Endoscopic management of Bouveret syndrome with electrohydraulic lithotripsy.

Video 1Endoscopic management of Bouveret syndrome with electrohydraulic lithotripsy.

Evaluation of Antioxidants in Discrete Regions of Brain after the Transplantation of Human Amniotic Epithelial Cells in 2,4,5-Trihydroxyphenylethylamine-lesioned Wistar Albino Rats.

Background and Aim: Parkinson's disease (PD) a neurodegenerative disorder for which no preventive or long term effective treatment strategies are available. Epidemiological studies have failed to identify specific environmental, dietary or lifestyle factors for PD. However oxidative stress in the substantia nigra (SN) and Corpus striatum is the most broadly accepted hypothesis for the etiopathology of PD. Many experiments state the notion that augmentation of neurotrophic factors and glial cell-derived neurotrophic factors, could prevent or halt the progress of neurodegeneration in PD. Material and Methods: The present study was designed to assess the motor behaviour with apomorphine injection and level of enzymatic and non-enzymatic antioxidants after transplantation of Human Amniotic Epithelial (HAE) cells in 2,4,5 trihydroxyphenylethylamine (6-OHDA) lesioned striatum in rats. Results: Human Amniotic Epithelial (HAE) cells ameliorated 6-OHDA induced changes in rotational behaviour and modulated the antioxidants. 6-OHDA induced neurotoxicity by the generation of free radicals was pronounced by indication of increased Lipid peroxidation (LPO) levels and decrease in antioxidants level. The present result suggest that increased free radicals and the decrease in the antioxidant defence system possibly lead to structural and functional alterations in membrane-related events and play significant role of the 6-OHDA induced neurotoxicity. In HAE cells transplanted animals the level of LPO was significantly reduced in striatum (36%) and moderately reduced (20%) in midbrain of the 6-OHDA lesioned animals. Conclusion: These alterations were found to be recovered after the HAE cells graft during long term. The 6-OHDA induced neurotoxicity by the generation of free radicals was pronounced by indication of the increased LPO level, decrease in antioxidants and alteration in the dopamine and its metabolites.

Nuciferine Attenuates Doxorubicin-Induced Cardiotoxicity: An In Vitro and In Vivo Study.

Chemotherapeutic drugs are a known factor that impairs the system of life due to their severe side effects. A more worrying fact is that the patients administered with doxorubicin fall under the risk of cardiotoxicity. The evolution of exploring plant-derived compounds is a possible way to combat health issues in therapeutic applications. Hence, this study focuses on the protective effect of plant-based compound nuciferine (NFN) against doxorubicin-induced cardiotoxicity in both in vitro and in vivo models. In this investigation, nuciferine significantly reduces DOX-mediated cardiotoxicity by mitigating reactive oxygen species, thereby preventing DNA fragmentation, regulating apoptosis genes and reducing the caspase 3/7 levels in vitro. Besides, nuciferine has shown significant protection against DOX-induced cardiac impairment and the upregulation of cardiogenic markers in vivo. The DOX-induced oxidative stress can be mitigated via enhancing the endogenous antioxidants, thereby controlling ROS-mediated apoptosis. In virtue of these potential features, nuciferine can be a budding candidate to address therapeutic needs.

Emergency general surgery 'Hot Clinic': Efficiency, prevention of hospital admissions and factors influencing patient experience.

OBJECTIVE: The constant pressure facing hospitals to reduce emergency inpatient admissions has led towards more consultant-led 'Hot Clinics' (HC). The patient experience in these settings remains poorly understood. This study evaluates the efficiency and ability of the HC to prevent unnecessary emergency surgical admissions and factors influencing the patient experience. METHODS: Patients were referred to the HC from the Emergency Department, General Practice or Out-of-Hours service over the initial six-week period. A questionnaire collected the reason for referral, management without a HC, final diagnosis and management. Appropriateness of referrals were evaluated by the HC consultant and retrospectively by a blinded consultant. A second questionnaire collected information on patient satisfaction in a subsequent study period. RESULTS: 119/126 referrals (94%) were judged appropriate in the HC analysis with 97/126 (77%) considered appropriate in the retrospective analysis. The HC reduced the amount of potential emergency surgical admissions from 114 to 14 (p < 0.001). In the second period, 114/121 patients (94%) rated the HC as very good or good; with privacy (p < 0.05) and decision-making (p < 0.001) linked to patient satisfaction. Comfort (p < 0.05) and decision-making (p < 0.001) were linked to patients recommending the service. 103 patients (85%) would be extremely, or very likely to recommend the HC service with 93 patients (77%) preferring HC treatment over a hospital admission. CONCLUSIONS: Most referrals to the HC were appropriate and it continues to prevent unnecessary emergency surgical admissions. The HC service is valued by NHS patients, who prefer HC treatment over admission. Various factors to improve the patient experience in HC have been identified.

Emergency general surgery 'Hot Clinics' reduce admission rates and duration of inpatient stay.

OBJECTIVE: To determine the impact of a 'Hot Clinic' (HC) on emergency general surgery patient flow-through. DESIGN: Prospective service evaluation study. SETTING: HC is a four-bedded area coordinated by a specialist nurse. The HC consultant sees emergency patients referred from the emergency department, general practitioners or those in preceding 24 h considered suitable for interim discharge while awaiting investigations and HC reassessment. PATIENTS: All patients with acute abdominal pain were evaluated in three 4 week groups: before (group 1), 1 month (group 2) and 6 months after the HC was introduced (group 3). Interhospital transfers, intrahospital ward referrals and trauma patients were excluded. INTERVENTION: Introduction of consultant-led surgical HC every weekday afternoon. MAIN OUTCOME MEASURES: Proportion of patients admitted under general surgeons, length of inpatient stay and the proportion of patients referred again within 3 months were investigated. RESULTS: 1409 patients were referred, of which 1061 met the inclusion criteria: 307 in group 1, 326 in group 2 and 428 in group 3. There was no difference in gender distribution (p=0.759). Inpatient admissions were significantly reduced (85.0% vs 78.2% vs 54.4%; p<0.001) and the inpatient duration of stay was significantly shorter after HC introduction (median (IQR) (95% CI) 63.8 (29.0-111.6) (51.8 to 72.8) hours vs 48.8 (21.7-101.2) (42.0 to 55.6) hours vs 47.7 (20.9-92.7) (42.8 to 56.9) hours; p=0.011). CONCLUSIONS: Emergency general surgery HCs are associated with significant reductions in admission rates and inpatient bed occupancy. This service redesign has the potential to dramatically relieve pressure on acute surgical services.

Are blood group and save samples needed for cholecystectomy?

BACKGROUND: Cholecystectomy is a common, safe procedure. This study aimed to determine whether a blood group and save approach still is required for primary cholecystectomy. METHODS: A retrospective regional analysis of all cholecystectomy patients identified from pathology records between January 1998 and February 2005 was undertaken. The study excluded from further analysis patients for whom cholecystectomy was not the primary operation or for whom the data were incomplete. RESULTS: A total of 4,652 patients were identified. Of these patients, 19 were excluded due to incomplete data and 171 were excluded because the cholecystectomy was secondary to another procedure. Of the remaining 4,462 patients, 2,916 (65.4%) had a blood sample sent to the blood transfusion service. The 2,916 patients were subdivided into blood group and save samples (2461/4462, 55.2%) and blood cross-matched samples (455/4462, 10.2%). Blood transfusion was required by 48 patients (48/4462, 1.1%). Subanalysis of the transfused group showed that 27 patients received a blood transfusion due to complications of the index operation, with 18 (18/27, 66.7%) undergoing transfusion while in the operating theater. The indication for transfusion in the remaining 21 patients was secondary to a reoperation for complications of laparoscopic cholecystectomy (n = 8), related to primary hematologic malignancy (n = 6), or not documented (n = 7). CONCLUSION: The use of routine blood group and save is not justified. A targeted approach will reduce the demand on blood transfusion service without detriment to those undergoing cholecystectomy. There is no substitute for adequate vigilance for bleeding as a complication with any surgical procedure.

Gallstone ileus: surgical strategies and clinical outcome.

OBJECTIVE: Gallstone ileus is a rare cause of intestinal obstruction affecting mainly the elderly. This study aimed to analyze the surgical treatments and outcome of the disease. METHODS: We present a retrospective study of 13 patients diagnosed with gallstone ileus from January 2000 to December 2005 in our hospital and a review of the published literature. RESULTS: Three men and 10 women participated in the study, with a mean age of 74.3 (range: 63-85). The mean duration of symptoms was 6 days (range 2-14). A pre operative diagnosis was made in 10 patients. The mean delay in diagnosis was 3.5 days (range 1-10). Ten patients had an enterolithotomy (E) and three patients had a one-stage procedure comprising enterolithotomy, cholecystectomy and fistula repair (EC). There was no postoperative mortality in either group. The mean postoperative hospital stay for group E was 14 (range 6-31) days and for group EC was 19 (range: 5-28) days. Twelve patients were alive at the time of review. One patient from group E died of unrelated causes after three years. One patient in group E developed cholangitis but no surgical intervention was required on case note review over a mean postoperative period of 3.4 years. CONCLUSION: E alone is best suited in all elderly gallstone ileus patients with significant comorbidities. A one-stage procedure (EC) should be reserved for young, fit and low risk patients.

Oxidative stress in brain and antioxidant activity of Ocimum sanctum in noise exposure.

Noise is a pervasive aspect of many modern communities, work environments and its damaging effects, particularly the production of free radicals are not limited to the auditory organ. The oxidative stress in three discrete brain regions, in wistar strain male albino rats subjected to three different durations of noise exposures (acute, sub-acute and chronic noise stress) and the in vivo as well as the in vitro antioxidant activity of Ocimum sanctum has been analyzed. Broadband white noise (100dB) exposure significantly increased the levels of superoxide dismutase (EC 1.15.1.1), catalase (EC 1.11.1.6), glutathione peroxidase (EC 1.11.1.9), lipid peroxidation, oxidized glutathione (GSSG) and decreased the levels of reduced glutathione (GSH), GSH/GSSG ratio. However, administration of ethanolic extract of O. sanctum attenuates the alterations induced by noise exposure. The antioxidant activity of O. sanctum is also evident from its effectiveness in scavenging the free radicals in a dose dependent manner in the herbal antioxidant assays. The results indicate that adaptation to noise does not occur in the brain regions even after 30 days of noise exposure. The abundance of phytochemicals such as phenolics and flavanoids in O. sanctum may be held responsible for its attenuating activity. Therefore, this study indicates that O. sanctum has the potential for further evaluation as an ideal antioxidant for the noise induced oxidative stress.

Stress response in rat brain after different durations of noise exposure.

The alteration in the levels of plasma corticosterone, brain norepinephrine (NE), and expression of brain heat shock proteins (Hsp70) after different durations of noise exposure (acute, 1 day; sub-acute, 15 days; chronic, 30 days) has been studied to analyze their role in combating time-dependent stress effects of noise. Broadband white noise (100dB) exposure to male Wistar albino rats significantly increased the levels of plasma corticosterone and NE in all three durations of noise exposure. The sustained increase observed in their levels in the chronic group suggests that animals are not getting adapted to noise even after 30 days of exposure. The important role of Hsp70 in combating noise induced stress is evident from the significant increase in its expression after chronic exposure, while there was a reciprocal decrease in the NE and corticosterone when compared with their levels after acute and sub-acute noise exposure. This clearly indicates that the time-dependent stress response to noise exposure is a complex mechanism involving highly interconnected systems such as hypothalamo-pituitary-adrenal (HPA) axis, heat shock proteins and may have serious implications in vital organs, particularly in the brain when there is a prolonged noise exposure.

A United Kingdom survey of surgical technique and handling practice of inguinal canal structures during hernia surgery.

BACKGROUND: Recent trials have assessed the impact of elective nerve division on patient outcome after inguinal herniorrhaphy. The aim of this study was to establish UK surgical practice of handling of structures in the inguinal canal during herniorrhaphy. METHODS: A cross-sectional survey of all Fellows (n = 1113) of the Association of Surgeons of Great Britain and Ireland (ASGBI) was performed. The main outcomes were to determine method of inguinal hernia repair and routine practice for intra-operative handling of structures in the inguinal canal. RESULTS: A total of 852 (77%) questionnaires were returned, of which 784 (92%) surgeons performed inguinal herniorrhaphy. Approximately two-thirds (63%) of responding surgeons performed less than 50 procedures per annum and 37% conducted more than 50 procedures annually. Mesh was the preferred method used by 90% of surgeons; 6% used non-mesh, and 4% used other (laparoscopic) methods. Routine practice in relation to the inguinal structures varied by volume of hernia surgery; surgeons who conducted more than 50 procedures annually were more likely to visualize and preserve inguinal nerve structures. However, inconsistency in the answers suggested confusion over anatomy. CONCLUSION: This is the first UK survey to investigate method of hernia repair and usual handling practice of inguinal canal structures. There was wide acceptance of the use of mesh in inguinal hernia repair, with the majority of UK surgeons favoring an open approach. Surgeons performing high volumes of herniorrhaphy were more likely to preserve, rather than transect, inguinal nerve structures. This variation in practice may confound assessment of long-term neuralgia and other post-herniorrhaphy pain syndromes.

Noise-stress-induced brain neurotransmitter changes and the effect of Ocimum sanctum (Linn) treatment in albino rats.

In this modern world, stress and pollution are unavoidable phenomena affecting the body system at various levels. A large number of people are exposed to potentially hazardous noise levels in daily modern life, such as noise from work environments, urban traffic, and household appliances. A variety of studies have suggested an association between noise exposure and the occurrence of disorders involving extra-auditory organs such as disorders of the nervous, endocrine, and cardiovascular systems. In this study, Wistar strain albino rats were subjected to 100 dB broadband white noise, 4 h daily for 15 days. The high-pressure liquid chromatographic estimation of norepinephrine, epinephrine, dopamine, and serotonin in discrete regions of the rat brain indicates that noise stress can alter the brain biogenic amines after 15 days of stress exposure. Ocimum sanctum (OS), a medicinal herb that is widely claimed to posses antistressor activity and used extensively in the Indian system of medicine for a variety of disorders, was chosen for this study. Administration of the 70% ethanolic extract of OS had a normalizing action on discrete regions of brain and controlled the alteration in neurotransmitter levels due to noise stress, emphasizing the antistressor potential of this plant.