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.     

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     

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.     

Insulin receptors on leukemia and lymphoma cells

Tumor cells obtained from leukemia and lymphoma patients were investigated for specific insulin receptors. Using radioactive 125I- labeled insulin, specific insulin binding sites were demonstrated on most acute lymphocytic leukemia (ALL) and acute myelocytic leukemia (AML) cells, including acute promyelocytic leukemia (APL), chronic myelocytic leukemia (CML), and acute monocytic leukemia (AMoL) cells. Insulin receptors were not found on chronic lymphocytic leukemia (CLL) and malignant lymphoma (ML) cells. Specific insulin binding sites were also found on monocytes and thymocytes after treatment with phytohemagglutinin (PHA-P), but not on inactivated tonsil cells, peripheral blood lymphocytes, or thymocytes. There was no inverse correlation between the content of insulin receptors and the basal level of circulating insulin. These data suggest that the insulin receptor may be a new marker of acute leukemia and chronic myelocytic leukemia.     

Serratus Anterior and Lower Trapezius Muscle Activities During Multi-Joint Isotonic Scapular Exercises and Isometric Contractions

Context:Proper scapular function during humeral elevation, such as upward rotation, external rotation, and posterior tilting of the scapula, is necessary to prevent shoulder injury. However, the appropriate intensity of rehabilitation exercise for the periscapular muscles has yet to be clarified.Objective:To identify the serratus anterior, lower trapezius, infraspinatus, and posterior deltoid muscle activities during 2 free-motion exercises using 3 intensities and to compare these muscle activities with isometric contractions during quadruped shoulder flexion and external rotation and abduction of the glenohumeral joint.Design:Cross-sectional study.Setting:Health Science Laboratory.Results:Significant interactions in electromyographic activity were observed between intensities and exercises (P < .05). The quadruped shoulder-flexion exercise activated all 4 muscles compared with other exercises. Also, the modified robbery free-motion exercise activated the serratus anterior, lower trapezius, and infraspinatus compared with the lawn-mower free-motion exercise. However, neither exercise showed a difference in posterior deltoid electromyographic activity.Conclusions:Three intensities exposed the nature of the periscapular muscle activities across the different exercises. The free-motion exercise in periscapular muscle rehabilitation may not modify serratus anterior, lower trapezius, and infraspinatus muscle activities unless knee-joint extension is limited.Key Words: upper extremity, shoulder joint, overhead performance

Key Points

• Modulation of electromyographic activity of the serratus anterior and lower trapezius muscles varied with multi-joint free-motion exercises though exercise intensity was increased.
• No increase in the electromyographic activity of the lower trapezius was found in the lawn-mower exercise despite increasing intensity.
• Isometric shoulder flexion in the quadruped position showed the highest amplitude of electromyographic activity of the serratus anterior and lower trapezius muscles compared with the free-motion exercises.

Periscapular muscles have been intensively studied for the purposes of injury prevention and rehabilitative exercise in patients with asymptomatic and symptomatic shoulders. These include symptomatic patients with shoulder impingement syndrome and rotator cuff injury.^1–13 The scapula acts as the base from which kinetic force and energy are transferred to the distal segments of the upper extremity, especially in overhead athletes.¹⁴ Also, the stability of the scapula enables the rotator cuff muscles to be maximally activated.¹⁵ For instance, the empty-can position at 90° of abduction (ABD) of the glenohumeral (GH) joint in the scapular plane increased ABD resistance when the scapular position was retracted by a clinician with forearm pressure on the medial scapular border.¹⁵The appropriate functional scapular motions of upward rotation, posterior tilt, and external rotation increase the width of the subacromial space during humeral elevation, whereas a lack of proper scapular function, so-called scapular dyskinesis, increases the translation of the humeral head and alters scapular position and motion in both static and dynamic applications.^2,16–18 A shoulder rehabilitation exercise program must emphasize the external rotation, posterior tilting, and upward rotation of the scapula.¹⁹ Moreover, current researchers have advocated that the serratus anterior (SA) and lower trapezius (LT) muscles be reconditioned even before the rotator cuff muscles for symptomatic shoulders of overhead athletes.²⁰ However, the effects of exercise intensity on conditioning these muscles has yet to be investigated. Most, if not all, previous authors used 1 intensity to compare periscapular muscle activities across a variety of scapular exercises.^{1,3,5,12,21–23} Although using 1 level of intensity may allow researchers to compare a certain amount of muscle activity across different exercises, the modulation in muscle activity cannot be fully determined with experimental paradigms using only 1 intensity. Some muscle activation may not increase proportionally as the level of exercise intensity increases, and different compensation from other muscles often occurs during the same movement with different intensities.²⁴Free-motion exercises that simultaneously extend the knee joints, hip joints, and trunk, such as the lawn-mower and robbery exercises, were analyzed for scapular muscle activity to identify the amounts of scapular retraction and depression. Exercises with multi-joint movement such as these activated the SA and LT by approximately 30% of maximum voluntary isometric contraction (MVIC) without providing information about exercise intensity.² The sequential motion inherent in these exercises, which transfer forces from the lower to upper extremities and follow a proximal-to-distal progression, has been of interest to clinicians for shoulder rehabilitation exercise programming.^17,25 However, researchers have not yet identified how different intensities of such multi-joint isotonic exercises affect the activities of the SA and LT muscles. Therefore, the purpose of our study was to identify the muscular activity of the SA and LT at different levels of intensity during the lawn-mower, robbery, and quadruped shoulder-flexion (QSF) exercises.