Repair of large midline incisional hernias with polypropylene mesh: Comparison of three operative techniques

Polypropylene mesh is widely used for the reconstruction of incisional hernias that cannot be closed primarily. Several techniques have been advocated to implant the mesh. The objective of this study was to evaluate, retrospectively, early and late results of three different techniques, onlay, inlay, and underlay. The records of 53 consecutive patients with a large midline incisional hernia — 25 women and 28 men, mean age 60.4 (range 28–94) — were reviewed. Polypropylene mesh was implanted using the onlay technique in 13 patients, inlay in 23 patients, and underlay in 17 patients. Either the greater omentum or a polyglactin mesh was interponated between the mesh and the viscera. The records of these 53 patients were reviewed with respect to: size and cause of the hernia, pre- and postoperative mortality and morbidity, with special attention to wound complications. Patients were invited to attend the outpatient clinic at least 12 months after implantation of the mesh for physical examination of the abdominal wall. Postoperative complications occurred in 14 (26.4%) patients. The onlay technique had significantly more complications, as compared to both other techniques. Reherniation occurred in 15 (28.3%) patients. The reherniation rate of the inlay technique was significantly higher than after the underlay technique (44% vs 12%, P=0.03) and tended to be higher than the onlay technique (44% vs 23%, P=0.22). Repair of large midline incisional hernias with the use of a polypropylene mesh carries a high risk of complications and has a high reherniation rate. The underlay technique seems to be the better technique.     

Characterization of antibody and selection of alternative drug therapy in hydrochlorothiazide-induced immune hemolytic anemia

The authors report the clinical and laboratory findings of a patient who had severe immune hemolytic anemia due to hydrochlorothiazide (HCTZ). In this case, the HCTZ antibody reacted not only with other thiazide and thiazide-like drugs, but also with a chemically unrelated diuretic, ethacrynic acid. These results indicate that HCTZ antibody activity is not restricted solely to the thiazides and imply that therapy with any of the reactive drugs would be contraindicated for this patient. The serologic screening for drug reactivity may be useful for selecting alternative therapy for patients with drug-induced immune hemolytic anemia.     

Health and human development

Participants at the 1988 World Conference on Medical Education in Edinburgh, Scotland, resolved to make the training of physicians more relevant to the needs of the majority in their own societies. The majority of the disadvantaged suffer from morbidity caused by malnutrition, low-quality water supplies, unsanitary conditions, inadequate housing, and illiteracy. It is with regard to these factors that greater interaction is needed between the medical profession and the non-medical education, research, and extension system on the one hand and social infrastructures on the other. The interactions may not be in general terms, but in terms of specific ethnic groups in which they happen to practice. Researchers and experts in the field of social science must make a concerted effort to provide a realistic baseline of information to the medical profession about the ethno-psycho-social environment of a given niche. The masses are apathetic, tired, and generally do not trust governmental medical functionaries. These feelings derive largely from poor people's necessary dependence upon poor facilities, practitioners' inhuman attitudes toward the sick, unclean surroundings, the widespread prevalence of unethical practices, excessive delays, and other negative factors. People who can afford to secure care in the private sector. The author comments on infant mortality, the concept of human development, social development, and population growth.     

SCREENING PROCEDURES IN PEDIATRICS

Pediatric health screening procedures, both prenatal and postnatal, have a tremendous potential in improving the health status of children and in turn reducing the resource burden on the parents and the State. The existing recommendations, inherent problems and different screening procedures are discussed. The need for suitable mass screening pediatric procedures in the Indian context is stressed.KEY WORDS: Pediatric screening procedures     

CLINICO-PATHOLOGICAL CORRELATION IN NEONATAL AUTOPSIES

Of the 253 neonates admitted to a neonate intensive care unit during the period Jan 91 to Sep 93, 43 neonates died. Autopsy was done in 23 of these (53%). The mean duration of stay of the neonates in the intensive care unit prior to death was 5.6 days (range 2 hours to 10 days). Antemortem diagnoses included asphyxia neonatorum (4), meconium aspiration syndrome (2), septicemia (5), prematurity (3), birth trauma (2), congenital anomalies (2), hypoxic ischemic encephalopathy (1), and non-specific diagnosis (4). There were 6 major autopsy findings that, if known prior to death, would have altered clinical management and might have resulted in cure or prolonged survival. There were 8 additional major findings that, if known prior to death, would not have altered management There were 14 minor findings related to major diagnoses but unrelated to the primary cause of death.KEY WORDS: Autopsy, Cause of death, Perinatal mortality     

Two steps forward; three backwards

The census indicated that India's population was about 850 million in 1991. This spiraling growth has resulted in a deteriorating standard of living, especially for women and children in the rural population. Minorities such as tribal women and low caste women also suffer disproportionately because of a lack of safe drinking water and fuel for the hearth. In certain areas women have to spend 3-4 hours to gather fuelwood. Despite achieving self-sufficiency in food-grain production by the 1980s, India's poor families do not have enough calories in their daily diets, they lack proper hygiene and sanitation, and do not send their children to school. In the remote villages of Arunachal Pradesh children are kept in school only for one year lest they get too much education and leave their families. Children are an economic asset to be put to work at an early age. Slum dwellers face not only an endless cycle of drudgery and hopeless poverty, but the associated evils of pests and diseases. The last 40 years and seven major economic plans have not made a dent in the lives of these people. All measures of poverty alleviation, rural and slum sanitation, child development schemes have eluded this group of people. Another segment of the population are rural people who were targeted by development programs, yet could not take advantage of the resources offered. Development programs are run by state and central governments, voluntary agencies, and cooperatives, but their performance remains unsatisfactory. General apathy is felt in the ranks of development workers, which is coupled with a corrupt bureaucracy and village leadership. Midday meal programs, soak pits, rural sanitation, immunization, and family welfare do not inspire this leadership. The bureaucracy has developed a vested interest in keeping the development workers as they are, and the funds received from international agencies are diluted down the line.     

Thyroid function in a population of children with attention deficit hyperactivity disorder

To determine the prevalence of thyroid hormone abnormalities and generalized resistance to thyroid hormone in a population of children with attention deficit hyperactivity disorder (ADHD) as compared to reference ranges determined from a control population and hence to determine if routine thyroid hormone screening in children with non-familial ADHD is indicated.

Method:

Children attending the State Child Development Centre in Perth, Western Australia with ADHD, as defined by the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) provided the study population. The control population consisted of 353 normal children with a history of allergy in whom radioallergosorbent (RAST) testing was being performed.

Results:

The prevalence of thyroid hormone abnormalities in the study population was 2.3% (95% CI 0.6%, 5.7%). There were no cases of generalized resistance to thyroid hormone. The prevalence of thyroid hormone abnormalities in the general population of children and adolescents has been reported to vary between 1 and 3.7%.

Conclusion:

Routine thyroid hormone screening is not indicated in children with non-familial ADHD.