed that impaired PrRP signaling led to failure in coping with chronic/repeated stress and was associated with altered MCH expression. We found alterations of the PrRP system also in suicidal human subjects. PrRP dysfunction may underlie stress disorders, and fine-tuning MCH activity by PrRP may be an important part of the mechanism.

Effectiveness of a counselling intervention implemented in antenatal setting for pregnant women facing domestic violence: a pre-experimental study.

OBJECTIVE: To assess the effectiveness of a counselling intervention in antenatal care settings for pregnant women who report domestic violence. DESIGN: Pre-experimental study with pretest-posttest design. SETTINGS: Two public hospitals in Mumbai, India. SAMPLE: In all, 2778 pregnant women accessing antenatal care (ANC) in the hospitals from February to November 2016 were approached for study participation; 2515 women consented. These women were screened by trained counsellors for domestic violence during pregnancy (domestic violence during pregnancy). Domestic violence during pregnancy was reported by 16.2% (408) of women. Of these, 155 women sought counselling services. Post-intervention analyses were carried out with 142 women at 6 weeks post-delivery; 13 women were not contactable. METHODS: The 442 women who reported domestic violence during pregnancy were provided a minimum of two counselling sessions by trained counsellors during their ANC visits. A counselling intake form was used to collect pre- and post-intervention data. MAIN OUTCOME MEASURES: Prevalence of domestic violence during pregnancy, change in women's ability to cope, safety, and health. RESULTS: Prevalence of domestic violence during pregnancy (16.1%) was comparable to those of common obstetric complications routinely screened for during ANC. In all, 60-65% women reported cognitive changes such as recognising impact of violence and need to speak out against it. In all, 50.7% women took action at the individual level to address domestic violence during pregnancy. This change was not statistically significant (P-value 0.193). Of the women studied, 35.9% adopted at least one safety measure, and 84% of the women reported better health status post-intervention. CONCLUSIONS: Routine enquiry and counselling for domestic violence during pregnancy are effective in improving women's ability to cope, safety, and health. FUNDING: This study was funded by The John D. and Catherine T. MacArthur Foundation. TWEETABLE ABSTRACT: Improving coping strategies, safety and health of pregnant women who reported domestic violence by providing counselling in antenatal care setting.

Transoral endoscopic thyroidectomy using vestibular approach: A single center experience.

Background: Thyroid Natural Orifice Transluminal Endoscopic Surgery (NOTES) or transoral endoscopic thyroidectomy using vestibular approach is a recent advance embraced by the surgical community because of its potential for a scar-free thyroidectomy. In this article, we present our initial experience with this technique. Materials and Methods: We used a three-port technique through the oral vestibule, one 10 mm port for the laparoscope and two additional 5 mm ports for the endoscopic instruments required. The carbon dioxide insufflation pressure was set at 12 mm of Hg. Anterior cervical subplatysmal space was created from the oral vestibule down to the sternal notch, and the thyroidectomy was done using conventional laparoscopic instruments and a harmonic scalpel. Results: From May 2016 to December 2017, we have performed ten such procedures in the Department of General Surgery in our hospital, which is a tertiary referral center. Six patients had solitary thyroid nodules, for which a hemi-thyroidectomy was done. Four patients had multi-nodular goiter and total thyroidectomy or near-total thyroidectomy was done. The preoperative fine-needle aspiration cytology (FNAC) was suggestive of Bethesda class 2 lesions in all the patients with multinodular goiter and in five of the six patients with solitary nodular goiter. Only one patient with solitary nodular goiter had a Bethesda class 3 lesion on FNAC. The final histopathological report of the specimen was benign, either colloid goiter, or degenerative nodule in all cases of multinodular goiter and in four cases of solitary thyroid nodule. In one Bethesda class 2 solitary nodule, the histopathological report was suggestive of follicular carcinoma; in the Bethesda class 3 solitary nodule, the histopathological report was suggestive of follicular variant of papillary carcinoma. No complication such as temporary or permanent vocal cord paralysis, hypoparathyroidism, subcutaneous emphysema, pneumomediastinum, tracheal injury, esophageal injury, mental nerve palsy, or surgical site infection was found postoperatively. However, two patients developed small hematomas in the midline. Conclusion: Transoral endoscopic thyroidectomy is a safe, feasible, and minimally invasive technique with excellent cosmetic results.

Challenges in the diagnosis of acute cyanide poisoning.

OBJECTIVE: The aim of this systematic review was to identify isolated acute cyanide poison cases and to identify reported signs, symptoms, and laboratory findings. METHODS: We searched MEDLINE, Cochrane Reviews, and Web of Science case reports and series using a number of MeSH descriptors pertaining to cyanide, toxicity, and poisonings. We excluded studies on plants, laboratory analyses, smoke inhalation poisonings, animals as well as non-English language articles and those in which data were not available. Data extracted included demographics, exposure characteristics, acute signs/symptoms, and medical management and outcome. RESULTS: From the initial 2976 articles retrieved, 65 articles (52 case reports, 13 case series) met inclusion criteria and described 102 patients. Most patients were unresponsive (78%), hypotensive (54%), or had respiratory failure (73%); other signs and symptoms included cardiac arrest (20%), seizures (20%), cyanosis (15%), cherry red skin (11%), and had an odor present (15%). Medical management included cyanide antidote kit (20%), sodium thiosulfate (40%), and hydroxocobalamin (29%). The majority of cases (66%) required intubation with mechanical ventilation and a substantial number (39%) developed refractory hypotension requiring vasopressor support. CONCLUSIONS: Contrary to general reviews published on cyanide toxicity, reports of cherry red skin and bitter almond odor were rare among published cyanide cases. Consistent with other studies, metabolic acidosis with significant lactic acidosis were the laboratory values consistently associated with cyanide toxicity. Healthcare providers may overlook cyanide toxicity in the differential diagnosis, if certain expected characteristics, such as the odor of almonds or a cherry red color of the skin are absent on physical examination.

Cost versus life cycle assessment-based environmental impact optimization of drinking water production plants.

Empowering decision makers with cost-effective solutions for reducing industrial processes environmental burden, at both design and operation stages, is nowadays a major worldwide concern. The paper addresses this issue for the sector of drinking water production plants (DWPPs), seeking for optimal solutions trading-off operation cost and life cycle assessment (LCA)-based environmental impact while satisfying outlet water quality criteria. This leads to a challenging bi-objective constrained optimization problem, which relies on a computationally expensive intricate process-modelling simulator of the DWPP and has to be solved with limited computational budget. Since mathematical programming methods are unusable in this case, the paper examines the performances in tackling these challenges of six off-the-shelf state-of-the-art global meta-heuristic optimization algorithms, suitable for such simulation-based optimization, namely Strength Pareto Evolutionary Algorithm (SPEA2), Non-dominated Sorting Genetic Algorithm (NSGA-II), Indicator-based Evolutionary Algorithm (IBEA), Multi-Objective Evolutionary Algorithm based on Decomposition (MOEA/D), Differential Evolution (DE), and Particle Swarm Optimization (PSO). The results of optimization reveal that good reduction in both operating cost and environmental impact of the DWPP can be obtained. Furthermore, NSGA-II outperforms the other competing algorithms while MOEA/D and DE perform unexpectedly poorly.

Brainstem projections of neurons located in various subdivisions of the dorsolateral hypothalamic area-an anterograde tract-tracing study.

The projections from the dorsolateral hypothalamic area (DLH) to the lower brainstem have been investigated by using biotinylated dextran amine (BDA), an anterograde tracer in rats. The DLH can be divided into 3 areas (dorsomedial hypothalamus, perifornical area, lateral hypothalamic area), and further subdivided into 8 subdivisions. After unilateral stereotaxic injections of BDA into individual DLH subdivisions, the correct sites of injections were controlled histologically, and the distribution patterns of BDA-positive fibers were mapped on serial sections between the hypothalamus and spinal cord in 22 rats. BDA-labeled fibers were observable over 100 different brainstem areas, nuclei, or subdivisions. Injections into the 8 DLH subdivisions established distinct topographical patterns. In general, the density of labeled fibers was low in the lower brainstem. High density of fibers was seen only 4 of the 116 areas: in the lateral and ventrolateral parts of the periaqueductal gray, the Barrington's, and the pedunculopontine tegmental nuclei. All of the biogenic amine cell groups in the lower brainstem (9 noradrenaline, 3 adrenaline, and 9 serotonin cell groups) received labeled fibers, some of them from all, or at least 7 DLH subdivisions, mainly from perifornical and ventral lateral hypothalamic neurons. Some of the tegmental nuclei and nuclei of the reticular formation were widely innervated, although the density of the BDA-labeled fibers was generally low. No definitive descending BDA-positive pathway, but long-run solitaire BDA-labeled fibers were seen in the lower brainstem. These descending fibers joined some of the large tracts or fasciculi in the brainstem. The distribution pattern of BDA-positive fibers of DLH origin throughout the lower brainstem was comparable to patterns of previously published orexin- or melanin-concentrating hormone-immunoreactive fibers with somewhat differences.

Nesfatin-1/NUCB2 as a potential new element of sleep regulation in rats.

STUDY OBJECTIVES: Millions suffer from sleep disorders that often accompany severe illnesses such as major depression; a leading psychiatric disorder characterized by appetite and rapid eye movement sleep (REMS) abnormalities. Melanin-concentrating hormone (MCH) and nesfatin-1/NUCB2 (nesfatin) are strongly co - expressed in the hypothalamus and are involved both in food intake regulation and depression. Since MCH was recognized earlier as a hypnogenic factor, we analyzed the potential role of nesfatin on vigilance. DESIGN: We subjected rats to a 72 h-long REMS deprivation using the classic flower pot method, followed by a 3 h-long 'rebound sleep'. Nesfatin mRNA and protein expressions as well as neuronal activity (Fos) were measured by quantitative in situ hybridization technique, ELISA and immunohistochemistry, respectively, in 'deprived' and 'rebound' groups, relative to controls sacrificed at the same time. We also analyzed electroencephalogram of rats treated by intracerebroventricularly administered nesfatin-1, or saline. RESULTS: REMS deprivation downregulated the expression of nesfatin (mRNA and protein), however, enhanced REMS during 'rebound' reversed this to control levels. Additionally, increased transcriptional activity (Fos) was demonstrated in nesfatin neurons during 'rebound'. Centrally administered nesfatin-1 at light on reduced REMS and intermediate stage of sleep, while increased passive wake for several hours and also caused a short-term increase in light slow wave sleep. CONCLUSIONS: The data designate nesfatin as a potential new factor in sleep regulation, which fact can also be relevant in the better understanding of the role of nesfatin in the pathomechanism of depression.

Formulation of a functional fat spread stabilised by natural antioxidants and emulsifiers.

INTRODUCTION: Essential fatty acids (EFAs) play a vital role in the human body and need to be taken through a regular diet. EFAs are susceptible to autoxidation, hence the stability of the EFAs and their products is a matter of concern. METHODS: Margarine containing sunflower oil as a carrier of EFAs was prepared and the effects of water content, incorporation of EFAs, emulsifiers and antioxidants on the physical properties of margarine, that is, slipping point, dropping point and spreadability were studied. The oxidative stability of the formulated margarine was also evaluated after incorporation of EFAs and antioxidants. RESULTS: The incorporation of EFAs in the form of sunflower oil resulted in improved physical properties especially spreadability. The study revealed that up to 45% sunflower oil can be incorporated using glycerol monostearate as an emulsifier with total fat to water ratio of 85:15. Lecithin imparted better spreadability and grainy structure but is known to be susceptible to microbial attack. The capsicum oleoresin showed good activity as an antioxidant. Further addition of kalonji seeds ethanol extract (KEE) as well as curcuminoids resulted in improved spreadability but showed a decrease in oxidation stability. CONCLUSION: A stable and nutritional margarine was developed with the addition of natural antioxidants. Consumers can avail the benefits of both the EFAs and natural antioxidants in the margarine.

Association between the activation of MCH and orexin immunorective neurons and REM sleep architecture during REM rebound after a three day long REM deprivation.

Rapid eye movement (REM) sleep rebound following REM deprivation using the platform-on-water method is characterized by increased time spent in REM sleep and activation of melanin-concentrating hormone (MCH) expressing neurons. Orexinergic neurons discharge reciprocally to MCH-ergic neurons across the sleep-wake cycle. However, the relation between REM architecture and the aforementioned neuropeptides remained unclear. MCH-ergic neurons can be divided into two subpopulations regarding their cocaine- and amphetamine-regulated transcript (CART) immunoreactivity, and among them the activation of CART-immunoreactive subpopulation is higher during the REM rebound. However, the possible role of stress in this association has not been elucidated. Our aims were to analyze the relationship between the architecture of REM rebound and the activation of hypothalamic MCH-ergic and orexinergic neurons. We also intended to separate the effect of stress and REM deprivation on the subsequent activation of subpopulations of MCH-ergic neurons. In order to detect neuronal activity, we performed MCH/cFos and orexin/cFos double immunohistochemistry on home cage, sleep deprived and sleep-rebound rats using the platform-on-water method with small and large (stress control) platforms. Furthermore, REM architecture was analyzed and a triple MCH/CART/cFos immunohistochemistry was also performed on the rebound groups in the same animals. We found that the activity of MCH- and orexin-immunoreactive neurons during REM rebound was positively and negatively correlated with the number of REM bouts, respectively. A negative reciprocal correlation was also found between the activation of MCH- and orexin-immunoreactive neurons during REM rebound. Furthermore, difference between the activation of CART-immunoreactive (CART-IR) and non-CART-immunoreactive MCH-ergic neuron subpopulations was found only after selective REM deprivation, it was absent in the large platform (stress control) rebound group. These results support the role of CART-IR subpopulation of MCH-ergic neurons and the inverse relationship of MCH and orexin in the regulation of REM sleep after REM sleep deprivation.

Breast gangrene in an HIV-positive patient.

INTRODUCTION: Breast gangrene has been reported as a complication following puerperal sepsis, breast surgery, nipple piercings, warfarin toxicity, etc. We report a case of primary breast gangrene in an HIV-positive individual which, to the best of our knowledge, is the first of its kind. CASE REPORT: A 40-year-old previously healthy woman presented with fulminating left breast gangrene. She was detected to be HIV positive. Mastectomy was performed. The detailed management of the condition is discussed. CONCLUSION: Severe necrotising infections may be initial manifestations of HIV infection and patients with such infections should be screened for HIV.

Adiposity, inflammation and hyperglycaemia in rural and urban Indian men: Coronary Risk of Insulin Sensitivity in Indian Subjects (CRISIS) Study.

AIMS/HYPOTHESIS: The aim of this study was to investigate whether the higher prevalence of insulin resistance and glucose intolerance in urban compared with rural Indian men is related to their higher adiposity (percentage body fat) and the associated inflammatory state. METHODS: We studied 149 rural, 142 urban slum and 150 urban middle-class male residents (age 30-50 years), who were selected by stratified random sampling. We measured body fat (bioimpedance), waist circumference, glucose tolerance (75 g OGTT), insulin resistance [homeostasis model assessment (HOMA-IR)], beta cell function (insulinogenic index) and inflammatory markers (total leucocyte count, IL-6, TNF-alpha and C-reactive protein). RESULTS: Adiposity, waist circumference, HOMA-IR, insulinogenic index and both fasting and 120 min plasma glucose concentrations increased progressively from rural through to urban slum and urban middle-class men. Inflammatory markers were higher in urban than in rural men. Adiposity was strongly related to HOMA-IR (r = 0.57, p < 0.001) and to insulinogenic index and glycaemic parameters (r = 0.25, p < 0.001 for both). Adiposity explained approximately two thirds of the difference in HOMA-IR between the urban middle-class men and the rural and slum residents, but its contribution to the difference in insulinogenic index and 120 min plasma glucose concentration was not significant. Inclusion of C-reactive protein, IL-6 and total leucocyte count in the models did not further explain these results, nor did the inclusion of waist circumference. There was a significant residual difference after these adjustments. CONCLUSIONS/INTERPRETATION: Adiposity is a major contributor to the difference in insulin resistance between rural and urban Indian men; there was no additional contribution from inflammation or central obesity. Other unmeasured factors also seem to contribute to the metabolic differences between rural and urban men.

Vitamin B12 and folate concentrations during pregnancy and insulin resistance in the offspring: the Pune Maternal Nutrition Study.

AIMS/HYPOTHESIS: Raised maternal plasma total homocysteine (tHcy) concentrations predict small size at birth, which is a risk factor for type 2 diabetes mellitus. We studied the association between maternal vitamin B12, folate and tHcy status during pregnancy, and offspring adiposity and insulin resistance at 6 years. METHODS: In the Pune Maternal Nutrition Study we studied 700 consecutive eligible pregnant women in six villages. We measured maternal nutritional intake and circulating concentrations of folate, vitamin B12, tHcy and methylmalonic acid (MMA) at 18 and 28 weeks of gestation. These were correlated with offspring anthropometry, body composition (dual-energy X-ray absorptiometry scan) and insulin resistance (homeostatic model assessment of insulin resistance [HOMA-R]) at 6 years. RESULTS: Two-thirds of mothers had low vitamin B12 (<150 pmol/l), 90% had high MMA (>0.26 micromol/l) and 30% had raised tHcy concentrations (>10 micromol/l); only one had a low erythrocyte folate concentration. Although short and thin (BMI), the 6-year-old children were relatively adipose compared with the UK standards (skinfold thicknesses). Higher maternal erythrocyte folate concentrations at 28 weeks predicted higher offspring adiposity and higher HOMA-R (both p < 0.01). Low maternal vitamin B12 (18 weeks; p = 0.03) predicted higher HOMA-R in the children. The offspring of mothers with a combination of high folate and low vitamin B12 concentrations were the most insulin resistant. CONCLUSIONS/INTERPRETATION: Low maternal vitamin B12 and high folate status may contribute to the epidemic of adiposity and type 2 diabetes in India.

Body fat measurement in Indian men: comparison of three methods based on a two-compartment model.

UNLABELLED: Obesity is a major risk factor for diabetes and related disorders. The current classification of obesity is based on body mass index (BMI, kg/m(2)), which is a surrogate for the total body fat. Since the relationship between BMI and body fat varies in different populations, an independent validation of the BMI-body fat relationship in the population of interest is desirable. OBJECTIVES: (1) To study the validity of field methods of measuring body fat (multiple skinfolds and bioimpedance) against a criterion method (deuterium dilution) and (2) To compare the prevalence of obesity (WHO 2000 criteria for BMI) with adiposity (body fat >25%) in middle-aged Indian men in rural and urban Pune. DESIGN: Community-based multistage stratified random sampling of middle-aged men from rural and urban Pune for study of body composition and cardiovascular risk. A third of these men, selected to represent wide BMI distribution, were studied for body fat measurements by specific methods. SUBJECTS: A total of 141 healthy men, approximately similar number from rural, urban slums and middle class from Pune. They were 39.3 (+/-6.2) y old and had a BMI of 21.9 (+/-3.7) kg/m(2). MEASUREMENTS: Anthropometry (height, weight and multiple skinfold thicknesses) by trained observers using standardised technique to calculate body fat by Durnin and Womersley's equation. Total body water and body fat by bioelectrical impedance analysis (BIA) and deuterium oxide dilution (D(2)O). RESULTS: Mean total body fat was 14.3 kg (23.0%) by anthropometry, 16.5 kg (26.0%) by BIA and 15.3 kg (24.6%) by D(2)O method. Although there was a good correlation between fat estimation by three methods (r= approximately 0.9, P<0.001 all), compared to D(2)O method anthropometry underestimated body fat by 1.0 kg and BIA overestimated fat by 1.2 kg (P<0.001 both). Using the standard cut-point of 25% body fat for 'adiposity' 29.5% rural, 46.0% slum and 75.0% middle class men were adipose. These proportions were considerably higher than the number of men who were 'preobese' (BMI> or =25-29.9 kg/m(2), 9.0% rural, 22.0% urban slums and 27.0% urban middle class) and 'obese' (BMI >30 kg/m(2), 4.0% urban slums, none in rural and urban middle class). CONCLUSION: We recommend that future studies assessing risk for chronic diseases in Indians should measure adiposity by anthropometry (multiple skinfolds) or BIA (calibrated for Indians) rather than relying only on BMI cut-points.

Laparoscopic splenectomy using conventional instruments.

INTRODUCTION: Laparoscopic splenectomy (LS) is an accepted procedure for elective splenectomy. Advancement in technology has extended the possibility of LS in massive splenomegaly [Choy et al., J Laparoendosc Adv Surg Tech A 14(4), 197-200 (2004)], trauma [Ren et al., Surg Endosc 15(3), 324 (2001); Mostafa et al., Surg Laparosc Endosc Percutan Tech 12(4), 283-286 (2002)], and cirrhosis with portal hypertension [Hashizume et al., Hepatogastroenterology 49(45), 847-852 (2002)]. In a developing country, these advanced gadgets may not be always available. We performed LS using conventional and reusable instruments in a public teaching the hospital without the use of the advanced technology. The technique of LS and the outcome in these patients is reported. MATERIALS AND METHODS: Patients undergoing LS for various hematological disorders from 1998 to 2004 were included. Electrocoagulation, clips, and intracorporeal knotting were the techniques used for tackling short-gastric vessels and splenic pedicle. Specimen was delivered through a Pfannensteil incision. RESULTS: A total of 26 patients underwent LS. Twenty-two (85%) of patients had spleen size more than 500 g (average weight being 942.55 g). Mean operative time was 214 min (45-390 min). The conversion rate was 11.5% (n = 3). Average duration of stay was 5.65 days (3-30 days). Accessory spleen was detected and successfully removed in two patients. One patient developed subphrenic abscess. There was no mortality. There was no recurrence of hematological disease. CONCLUSION: Laparoscopic splenectomy using conventional equipment and instruments is safe and effective. Advanced technology has a definite advantage but is not a deterrent to the practice of LS.

Characteristics of gestational diabetic mothers and their babies in an Indian diabetes clinic.

AIMS AND OBJECTIVES: To compare clinical and metabolic features of mothers with gestational diabetes (GDM) and their offspring with those in non-diabetic pregnancies at the King Edward Memorial Hospital, Pune, India. MATERIALS AND METHODS: Antenatal information was obtained from hospital records. GDM was diagnosed by 75 g OGTT (Oral Glucose Tolerance Test) in clinically high-risk women. Anthropometric measurements of mother and the babies were recorded within 24h of delivery and a maternal blood sample collected for hematological and biochemical measurements. RESULTS: Between the period Jan 1998 to December 2003,265 women with gestational diabetes were treated in our Unit. Forty nine percent had first-degree relatives with diabetes. Compared to non-diabetic mothers (n=215) GDM mothers were older (29.0 vs. 26.0y, p<0.001), more obese (body mass index- BMI 26.0 vs. 22.0 kg/m2, p<0.001), centrally obese (Waist hip ratio-WHR 0.89 vs 0.86, p<0.001), adipose (sum of 4 skinfolds 98.4 vs. 61.4 mm, p<0.001) and had higher blood pressure (127/80 vs. 122/70 mmHg, p<0.001). GDM mothers had higher concentrations of plasma triglycerides (195.0 vs. 153.0 mg/dl, p<0.01); blood hemoglobin (11.7 vs 10.9 g/dl, p<0.001) and higher platelet count but lower concentration of HDL cholesterol and albumin. Sixty percent GDM mothers and 34% of non-diabetic mothers were delivered by caesarean-section, 23% of GDM mothers delivered pre term (<37 wk). Despite the smaller gestation, babies of GDM mothers were heavier (BW 2950.0 vs. 2824.0g, p<0.001, adjusted for gender), longer (48.9 vs. 48.0 cm, p<0.01) and more adipose (sum of 2 skinfolds 10.5 vs. 8.5 mm). Only 5% of babies born to GDM mothers weighed > 4000 g but 30% were >90th centile of birth weight of babies born to non-diabetic mothers. Babies of GDM mothers suffered higher neonatal morbidity. CONCLUSIONS: GDM mothers in urban India are more obese and more adipose than non-diabetic mothers, frequently have a family history of diabetes and show metabolic features of insulin resistance syndrome, suggesting high cardiovascular risk. Neonates of GDM mothers are heavier, longer and more adipose than those born to non-diabetic mothers, and suffer higher neonatal morbidity.

Giant renal capsular leiomyoma: study of two cases.

Leiomyomas of the renal parenchyma and of the capsule are rare. These tumours are normally small asymptomatic and often detected incidentally. Large renal leiomyomas can present with pain or as an abdominal mass, but they are rare. The imaging features of these tumours have been poorly described in the literature. A radiological distinction from other renal neoplasms is often difficult to make owing to the similarity of imaging findings. We report two patients with renal leiomyomas who presented with pain and an abdominal mass. Both patients underwent nephrectomy and histological evaluation confirmed the diagnosis of leiomyoma.

Maternal activity in relation to birth size in rural India. The Pune Maternal Nutrition Study.

OBJECTIVE: To describe the relationship of the mother's physical activity to the birth size of her baby in a rural Indian population. DESIGN: : Prospective observational study. SETTING: Six villages near Pune, Maharashtra, India. SUBJECTS: : A total of 797 women were studied after excluding abortions and termination of pregnancies (112), foetal anomalies (8), multiple pregnancies (3), incomplete pre-pregnancy anthropometry (14) and pregnancies detected later than 21 weeks of gestation (168). METHOD: An activity questionnaire was developed after focus group discussions and incorporated community-specific activities. It was validated against an observer-maintained diary. Activity scores were derived using published data on energy costs to weight the contributions of various activities. It was then administered to assess physical activity at 18 (+/-2) and 28 (+/-2) weeks of gestation. OUTCOME MEASURES: Birth outcome, maternal weight gain and neonatal anthropometry. RESULTS: The activity questionnaire was used to classify women into light, moderate and heavy activity categories. Maternal activity did not influence the incidence of prematurity or stillbirth, or the duration of gestation. It was inversely related to maternal weight gain up to 28 weeks of gestation (P=0.002). Higher maternal activity in early, as well as mid gestation, was associated with lower mean birth weight (P=0.05 and 0.02, respectively ), and smaller neonatal head circumference (P=0.005 and 0.009) and mid-arm circumference (P=0.03 and 0.01) after adjusting for the effect of major confounding factors. CONCLUSIONS: The Findings suggest that excessive maternal activity during pregnancy is associated with smaller foetal size in rural India, The approach described for developing an activity questionnaire has potential for adoption in other settings.

An open-label, flexible-dose study of olanzapine in the treatment of trichotillomania.

BACKGROUND: Thus far, only selective serotonin reuptake inhibitors have been systematically studied in the treatment of trichotillomania, and the results are conflicting. This open-label study is the first to systematically evaluate an atypical neuroleptic, olanzapine, as a monotherapy in the treatment of trichotillomania. METHOD: Twenty-one patients were screened and 18 patients were enrolled in a 3-month open-label study of olanzapine for trichotillomania (diagnosis based on modified DSM-IV criteria). Patients with comorbid psychiatric disorders or on treatment with psychoactive medication were excluded. Olanzapine was titrated gradually in 2.5-mg/week increments up to a maximum dose of 10 mg/day. RESULTS: Seventeen patients who completed at least 1 week of olanzapine treatment were evaluated. Hair pulling, as measured by the Massachusetts General Hospital Hairpulling Scale, decreased by 66% from baseline (p < or =.001), and mean scores on the Hamilton Rating Scale for Anxiety decreased by 63% (p < or =.05). Clinical Global Impressions scale scores also revealed significant improvement as a whole (p < or =.001), with 4 patients having complete symptom remission at the end of the study period. CONCLUSION: Findings suggest that olanzapine may be an effective monotherapy for trichotillomania.