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.

Meiotic abnormalities affect genetic constitution and pollen viability in dicots from Indian cold deserts

BACKGROUND

Meiotic abnormalities lead to morphological and genetic variations which caused not only to evolution but also intraspecific reproductive barriers. During present study of detailed meiotic course in dicotyledonous plants sampled from Indian cold deserts, various meiotic abnormalities have been detected. For this, the plant materials fixed in Carnoy's fixative and studied detailed meiotic course by standard squash method in 1% acetocarmine.

RESULTS

Meiotic abnormalities have been presently detected in 71 species which include multiple associations in diploids (Achillea millefolium L.), multivalents and univalents in polyploids (4 species), cytomixis (40 species), chromosome stickiness (20 species), nonsynchronous disjunction of bivalents (32 species), interbivalent connections (15 species), synaptic mutants (2 species), syncyte meiocytes (2 species), abnormal spindles (7 species), and fusion of pollen grains (1 species), laggards and chromatin bridges, hypo-, hyperploid PMCs, monads, dyads, triads, tetrads with micronuclei and polyads.

CONCLUSIONS

Consequently, variable sized apparently fertile pollen grains and considerable amount of sterile pollen grains are resulted as end products which lead to different genetic constitution (aneuploids and polyploids) and curtailed sexual reproductive success in these species.

Chromosome number and secondary chromosomal associations in wild populations of Geranium pratense L. from the cold deserts of Lahaul-Spiti (India)

In this work we studied the meiotic chromosome number and details of secondary chromosomal associations recorded for the first time in Geranium pratense L. from the alpine environments in the cold deserts of Lahaul-Spiti (India). All the presently studied individuals of the species existed at 4x level (x = 14). The present chromosome count of n = 28 in the species adds a new cytotype to the already existing diploid chromosome count of 2n = 28 from the Eastern Himalayas and outside of India. Out of the six accessions scored presently four showed normal meiotic course. However, two accessions investigated from Mud, 3800 m and Koksar, 3140 m depicted abnormal meiotic course due to the presence of multivalents and univalents, and secondary associations of bivalents/chromosomes. The secondary chromosomal associations in the species existed among bivalents/chromosomes were noticed in the PMCs at prophase-1 (diakinesis) and persisted till the separation of sister chromatids at M-II. The variation in the number of bivalents/chromosomes involved in the secondary associations at M-I (2-8) and A-I/M-II (2-12) has also been recorded. The occurrence of such secondary associations of bivalents/chromosomes in G. pratense which existed at 4x level indicated the secondary polyploid nature of the species.

The effects of lactation education and a prosthetic obturator appliance on feeding efficiency in infants with cleft lip and palate

OBJECTIVE

This prospective study examined the effect of lactation instruction and palatal obturation in decreasing time to feed, increasing intake, and on growth in eight breast milk bottle-fed newborn infants with cleft lip, cleft palate, or both.

DESIGN

An A, B1, C1, B2, and C2 reversal design was used with eight mothers. In A, baseline data on minutes fed by breast were recorded. In B1, baseline on minutes fed with a Haberman bottle was recorded. In C1, minutes fed following lactation education and palatal obturation were documented. Lactation education was information given to mothers to recognize infant feeding cues and to have infant-led feedings. The palatal obturator was a passive molding appliance. In B2, the obturator was removed and minutes fed noted. In C2, the obturator was returned and lactation support provided. Mothers kept feeding logs, satisfaction was assessed, and infant breast milk intake and flow rate were recorded during each study phase. Routine nutrition evaluation of weight, height, weight for height, and feed volume was completed by a registered dietitian during and following completion of the study.

RESULTS

Feeding times decreased with all infants, volume consumed increased with seven of eight infants, and flow rate increased with all infants. Mean feeding times during B1 and B2 phases (Haberman bottle only) were 34.4 and 32.3 minutes, respectively. Mean feeding times during C1 and C2 phases (obturation and lactation education) were 15.1 and 15.6 minutes. Volume of milk consumed during B1 and B2 feedings averaged 36.5 and 37 mL, compared with 67 mL and 76 mL during C1 and C2 phases. Growth as measured by height, weight gain, and weight for height during the study and the first 2 years of life compared favorably with that of children born without clefts.

CONCLUSIONS

The combined use of a palatal obturator and lactation education reduced feeding time and increased volume intake and was associated with good growth. Mothers who had desired to breast-feed elected to use the obturator to support high-volume intake, decrease infant fatigue, and provide breast milk for nutrition.

Intracranial volume in craniosynostotic rabbits

Although craniosynostosis alters brain growth direction resulting in compensatory changes in the neurocranium, it has been suggested that such compensations occur with little reduction in intracranial volume (ICV). This hypothesis was tested in a rabbit model with nonsyndromic, familial coronal suture synostosis. Cross-sectional three-dimensional computed tomographic head scans were obtained from 79 rabbits (25 normal, 28 with delayed-onset synostosis, and 26 with early-onset synostosis) at 25, 42, and 126 days of age. Intracranial contents were reconstructed and indirect ICV was calculated. Results revealed that by 25 days of age the intracranial contents from early-onset synostosed rabbit skulls showed rostral (anterior) constrictions and a "beaten copper" morphology in the parietal and temporal regions compared with the other two groups. These deformities increased in severity with age. Quantitatively, ICV was significantly reduced (P < 0.05) by 7% in rabbits with early-onset synostosis compared with both control rabbits and rabbits with delayed-onset synostosis at 25 days of age. By 126 days of age, ICV in rabbits with synostosis was significantly reduced (p < 0.05) by 11% in early-onset synostosis and by 8% in delayed-onset synostosis compared with normal rabbits. Results suggest that in rabbits with uncorrected craniosynostosis, compensatory changes in the neurocranium were not adequate to allow normal expansion of the neurocapsular matrix. Further research is needed to determine if ICV reduction is correlated with cerebral atrophy or cerebral spinal fluid (i.e., ventricular or subarachnoid) space compression in this model.

Age related changes in intracranial volume in rabbits with craniosynostosis

Neurocapsular growth is highly heritable and determines neurocranial form. Although craniosynostosis alters brain growth direction, resulting in compensatory changes in the neurocranium, it is believed that such compensations occur without reduction in intracranial volume. This hypothesis was tested in a rabbit model with nonsyndromic, familial coronal suture synostosis. Skulls of 56 rabbits (20 normals, 20 with delayed onset synostosis, and 16 with complete synostosis) were scanned using three-dimensional computed tomography at 6 and 18 weeks of age. Intracranial contents were reconstructed, and indirect intracranial volume was calculated. Qualitatively, re-formations of intracranial contents from completely synostosed rabbit skulls exhibited the typical "copper beaten" morphology. Quantitatively, intracranial volume was significantly (p < 0.05) reduced in rabbit skulls with complete synostosis compared with both control rabbit skulls and rabbit skulls with delayed onset synostosis at 6 weeks by 11 percent and 14 percent, respectively). By 18 weeks, intracranial volume in rabbit skulls with synostosis was significantly (p < 0.05) reduced (by 12 percent in complete synostosis and 8 percent in delayed onset synostosis) compared with normal rabbits. Results suggest that in rabbits with uncorrected craniosynostosis, compensatory changes in the neurocranium were not adequate to allow normal expansion of the neurocapsular matrix. Further research is needed to determine whether reduction in intracranial volume was a result of neural tissue deficiency or cerebrospinal fluid (i.e., ventricular or subarachnoid) space compression in this model.

Clinical presentation of tuberculosis in patients with AIDS: an Indian experience

A retrospective series of 25 patients with AIDS and tuberculosis is presented. Their clinical presentation, absolute lymphocyte count, CD4+ and CD8+ lymphocyte counts, treatment details and outcome are detailed. Commonest method of acquiring HIV infection was through heterosexual contact (10 of the 25; 40%) and blood transfusion (10 of the 25; 40%). More than 50% of the patients (14 of the 25) had extrapulmonary tuberculosis. Eighteen of the 19 patients for whom values were available had CD4+ lymphocyte count < 200/mm3. Four of the 18 patients for whom follow-up details were available died.

Vascularized fronto-orbital advancement

Fronto-orbital advancement is the procedure of choice for correction of fronto-orbital recession resulting from coronal synostosis in children. However, long-term follow-up evaluations often reveal "undercorrection" of the deformity with development of recurrent recession of lateral supraorbital regions. One factor that may contribute to this process is devascularization of the fronto-orbital bar during its reshaping and advancement. If subsequent revascularization is suboptimal, excessive resorption or inadequate growth of the bar may lead to supraorbital recession. On the basis of studies of temporal bone grafts, which have shown that vascularized grafts are superior to free bone grafts in terms of bone graft survival, we postulated that maintaining vascularization of the fronto-orbital bar would favor better healing and growth that would translate to more favorable aesthetic results. Herein, we review the vascular anatomy of the fronto-orbital region and report the application in six patients of a technique for fronto-orbital advancement that preserves a significant portion of this blood supply. Technical caveats involved in the successful application of this approach are discussed. The attachment of the periosteum to the lateral two thirds of the supraorbital bar allows additional stability. This prevented the use of plates and screws in these patients.

Crouzon syndrome: mutations in two spliceoforms of FGFR2 and a common point mutation shared with Jackson-Weiss syndrome

Dominant mutations in the fibroblast growth factor receptor 2 (FGFR2) gene have been recently identified as causes of four phenotypically distinct craniosynostosis syndromes, including Crouzon, Jackson-Weiss, Pfeiffer, and Apert syndromes. These data suggest that the genetics of the craniosynostosis syndromes is more complex than would be expected from their simple autosomal-dominant inheritance pattern. Identical mutations in the FGFR2 gene have been reported to cause both Pfeiffer and Crouzon syndrome phenotypes. We now report the finding of a mutation in exon IIIc of the FGFR2 gene in a kindred affected with Crouzon syndrome (C1043 to G; Ala344Gly) that is identical to the mutation previously associated with Jackson-Weiss syndrome. We also report finding in a Crouzon kindred a mutation in the 3' end of exon IIIu (formerly referred to as exon 5, exon 7, or exon U) (A878 to C; Gln289Pro) which encodes the amino terminal portion of the Ig-like III domain of the FGFR2 protein. This exon is common to both the FGFR2 and the KGFR spliceoforms of the FGFR2 gene, unlike all previously reported Crouzon mutations, which have been found only in the FGFR2 spliceoform. These findings reveal further unexpected complexity in the molecular genetics of these craniosynostosis syndromes. The data implies that second-site mutations in FGFR2 itself (outside of exon IIIc) or in other genes may determine specific aspects of the phenotypes of craniosynostosis syndromes.

Carcinoma penis

In the present study 90 cases of carcinoma penis were studied. The disease is more common after the age of 40 years; phimosis was found to be most important predisposing factor. Most common presentation was proliferative lesion with commonest involvement of glans penis. All the cases were of squamous cell carcinoma except one case of malignant melanoma. Clinical determination of lymph node metastasis is falacious as there was discrepancy between clinical and histopathological stage of the disease in 26.67% of cases. Therefore lymph node biopsy at the time of primary surgery is advocated. The result of total amputation is better than other mode of treatment.

Study of interaction between catechin and native and modified bovine serum albumin by physico-chemical methods

The interaction of native and modified bovine serum albumin (BSA) with catechin, a flavanoid having vitamin P activity, has been studied using equilibrium dialysis, pH-metric, viscosity and spectrophotometric methods. The order of reactivity of catechin binding to proteins was found to be: esterified BSA greater than BSA greater than formylated BSA greater than acetylated BSA with log K values of 3.778, 3.879, 3.748 and 3.813 and free energy change equal to -5.11, -5.16, -5.07 and -5.15 kcal/mole, respectively.