MIS retromuscular repair of lateral incisional hernia: technological deliberations and short-term outcome.

BACKGROUND: Lateral abdominal wall hernias (LAWH) constitute about 1-4% of hernia surgical procedures. They represent a unique surgical challenge on account of their potential for anatomical complexity and consequent operative technical demand. Furthermore, LAWH repairs are currently not standardized, and remain contentious, despite a variety of approaches. These repairs are attendant with not insignificant morbidity and recurrence rates. We profile here our endoscopic and hybrid surgical approach to the management of LAWH and early therapeutic outcomes. METHODS: A retrospective review of our hernia clinical database between March 2018 and December 2020 was performed to extract all LAWH (with and without an associated midline component) patients, who underwent an enhanced-view totally extra peritoneal (eTEP) hernia repair with a transversus abdominis release (TAR), or a hybrid repair. Initial outcome data (6-month follow-up) is profiled here. The primary outcome measures were hernia recurrence and hernia-site bulging. The secondary measures were surgical site occurrence (SSO) and hernia-related quality of life (QoL). RESULTS: A total of 33 LAWH patients underwent an eTEP TAR or hybrid hernia repair. 11 patients had an associated midline defect and 12 were recurrent hernias. The mean hernia defect area was 84.2 ± 49 cm2 and mean mesh size was 859.6 ± 263 cm2. There was no hernia recurrence at initial follow-up of 24 months. The SSO rate was 12%. The CCS QoL scores were 34.6 ± 2 pre-operatively, and improved to 27.2 ± 4 at 6 months. CONCLUSIONS: Our endoscopic and hybrid technique is a safe, reproducible, and technically promising approach for the repair of LAWH. Thorough knowledge of the surgical anatomy of the lateral abdominal wall and advanced endosurgical skills are imperative for good outcomes. We await the long-term results of our LAWH cohort to confirm the findings.

A synchronous presentation of two different ovarian tumors: a rare occurrence.

Approximately 60% of all ovarian tumors are epithelial in origin, and these neoplasms are thought to arise from the ovarian surface epithelium or small epithelial inclusion cysts. Surface epithelium is capable of differentiating into serous (tubal), mucinous, endometrioid or transitional epithelium. Serous and mucinous cystadenomas are the most common epithelial tumors and, together, account for about 30% of ovarian tumors We report a case of a 29-year-old lady P1L1 presenting with the chief complaints of pain abdomen off and on since the last 1 year. Ultrasonography revealed normal uterus with enlarged right ovary, with a cyst measuring 46 mm × 36 mm × 55 mm showing internal echoes with volume of 50 cc., left ovary also enlarged with multiple well-defined cysts measuring 34 mm × 44 mm × 69 mm with volume of 55 cc and the largest cyst measuring 37 mm. Bilateral ovarian cystectomy was done and sent for histopathology. To our surprise, both the ovaries revealed different histopathological pictures, with the right ovary revealing serous cystadenoma and the left ovary showing mucinous cystadenoma. This rare occurrence has never been reported so far in the literature to the best of our knowledge.

Histopathologic changes following neoadjuvant chemotherapy in locally advanced breast cancer.

AIMS: To compare the clinical and pathologic assessment of response to neoadjuvant chemotherapy and describe the various histopathologic changes observed. MATERIALS AND METHODS: We studied a group of 40 patients with locally advanced breast cancer who had their initial workup in the form of clinico-imaging assessment of the size and pretreatment biopsy from the lesion. All the patients received two to six cycles of neoadjuvant chemotherapy, either cyclophosphamide 50 to 60 mg/m 2 IV, doxorubicin 40 to 50 mg/m 2 IV and 5-fluorouracil 500 to 800 mg/m 2 IV (CAF) or cyclophosphamide, epirubicin, and 5-fluorouracil (CEF). Clinical and pathologic assessment of response to chemotherapy was done based on the UICC guidelines. RESULT: Complete clinical response (cCR) was seen in 10% cases (4/40), thirty percent patients had (12/40) partial response and 60% (24/40) had stable disease after neoadjuvant chemotherapy. Pathologic complete response (pCR) with no evidence of viable tumor was observed in 20% patients (8/40). Fifteen patients (37.5%) showed partial response and 42.5% patients (17/40) had a stable disease. No patient progressed during the course of chemotherapy. Changes in the tumor type were observed following chemotherapy, most common being the mucinous change. Histologic changes like dyscohesion, shrinkage of tumor cells, elastosis, collagenization, necrosis, lymphocytic reaction, giant cell response are some of the common observations seen following treatment with neoadjuvant chemotherapy. CONCLUSION: Pathologic assessment of response to neoadjuvant chemotherapy is a better predictor than the clinical response. The chemotherapy drugs can be modified based on the response observed after 1-2 cycles of neoadjuvant, the response being based on both tumor and patient's responsiveness.

Postoperative adhesive intestinal obstruction from gossypiboma.

Retained foreign bodies after surgery is a rare condition which can have medico-legal consequences. Foreign bodies forgotten in the abdomen include towels, artery forceps, pieces of broken instruments or irrigation sets, and rubber tubes. The most common surgically retained foreign body is the laparotomy sponge. Such materials cause foreign body reaction in the surrounding tissue. The complications caused by these foreign bodies are well known, but cases are rarely published because of medico-legal implications. We report a case of 41-year-old female admitted with features of intestinal obstruction and had a previous history of hysterectomy performed 2 months back at another hospital. Pathologists must be aware of this entity and its proper reporting as the cases are liable to go to court. Surgeons must recognize the risk factors that lead to a gossypiboma and take measures to prevent it.

New protocol for oligonucleotide microarray fabrication using SU-8-coated glass microslides.

Microarray technology has become an important tool for detection and analysis of nucleic acid targets. Immobilization of modified and unmodified oligonucleotides on epoxy-functionalized glass surfaces is often used in microarray fabrication. Here, we demonstrate a protocol that employs coating of SU-8 (glycidyl ether of bisphenol A) onto glass microslides to obtain high density of epoxy functions for efficient immobilization of aminoalkyl-, thiophosphoryl-, and phosphorylated oligonucleotides with uniform spot morphology. The resulting microarrays exhibited high immobilization (∼65%) and hybridization efficiency (30-36%) and were sufficiently stable over a range of temperature and pH conditions. The prominent feature of the protocol is that spots can be visualized distinctly at 0.05 µM probe (a 20-mer oligonucleotide) concentration. The constructed microarrays were subsequently used for detection of base mismatches and bacterial diseases (meningitis and typhoid).

Ministry of Health clinical practice guidelines: Management of Rhinosinusitis and Allergic Rhinitis.

The Ministry of Health publishes national clinical practice guidelines to provide doctors and patients in Singapore with evidence-based guidance on managing important medical conditions. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the Ministry of Health clinical practice guidelines on Management of Rhinosinusitis and Allergic Rhinitis, for the information of readers of the Singapore Medical Journal. Chapters, page and figure numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website (http://www.moh.gov.sg/mohcorp/publications.aspx?id=24046). The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Sphenoid sinus mucocele: 10 cases and literature review.

INTRODUCTION: Sphenoid sinus mucoceles represent only 1-2 per cent of all paranasal sinus mucoceles. Patients may present with a myriad of symptoms. Pre-operative investigations include nasoendoscopy, computed tomography and/or magnetic resonance imaging. Treatment is by endoscopic sinus surgery. METHODOLOGY: A retrospective review of the archives of the Singapore General Hospital otolaryngology department (1999-2006) identified 10 cases of sphenoid sinus mucocele. Patient demographics, presenting symptoms, investigations and treatment were evaluated. RESULTS: The 10 patients identified (three women and seven men) had a mean age of 54.5 years (range 24-70 years). Thirty per cent of patients had a history of nasopharyngeal carcinoma treated with radiotherapy. Presenting symptoms, in order of decreasing frequency, were: ocular symptoms (50 per cent), headaches (30 per cent), nasal discharge (30 per cent) and facial pain (10 per cent). All patients underwent pre-operative computed tomography or magnetic resonance imaging. Twenty per cent of patients had evidence of intracranial involvement on imaging. All patients underwent uncomplicated transnasal sphenoidotomy and drainage of the mucocele. There was no clinical or radiological evidence of recurrence at a mean follow up of 29 months (range 4-90 months). CONCLUSION: Sphenoid sinus mucocele is a rare condition. In this study, radiation to the head and neck appeared to be a predisposing factor, and eye symptoms were the commonest presentation. Endoscopic sinus surgery is a safe and effective treatment modality.

Construction of oligonucleotide microarrays (biochips) via thioether linkage for the detection of bacterial meningitis.

Oligonucleotide-based arrays are increasingly becoming useful tools for the analysis of gene expression and single-nucleotide polymorphism. Here, we report a method that allows the direct immobilization of thiolated oligonucleotides onto an epoxy-activated glass surface via a stable thioether linkage under microwaves. The described chemistry efficiently immobilizes the probes via terminal thiol groups with uniform spot morphology. The thioether linkage could endure repeated PCR-like heat cycling with only 2.5% loss after 20 cycles, indicating that the chemistry can be used in integrated PCR/microarray devices. The highlighting feature of the proposed method is that the detection limit for the probe concentration can be reduced to 0.25 microM with 20-mer oligonucleotides. The efficiency of the projected method (approximately 33%) indicates its advantage over the existing standard methods, viz., NTMTA (approximately 9.8%), epoxide-amine (approximately 9.8%) and disulfide (approximately 1.7%). The constructed microarrays were validated through the detection of base mismatches and bacterial meningitis. These features make the projected strategy ideal for manufacturing oligonucleotide arrays and detection of mismatches and bacterial diseases.

Mortality due to injuries by place of occurrence in the European region: analysis of data quality in the WHO mortality database.

BACKGROUND AND OBJECTIVE: The 10th revision of the International Classification of Diseases (ICD-10) has codes for the place of occurrence of external causes of mortality. The purpose of this study was to investigate the quality of data available in the World Health Organization (WHO) mortality database on the place of occurrence of fatal injuries in the European region. METHODS: Data on external causes of mortality from countries in the European region according to the ICD-10 with four-character subdivision, between the years 1998 and 2003, were analysed. The quality of ICD-10 place of occurrence data was analysed for each country, based on the completeness, coverage and percentage of unspecified place of injury occurrence. RESULTS: Only three countries in the European region (Hungary, Iceland and Lithuania) had high quality of data on place of occurrence of injuries, and six had medium-quality data. CONCLUSIONS: Few countries in the European region have injury mortality data of adequate quality by place of occurrence.

Polymer supported synthesis of aminooxyalkylated oligonucleotides, and some applications in the fabrication of microarrays.

A new protocol has been described for solid phase preparation of 3'- and 5'-aminooxylalkylated oligonucleotides using commercially available reagents. This involves attachment of linker 4 either with an LCAA-CPG support via succinoylation followed by synthesis (3'-aminooxyalkylated oligomers) or formation of its phosphoramidite 6 followed by coupling with desired oligomer (for generating 5'-aminooxyalkylated oligomers). Both the routes produced modified oligonucleotides in sufficiently high yields and purity (on HPLC) via conventional oligonucleotide synthesis on an automated synthesizer and deprotection step using aqueous ammonia (16 h, 60 degrees C). Aminooxyalkylated oligonucleotides were used to construct microarrays on glass surface (biochips). The performance of the biochips was evaluated by immobilizing modified oligonucleotides on epoxylated glass microslides under different sets of conditions with respect to pH, temperature and time. Further, the constructed microarrays were successfully used for detection of nucleotide mismatches and bacterial typhoid.

Long-term results of endoscopic resection of nasopharyngeal tumours.

Traditional open approaches to the nasopharynx either provide limited access and risk significant morbidity. Here we describe our experience with endoscopic resection of nasopharyngeal tumours. Retrospective chart review was performed for all patients who underwent endoscopic nasopharyngeal resection from September 1993 to January 2007 at a tertiary rhinology centre. Six patients underwent endoscopic nasopharyngectomy for tumours arising from or involving the nasopharynx. The mean age was 49.8 years (range 23 - 70). The sex distribution was five males and one female. Four tumours were malignant and two were benign. The mean disease-free and overall survival for malignant tumors was 90.75 months (range 66 - 120 months). None of the benign tumors recurred. The endoscopic nasopharyngectomy technique may be successfully used for resection of tumors arising from or involving the nasopharynx with good efficacy and a decrease in morbidity when compared to open approaches.

Giant petrous carotid aneurysm: persistent epistaxis despite internal carotid artery ligation.

OBJECTIVES: We report a rare case of giant petrous carotid aneurysm. METHOD: Case report and a review of the literature regarding treatment options for such aneurysms. RESULTS: A 30-year-old man presented with epistaxis, headaches and visual disturbance. Definitive diagnosis was achieved by non-invasive imaging techniques, including magnetic resonance angiography and carotid angiography. Carotid angiography demonstrated a giant petrous carotid aneurysm effacing the petrous apex. The aneurysm was obliterated by internal carotid artery ligation, following successful tolerance of the balloon occlusion test. However, despite internal carotid artery ligation, this patient continued to have minor episodes of epistaxis. CONCLUSION: Some aneurysms are too large to be treated with endovascular occlusion techniques; in such cases, ligation of the parent vessel is indicated. However, our patient continued to experience persistent, mild epistaxis despite internal carotid artery ligation, as a result of the reperfusion phenomenon.

Tubercular and chronic pyogenic osteomyelitis of cranio-facial bones: a retrospective analysis.

AIM: To analyse current trends in our population with respect to the presentation, diagnosis and management of tubercular and chronic pyogenic osteomyelitis of the cranio-facial bones. DESIGN: Retrospective study. SETTING: Tertiary healthcare centre. PATIENTS AND METHODS: The study population comprised 14 patients with tubercular and chronic pyogenic osteomyelitis who were managed in the otorhinolaryngology department between May 2002 and December 2005. RESULTS: Odontogenic infections, sinus infections and aural infections were the most commonly identified aetiological factors. Most of the patients presented with swelling, pain and discharging sinus. The diagnosis was established on the basis of clinical evaluation, radiological investigations and histopathological analysis, with six cases diagnosed with tubercular osteomyelitis and eight cases with chronic pyogenic osteomyelitis. All the patients were initially commenced on oral antibiotics, which were continued for two weeks in all cases with chronic pyogenic osteomyelitis. All the patients with pyogenic osteomyelitis underwent surgical management, with one patient requiring repeated surgical interventions. All the patients with tubercular osteomyelitis received anti-tubercular chemotherapy, with complete cure. CONCLUSIONS: Osteomyelitis of the cranio-facial bones is an uncommon entity which requires a high index of clinical suspicion along with radiological and histopathological investigations in order to establish the diagnosis. Tubercular osteomyelitis is clinically and radiologically indistinguishable from pyogenic osteomyelitis, and the two conditions can be differentiated only on the basis of histopathological evaluation of involved tissue.

Recurrence of focal seizure activity in an infant during induction of anaesthesia with sevoflurane.

A three-month-old male infant, previously diagnosed with seizures with a focal origin induced by hypocalcaemia secondary to hypoparathyroidism, presented for right cataract surgery. The hypocalcaemia and seizure activity had resolved with medical therapy, with normal calcium levels and no seizures for a month. Anaesthesia with halothane and isoflurane for left cataract surgery two days previously had been uneventful. During induction of anaesthesia with sevoflurane for the right cataract surgery, the patient had a focal seizure similar to those previously occurring when the patient was hypocalcaemic. The patient had normal calcium levels at the time of surgery. It appears likely that sevoflurane had triggered seizure activity in the apparently controlled focus. The potential for sevoflurane to induce epileptogenic activity in patients with reduced seizure threshold is discussed.

Coexistent acute pyogenic and tubercular petrous apicitis: a diagnostic dilemma.

We report the case of a 16-year-old boy who presented to us with acute otitis media, facial weakness and retro-orbital pain. Computed tomography and magnetic resonance imaging (MRI) scans of the head and temporal bone revealed otitis media with petrous apicitis. The patient responded to broad-spectrum, parenteral antibiotics, with disappearance of facial weakness and reduction in pain. One month following the completion of treatment, the patient continued to have dull retro-orbital pain and developed ear discharge. A repeat MRI of the temporal bone revealed a persistent inflammatory lesion in the petrous apex, with a nodular, ring-enhancing lesion in the cerebellum, strongly suggestive of tuberculosis. The ear discharge stained positive for acid-fast bacilli and the patient's serum enzyme-linked immunosorbent assay for tuberculosis was reactive. The patient responded well to anti-tubercular treatment and was disease free eight months following the completion of treatment.

Experience of domestic violence by women attending an inner city accident and emergency department.

OBJECTIVES: To identify the prevalence of domestic violence (DV) (defined as physical abuse perpetrated by intimate partners) in women attending an inner city accident and emergency department and to elicit women's response about being asked routinely about domestic violence in this setting. METHODS: 22 nursing shifts were purposefully sampled to be representative of day, night, and weekends. A questionnaire was administered to 198 consenting women who were not intoxicated, confused, or critically ill. RESULTS: The prevalence of acute trauma in women attributable to DV was 1% (95%CI 0.14 to 3.6), the prevalence of lifetime physical abuse was 34.8% (95%CI 28.2 to 41.5), of past year physical abuse was 6.1% (95%CI 3.2 to 10.3), and of lifetime life threatening physical abuse was 10.6% (95%CI 6.3 to 14.9). Seventy six per cent of women felt comfortable about being asked about DV and 60.5% of women felt that they should always or usually be asked about DV in this setting. CONCLUSION: This cross sectional survey adds to the body of knowledge showing that the prevalence of DV in women attending an accident and emergency department is high. Most women were in favour of being asked, and disclosure was associated with discomfort in few women. This sensitive area of history taking and referral could be undertaken by health professionals using a supportive approach.

The infectious intestinal disease study of England: a prospective evaluation of symptoms and health care use after an acute episode.

The sequelae of Infectious Intestinal Disease (IID) in a population-based sample of cases and matched controls were investigated for a period of 3 months following the initial infection. Incident cases of IID presenting to GPs or occurring in the community and controls were studied at 3 weeks and over a 3-month follow-up period. Cases were six times more likely than controls to have gastrointestinal symptoms, particularly diarrhoea, at 3 weeks. Ten per cent of cases consulted their GP in the 3 months after episode and 2.3% were referred to hospital. GP presentation rates were twice as high in cases. Gastrointestinal symptoms persist after IID, leading to an increased likelihood of GP consultation and hospital referral. Diagnosis of irritable bowel syndrome may be more likely following IID. The burden of IID is likely to be considerable given its high incidence and the frequency of such sequelae.

The study of infectious intestinal disease in England: socio-economic impact.

To assess the socio-economic impact of infectious intestinal disease (IID) on the health care sector, cases and their families, cases of IID ascertained from a population cohort component and those presenting to general practices were sent a socio-economic questionnaire 3 weeks after the acute episode. The impact of the illness was measured and the resources used were identified and costed. The duration, severity and costs of illness linked to viruses were less than those linked to bacteria. The average cost per case of IID presenting to the GP was Pound Sterling253 and the costs of those not seeing a GP were Pound Sterling34. The average cost per case was Pound Sterling606 for a case with salmonella, Pound Sterling315 for campylobacter, Pound Sterling164 for rotavirus and Pound Sterling176 for SRSV. The estimated cost of IID in England was Pound Sterling743m expressed in 1994/5 prices. The costs of IID are considerable and the duration of the illness was found to be longer than previous reports have suggested.

The study of infectious intestinal disease in England: risk factors for cases of infectious intestinal disease with Campylobacter jejuni infection.

This is a case-control study aimed at identifying risk factors for intestinal infection with Campylobacter jejuni. Cases were defined as subjects with diarrhoea occurring in community cohorts or presenting to General Practitioners (GPs) with Campylobacter jejuni in stools. Controls were selected from GP lists or cohorts, matched by age, sex, and GP practice. Travel abroad and consumption of chicken in a restaurant were statistically significantly associated with being a case. There was no statistically significant risk associated with consumption of chicken other than in restaurants nor with reported domestic kitchen hygiene practices. Consumption of some foods was associated with a lower risk of being a case. Most cases remained unexplained. We suggest that infection with low numbers of micro-organisms, and individual susceptibility may play a greater role in the causation of campylobacter infection than previously thought. It is possible that in mild, sporadic cases infection may result from cross contamination from kitchen hygiene practices usually regarded as acceptable. Chicken may be a less important vehicle of infection for sporadic cases than for outbreaks, although its role as a source of infection in both settings requires further clarification in particular in relation to the effect of domestic hygiene practices. The potential effect of diet in reducing the risk of campylobacteriosis requires exploration.

Advanced trauma life support training for ambulance crews.

BACKGROUND: There is an increasing global burden of disease from injuries. Models of trauma care initially developed in high-income countries are also being adopted in low and middle-income countries (LMIC). Amongst these ambulance crews with Advanced Life Support (ALS) training are being promoted in LMIC as a strategy for improving outcomes for victims of trauma. However there is controversy as to the effectiveness of this health service intervention, and the evidence has yet to be rigorously appraised. OBJECTIVES: To quantify the effectiveness of ambulance crews with ALS training versus crews with any other level of training in reducing mortality and morbidity in trauma patients. SEARCH STRATEGY: We searched the Cochrane Controlled Trial Register (CCTR), the specialised register of the Cochrane Injuries Group, MEDLINE, EMBASE, CINAHL, PubMed and the National Research Register. We checked references of background papers and contacted authors to identify additional published or unpublished data. SELECTION CRITERIA: Randomised controlled trials, quasi-randomised controlled trials and controlled before-and-after studies comparing effectiveness of ambulance crews with ALS training versus crews with any other levels of training in reducing mortality and morbidity in trauma patients. Studies which compared crews staffed by physicians versus others were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied eligibility criteria to trial reports for inclusion and extracted data. MAIN RESULTS: We found one randomised controlled trial, which included 16 trauma cases. However, outcome data were added to the main non-randomised cohort in the analysis, and data on these 16 cases are not yet available. REVIEWER'S CONCLUSIONS: In the absence of evidence of the effectiveness of advanced life support, strong argument could be made that it should not be promoted outside the context of a properly concealed and otherwise rigorously conducted randomised controlled trial.