Mini-lap cholecystectomy: a viable alternative to laparoscopic cholecystectomy for the Third World?

BACKGROUND

Laparoscopic cholecystectomy (LC) requires expensive equipment and special training. Mini-lap cholecystectomy (MLC) has no start-up costs but no large series from a single centre has been reported as the procedure is considered hazardous because of inadequate exposure of the surgical field.

METHODS

We retrospectively reviewed the outcome of 737 cholecystectomies performed through a 3-5-cm transverse subcostal incision and compared the results to published series of laparoscopic cholecystectomy.

RESULTS

The operating time (61.6 min; range 35-130), conversion rate (4%), rate of postoperative complications (3.6%), bile duct injuries (0.3%), number of analgesic doses required (3.4; range 3-8), duration of postoperative hospital stay (1.4; range 1-15 days), and the time off work (13.3 days; range 8-61) compare well with the reported results of laparoscopic and MLC. Ninety-three per cent of the patients were followed up for a median period of 28.4 months and none developed biliary stricture.

CONCLUSIONS

Mini-lap cholecystectomy is considered a safe, viable alternative to LC in the Third World.

Knowledge, attitude, belief and practice (K.A.B.P) study on AIDS among senior secondary students

A cross-sectional survey was done among students of four senior secondary schools including two boys and two girls schools of rural Delhi to know the knowledge, attitude, belief and practices regarding AIDS. A large majority (83.0%) of students though had heard about AIDS, yet majority of them did not know the possible methods for prevention of AIDS. There were only 27.1% girls who knew about regular condom usage. Half of them had permissible attitude for pre-maritial sex, while sexual activity was observed in one-fourth students. Students were less reluctant to discuss about AIDS than sex, and teachers were preferred as compared to parents in this regard. School is an ideal setting to educate adolescents regarding HIV/AIDS transmission and safer sex behaviour.

Role of members of the Wnt gene family in human hematopoiesis

The hematopoietic system is derived from ventral mesoderm. A number of genes that are important in mesoderm development have been identified including members of the transforming growth factor-beta (TGF-beta) superfamily, the fibroblast growth factor (FGF) family, and the Wnt gene family. Because TGF-beta plays a pleiotropic role in hematopoiesis, we wished to determine if other genes that are important in mesoderm development, specifically members of the Wnt gene family, may play a role in hematopoiesis. Three members of the Wnt gene family (Wnt-5A, Wnt-2B, and Wnt-10B) were identified and cloned from human fetal bone stromal cells. These genes are expressed to varying levels in hematopoietic cell lines derived from T cells, B cells, myeloid cells, and erythroid cells; however, only Wnt-5A was expressed in CD34(+)Lin- primitive progenitor cells. The in vitro biological activity of these Wnt genes on CD34(+)Lin- hematopoietic progenitors was determined in a feeder cell coculture system and assayed by quantitating progenitor cell numbers, CD34(+) cell numbers, and numbers of differentiated cell types. The number of hematopoietic progenitor cells was markedly affected by exposure to stromal cell layers expressing Wnt genes with 10- to 20-fold higher numbers of mixed colony-forming units (CFU-MIX), 1.5- to 2. 6-fold higher numbers of CFU-granulocyte macrophage (CFU-GM), and greater than 10-fold higher numbers of burst-forming units-erythroid (BFU-E) in the Wnt-expressing cocultures compared with the controls. Colony formation by cells expanded on the Wnt-expressing cocultures was similar for each of the three genes, indicating similar action on primitive progenitor cells; however, Wnt-10B showed differential activity on erythroid progenitors (BFU-E) compared with Wnt-5A and Wnt-2B. Cocultures containing Wnt-10B alone or in combination with all three Wnt genes had threefold to fourfold lower BFU-E colony numbers than the Wnt-5A- or Wnt-2B-expressing cocultures. The frequency of CD34(+) cells was higher in Wnt-expressing cocultures and cellular morphology indicated that coculture in the presence of Wnt genes resulted in higher numbers of less differentiated hematopoietic cells and fewer mature cells than controls. These data indicate that the gene products of the Wnt family function as hematopoietic growth factors, and that they may exhibit higher specificity for earlier progenitor cells.

Osteodysplastic primordial dwarfism type II with normal intellect but delayed central nervous system myelination

We describe a 7-year-boy with severe prenatal and postnatal growth retardation, skeletal changes, normal intellect, and unusual facial appearance. The skeletal changes are suggestive of osteodysplastic primordial dwarfism type II (OPD II). He is the first patient of this kind from the Indian subcontinent and the 18th to be reported, based on a literature search (MEDLINE; 1982 to April 1997). He also represents the first case of OPD-II with normal intellect but delayed central nervous system myelination.

Autophosphorylation of Src and Yes blocks their inactivation by Csk phosphorylation

Csk phosphorylates Src family protein tyrosine kinases on a tyrosine residue near their C-terminus and downregulates their activity. We previously observed that this regulation requires a stoichiometric ratio of Csk:Src in a time-independent manner. In this report we examined this unusual kinetic behavior and found it to be caused by Src autophosphorylation. First, pre-incubation of Src with ATP-Mg led to time-dependent autophosphorylation of Src, activation of its kinase activity and loss of its ability to be inactivated by Csk. However, the autophosphorylated Src can still be phosphorylated by Csk. The SH2 binding site for phospho-Tyr of this hyperactive and doubly phosphorylated form of Src is not accessible. Second, dephosphorylation of autophosphorylated Src by protein tyrosine phosphatase 1B allowed Src to be inactivated by Csk. Third, protein tyrosine phosphatase 1B preferentially dephosphorylates the Src autophosphorylation site and allows for Src regulation by Csk. Finally, Yes, another member of the Src family, was also only partially inactivated when a sub-stoichiometric amount of Csk was used. Mutation of the tyrosine autophosphorylation site of Yes to a phenylalanine resulted in a mutant Yes enzyme that can be fully inactivated by a sub-stoichiometric amount of Csk in a time-dependent manner. These results demonstrate that Csk phosphorylation inactivates Src and Yes only when they are not previously autophosphorylated and Src autophosphorylation can block the inactivation by Csk phosphorylation. This conclusion suggests a dynamic model for the regulation of the Src family protein tyrosine kinases, which is discussed in the context of previously reported observations on the regulation of Src family protein tyrosine kinases.

Modulation of lympho-proliferative responses of ovine peripheral blood mononuclear cells by Mycoplasma mycoides ssp. mycoides (LC type)

The present study was carried out to investigate the immunomodulating potential of M. mycoides ssp. mycoides (Mmm) (LC): a standard strain (Y-Goat, YG) and a local strain (M30) isolated from the pneumonic lung of a lamb during an outbreak of respiratory disease. The study was conducted in two parts to determine in vitro and in vivo aspects of the Mmm-induced modulation of cellular immune responses. In vitro experiments, using peripheral blood mononuclear cells (PBMC) of naive lambs, showed that live (Lv) or inactivated (Ina) antigens of Mmm (strains YG and M30) were not mitogenic for PBMC. Live antigens of both the strains, however, induced significant suppression of the PHA-driven lympho-proliferative (LP) responses. Suppression of LP responses by infectious Mmm (both strains) was restored in the presence of exogenous recombinant human interleukin-2 (rhIL-2). Following experimental inoculation of lambs with Mmm (YG), a significant reduction in non-specific LP responses was observed on days 6, 10 and 14 post inoculation (p.i.). There was a slow but significant rise in memory LP responses to Mmm strains (YG and M30). Specific subset depletion studies, using immunomagnetic cell separation (IMCS) technique, carried out on days 10 and 14 p.i., revealed that the OvCD4+ cell population was the main proliferating lymphocyte subset following an infection with Mmm (LC type).

Effects of Momordica charantia fruit juice on islet morphology in the pancreas of the streptozotocin-diabetic rat

An investigation was made of the effect of Momordica charantia fruit juice on the distribution and number of alpha, beta and delta cells in the pancreas of streptozotocin (STZ)-induced diabetic rats using immunohistochemical methods. The results indicated that there was a significant (Student's t-test, P < 0.004) increase in the number of beta cells in M. charantia-treated animals when compared with untreated diabetics, however, their number was still significantly less than that obtained for normal rats. There was also a significant (P < 0.006) increase in the number of delta cells in STZ-diabetic rats compared to non-diabetic rats. This increase in the number of delta cells was not affected by M. charantia treatment. The number of alpha cells did not change significantly in M. charantia-treated rats when compared with untreated diabetic rats. Our results suggest that oral feeding of M. charantia fruit juice may have a role in the renewal of beta cells in STZ-diabetic rats or alternately may permit the recovery of partially destroyed beta cells.

Acute suppurative thyroiditis with demonstrable distant primary focus: a report of two cases

Two cases of acute suppurative thyroiditis occurring in a normal thyroid gland secondary to a demonstrable primary focus at a distant site are described and the role of interventional radiology in the management is discussed.

Pitfalls in the management of Mirizzi's syndrome

Pressure on the common hepatic duct due to a gallstone impacted in Hartmann's pouch or cystic duct results in jaundice and cholangitis. Repeated episodes of inflammation and pressure necrosis lead to the formation of a cholecysto-choledochal fistula (Mirizzi's syndrome Type I & II). Preoperative diagnosis is difficult and a formal cholecystectomy may lead to bile duct injury. Of the 792 patients operated upon for symptomatic gallstone disease from June 1992 to June 1997 at our centre, 18 patients (2%) had Mirizzi's syndrome. There were 11 females and 5 males, with a mean age of 48 (SD 20; range 20-74) years. Thirteen patients (81%) presented with cholangitis. Ultrasound scan suggested the diagnosis of carcinoma gallbladder in 9 (56%). Endoscopic Retrograde Cholangiopancreatography (ERCP) confirmed the diagnosis in 16. Cholecystectomy was done by the fundus first technique. A complete cholecystectomy was done only if there was no cholecysto-choledochal fistula (n = 5), otherwise a cuff of gallbladder was used to repair the bile duct (n = 10). Hepatico-jejunostomy was done to drain the fistula in one patient. A T-tube drain was placed in the common bile duct (CBD) and a cholangiogram done, before closing the abdomen in all. Histology revealed carcinoma in fundus of gallbladder in one patient (6%). One patient died of haemobilia 3 weeks after operation. Wound infection developed in 5 (30%) patients and 12 (75%) have been followed up for a median period of 28 months. One patient developed a biliary stricture with intrahepatic stones and later underwent a hepatico-jejunostomy. Two have undergone repair of incisional hernia. High index of clinical suspicion, ERCP to clinch the diagnosis, NBD to drain the infected bile, a fundus first partial cholecystectomy and primary repair of CBD, followed by a peroperative T-tube cholangiogram, usually leads to a satisfactory outcome.

A novel sialic acid binding site on factor H mediates serum resistance of sialylated Neisseria gonorrhoeae

Factor H (fH), a key alternative complement pathway regulator, is a cofactor for factor I-mediated cleavage of C3b. fH consists of 20 short consensus repeat (SCR) domains. Sialic acid binding domains have previously been localized to fH SCRs 6-10 and 13. To examine fH binding on a sialylated microbial surface, we grew Neisseria gonorrhoeae in the presence of 5'-cytidinemonophospho-N-acetylneuraminic acid, which sialylates lipooligosaccharide and converts to serum resistance gonococci previously sensitive to nonimmune serum killing. fH domains necessary for binding sialylated gonococci were determined by incubating organisms with recombinant human fH (rH) and nine mutant rH molecules (deletions spanning the entire fH molecule). rH and all mutant rH molecules that contained SCRs 16-20 bound to the sialylated strain; no mutant molecule bound to serum-sensitive nonsialylated organisms. Sialic acid was demonstrated to be the fH target by flow cytometry that showed a fourfold increase in fH binding that was reversed by neuraminidase-mediated cleavage of sialic acid off gonococci. Functional specificity of fH was confirmed by decreased total C3 binding and almost complete conversion to iC3b on sialylated gonococci. Sialic acid can therefore bind fH uniquely through SCRs 16-20. This blocks complement pathway activation for N. gonorrhoeae at the level of C3.

Burn mortality in Chandigarh zone: 25 years autopsy experience from a tertiary care hospital of India

An analysis of autopsy records of burn victims revealed that most burn deaths occurred in the age group 21-40 years (67 per cent) with female preponderance (61 per cent) in all age groups except in the extreme age groups. 62 per cent of burn cases originated in urban areas. The majority of subjects (99 per cent females and 76 per cent males) died as a result of flame burns. Kerosene was the most common factor (76 per cent) in burn deaths. 11 per cent of deaths were due to the stove bursting and 27 per cent of victims died due to leakage of oil from the stove. 39 per cent of subjects sustained burns when their clothes caught fire. Scalds (3.3 per cent), electrical (4.7 per cent) and chemical (2.3 per cent) burns were more commonly seen in males, mainly sustained at their working place. Accidental burns were observed in 80 per cent of subjects followed by suicidal (16.2 per cent) and homicidal burn assaults (4.1 per cent). Peak incidence of burns in females was observed between 5.01 a.m. and 11 a.m. (38 per cent), which was the time of least incidence in males (10.3 per cent). The opposite trend was seen between 11.01 p.m. and 5 a.m. Among males, burn deaths were more common (85 per cent) in those who were living alone, away from their families; whereas in women the incidence of burn deaths was higher (74 per cent) in those living with their families. The majority of deaths due to burns occurred within one week (77 per cent) of the incident. Septicaemia was the major cause of death (55 per cent).

Pyogenic liver abscess in children--South Indian experiences

PURPOSE

Eighteen cases of pyogenic liver abscess (PLA) admitted at JIPMER hospital, South India, over a 6-year period were analyzed to document the clinical profile and to evaluate the management of PLA among children.

METHODS

Records of all these patients were reviewed for presenting signs and symptoms, any associated condition, investigative results, management, and follow-up findings.

RESULTS

The overall incidence of PLA was 78.9 per 100,000 pediatric (under 12 years) admissions. One patient had aplastic anemia and was on long-term steroid therapy, whereas another had measles in recent past. Moderate to severe malnutrition was present in five (27.8%) and ascariasis in seven (38.9%) children. Common presentations were fever (100%), abdominal pain (76.9%), and tender hepatomegaly (83.3%). Ultrasonography results were positive in all cases. Fourteen patients (77.8%) had solitary liver abscess, and four had multiple abscesses. Organism was isolated in 11 cases (63.6%), and Staphylococcus aureus was the commonest isolate (66.7%). All patients received antibiotics. Twelve cases were managed conservatively with antibiotics alone, of these only two (16.7%) required drainage later on. Percutaneous aspiration was also undertaken in four additional (22.2%) cases and open drainage in two (11.1%), at presentation. The overall mortality rate was 11.1%. Time taken for complete resolution ranged from 10 days to 40 days.

CONCLUSIONS

Any child presenting with fever, abdominal pain, and tender hepatomegaly should be subjected to ultrasound scan for early detection of PLA. S aureus is the commonest causative agent. Enterobacteriaceae contribute significantly during infancy. A combination of cloxacillin and gentamicin or a third generation cephalosporine and gentamicin, especially in infants, is a satisfactory initial coverage. Therapeutic drainage is not a must in all cases of PLA. When required, percutaneous needle aspiration is safe and effective. Resolution and significant reduction in mortality has been made possible by early detection and optimum antibiotics therapy.

Surgery for nonalcoholic chronic pancreatitis

There are few reports on operations in patients with nonalcoholic pancreatitis. Between 1985 and 1995 we operated on 58 such patients, 38 of whom were male and 20 female with a mean age of 35 years (range 5-72 years). The indications for operation were pain (n = 49), biliary obstruction (n = 12), duodenal obstruction (n = 10), portal hypertension (n = 11), cysts (n = 14), and pancreatic ascites (n = 3). Thirty-four patients with a dilated pancreatic duct underwent pancreaticojejunostomy; cysts were drained internally in eight, and biliary and duodenal obstruction was bypassed. Ten patients also underwent surgery for portal hypertension. Four (7%) patients died during the postoperative period. Of the remaining 54 patients, 48 (89%) were followed up for a median period of 63 months (range 6 months to 10 years). Six died: four of pancreatic cancer, one of cerebrovascular accident, and one of malnutrition. Of the 34 surviving patients operated for pain, 30 (88%) felt better, of whom 24 (71%) had complete relief of pain; 14 (41%) recorded a weight gain. Pancreatic decompression results in immediate and lasting pain relief in most patients with nonalcoholic chronic pancreatitis.

Systemic juvenile rheumatoid arthritis complicated by two different renal lesions

Systemic-onset juvenile rheumatoid arthritis (JRA) is a complex disease which affects many organ systems. Associated renal lesions are unusual, with the possible exception of amyloidosis. We describe a girl with systemic-onset JRA who developed first membranous nephropathy and then, 3.5 years later, a severe crescentic glomerulonephritis. The membranous lesion followed therapy with intravenous immune globulin, and the possibility that this intervention caused the renal disease must be considered. It appears that both of these lesions should be added to the list of possible complications of systemic-onset JRA.

Psychophysiological evaluation of leg fracture patients

Fifty consecutive leg fracture patients and an equal number of age and sex matched normal controls were evaluated by psychiatric interview and mental status examination, Sinha's anxiety scale (SAS). Hamilton depression rating scale (HDRS) and the Michigan alcoholism screening test (MAST). Detailed evaluation revealed a high prevalence of alcohol dependence/ abuse (34%) and depression (8%). Leg fracture patients were significantly less anxious but significantly more depressed as compared to the normal subjects. Psychiatric assistance would greatly aid in the management of these patients.

Infusion clearance of subcutaneous iothalamate versus standard renal clearance

Accurate, timed urine collections for the measurement of glomerular filtration rate (GFR) may be impractical in infants or in patients with urological abnormalities. GFR may be measured without urine collection using a constant subcutaneous infusion of iothalamate. We compare the infusion clearance with conventional renal clearance in 14 children and young adults. The mean clearance ratio (infusion clearance/renal clearance +/- 1 SD) was 0.99 +/- 0.1 and the mean discrepancy between the two methods was 8.5% +/- 4.7%. The 95% limits of agreement for the ratio of the two methods are 0.83-1.23. These data indicate that subcutaneous infusion of iothalamate is a practical method for measuring GFR in children without a urine collection.

Atopic dermatitis and Staphylococcus aureus-induced osteomyelitis--a peculiar association in a case

A 4-year-old boy with atopic dermatitis who was demonstrated to have cutaneous colonization with Staphylococcus aureus did not respond favorably to topical medication (steroid-antibiotic combination). Incidental detection of severe osteomyelitis, that proved to be due to infection with S. aureus, led to institution of systemic antibiotic therapy along with surgical removal of the involved bone. A very favorable response in the cutaneous eruption followed. Certain unusual findings related to the osteomyelitis are highlighted.

Paget's disease of the sternum simulating an ectopic adenoma on parathyroid scintigraphy

The authors present the case of a patient with recurrent hyperparathyroidism who was shown on thallium-technetium subtraction scintigraphy, ultrasound, and magnetic resonance imaging to have recurrent parathyroid tissue in the right side of the neck. The thallium scan also showed intense uptake centrally in the chest, mimicking an intrathoracic adenoma. This was subsequently shown on plain films and a radionuclide bone scan to be due to Paget's disease of the sternum. This case illustrates the value of a combined imaging strategy in preventing an unnecessary thoracotomy after a false-positive nuclear medicine scan.