Hereditary pancreatitis

Hereditary pancreatitis is an autosomal dominant condition,which results in recurrent attacks of acute pancreatitis,progressing to chronic pancreatitis often at a young age.The majority of patients with hereditary pancreatitis expressone of two mutations (R122H or N29I) in the cationictrypsinogen gene (PRSS1 gene). It has been hypothesisedthat one of these mutations, the R122H mutation causespancreatitis by altering a trypsin recognition site sopreventing deactivation of trypsin within the pancreas andprolonging its action, resulting in autodigestion. Families withthese two mutations have been identified in many countriesand there are also other rarer mutations, which have alsobeen linked to hereditary pancreatitis.Patients with hereditary pancreatitis present in the sameway as those with sporadic pancreatitis but at an earlierage. It is common for patients to remain undiagnosed formany years, particularly ifthey present with non-specificsymptoms. Hereditary pancreatitis should always beconsidered in patients who present with recurrent pancreatitiswith a family history of pancreatic disease. If patients withthe 2 common mutations are compared, those with theR122H mutation are more likely to present at a younger ageand are more likely to require surgical intervention than thosewith N29I. Hereditary pancreatitis carries a 40 % lifetimerisk of pancreatic cancer with those patients aged between50 to 70 being most at risk in whom screening tests maybecome important.

眼内炎:白内障术前及术后控制感染

眼内炎是一种少见但非常严重的白内障术后并发症，它能够使患者完全丧失视力，直至无光感。已有的报道认为眼内炎的发病率为0．13％至0．70％之间，病原体一般来源于眼表（角膜、结膜）和眼附属器（泪器、眼睑、眼外肌）。最常见的致病菌为表皮葡萄球菌，约占70％，金葡菌约占10％，链球菌属占9％，肠球菌属占2％，其余各种革兰氏阳性菌占3％。革兰氏阴性菌占约6％，但其中的绿脓杆菌感染是最为严重的。

Tissue engineering in urethral reconstruction--an update

The field of tissue engineering is rapidly progressing. Much work has gone into developing a tissue engineered urethral graft. Current grafts, when long, can create initial donor site morbidity. In this article, we evaluate the progress made in finding a tissue engineered substitute for the human urethra. Researchers have investigated cell-free and cell-seeded grafts. We discuss different approaches to developing these grafts and review their reported successes in human studies. With further work, tissue engineered grafts may facilitate the management of lengthy urethral strictures requiring oral mucosa substitution urethroplasty.

Role of diaphragm in pancreaticopleural fistula

A pancreatic pleural effusion may result from a pancreatopleural fistula. We herein discuss two interesting issues in a similar case report of a pleural effusion caused after splenectomy, which was recently published in the World Journal of Gastroenterology . Pancreatic exudate passes directly through a natural hiatus in the diaphragm or by direct penetration through the dome of the diaphragm from a neighboring subdiaphragmatic collection. The diaphragmatic lymphatic "stomata" does not contribute to the formation of such a pleural effusion, as it is inaccurately mentioned in that report. A strictly conservative approach is recommended in that article as the management of choice. Although this may be an option in selected frail patients, there has been enough accumulative evidence that a pancreaticopleural fistula may be best managed by early endoscopy in order to avoid complications causing prolonged hospitalization.

Topical negative pressure in managing severe peritonitis: A positive contribution?

AIM： To assess the use of topical negative pressure （TNP） in the management of severe peritonitis. METHODS： This is a four-year prospective analysis from January 2005 to December 2008 of 20 patients requiring TNP following laparotomy for severe peritonitis. RESULTS： There were 11 males with an average age of （59.3 ± 3.95） years. Nine had a perforated viscus, five had anastomotic leaks, three had iatrogenic bowel injury, and a further three had severe pelvic inflammatory disease. TNP and the VAC Abdominal Dressing System were initially used. These were changed every two to three days. Abdominal closure was achieved in 15/20 patients within 4.53 ± 1.64 d. One patient required relaparotomy due to residual sepsis. Two patients with severe faecal peritonitis due to perforated diverticular disease received primary anastomosis at second look laparotomy, as sepsis and their general condition improved. In the remaining 5/20 cases, the abdomen was lee open due to bowel oedema and or abdominal wall oedema. Dressing was switched to TNP and VAC GranuFoam . Three of the five patients returned a few months later for abdominal wall reconstruction and restoration of intestinal continuity. Two patients developed intestinal fistulae. All 20 patients survived.CONCLUSION： The use of TNP is safe. Further studies are needed to assess its value in managing these difficult cases.

白内障术中后囊膜破裂和玻璃体脱失的处理

每一名眼外科医生都会经历晶体后囊膜破裂和玻璃体脱出的考验，那个时刻医生的心跳加速、血压上升，脑海中会闪现所有可能的并发症.

Measurement of forces generated during distraction of growing-rods in early onset scoliosis

AIM: To measure the forces applied during distraction of growing-rods in early onset scoliosis(EOS), aimed at developing a motorized elongation device.METHODS: A consecutive series of measurements were carried out to analyze the forces applied by the surgeon during distraction of single growing-rods in 10 patients affected by EOS(mean age 8.3 years; range 6 to 10 years) undergoing the first distraction 6 months following implantation of the rods. For each measurement, output from the transducer of a dedicated pair of distraction calipers was recorded at zero load status and at every 1 mm of distraction, up to a maximum of 12 mm for each of the two connected rods.RESULTS: Twenty measurements were obtained showing a linear increase of the load with increasing distraction, with a mean peak force of 485 N at 12 mm distraction and a single reading over 500 N. We did not observe bone fractures or ligament disruptions during or after rod elongations. There was one case of superficial wound infection in the cohort.CONCLUSION: The safe peak force carrying capacity of a motorized device for distraction of growing-rods is 500 N.

Risk profile and outcomes of aortic valve replacement in octogenarians

AIM: To investigate the patient characteristics, relationship between the Logistic EuroSCORE (LES) and the observed outcomes in octogenarians who underwent surgical aortic valve replacement (AVR). METHODS: Two hundred and seventy three octogenarians underwent AVR between 1996 and 2008 at Bristol Royal Inf irmary. Demographics, acute outcomes,length of hospital stay and mortality were obtained. The LES was calculated to characterize the predicted operative risk. Two groups were def ined: LES ≥ 15 (n = 80) and LES < 15 (n = 193). RESULTS: In patients with LES ≥ 15, 30 d mortality was 14% (95% CI: 7%-23%) compared with 4% (95% CI: 2%-8%) in the LES < 15 group (P < 0.007). Despite the increase in number of operations from 1996 to 2008, the average LES did not change. Only 5% of patients had prior bypass surgery. The LES identifi ed a low risk quartile of patients with a very low mortality (4%, n = 8, P < 0.007) at 30 d. The overall surgical results for octogenarians were excellent. The low risk group had an excellent outcome and the high risk group had a poor outcome after surgical AVR. CONCLUSION: It may be better treated with transcatheter aortic valve implantation.

Patients with Crohn’s disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications’ rate

BACKGROUND Right hemicolectomy or ileocecal resection are used to treat benign conditions like Crohn’s disease(CD)and malignant ones like colon cancer(CC).AIM To investigate differences in pre-and peri-operative factors and their impact on post-operative outcome in patients with CC and CD.METHODS This is a sub-group analysis of the European Society of Coloproctology’s prospective,multi-centre snapshot audit.Adult patients with CC and CD undergoing right hemicolectomy or ileocecal resection were included.Primary outcome measure was 30-d post-operative complications.Secondary outcome measures were post-operative length of stay(LOS)at and readmission.RESULTS Three hundred and seventy-five patients with CD and 2,515 patients with CC were included.Patients with CD were younger(median=37 years for CD and 71 years for CC(P<0.01),had lower American Society of Anesthesiology score(ASA)grade(P<0.01)and less comorbidity(P<0.01),but were more likely to be current smokers(P<0.01).Patients with CD were more frequently operated on by colorectal surgeons(P<0.01)and frequently underwent ileocecal resection(P<0.01)with higher rate of de-functioning/primary stoma construction(P<0.01).Thirty-day post-operative mortality occurred exclusively in the CC group(66/2515,2.3%).In multivariate analyses,the risk of post-operative complications was similar in the two groups(OR 0.80,95%CI:0.54-1.17;P=0.25).Patients with CD had a significantly longer LOS(Geometric mean 0.87,95%CI:0.79-0.95;P<0.01).There was no difference in re-admission rates.The audit did not collect data on post-operative enhanced recovery protocols that are implemented in the different participating centers.CONCLUSION Patients with CD were younger,with lower ASA grade,less comorbidity,operated on by experienced surgeons and underwent less radical resection but had a longer LOS than patients with CC although complications'rate was not different between the two groups.

Exteriorized colon anastomosis for unprepared bowel: An alternative to routine colostomy

AIM: To see the possibility of avoiding routine colostomy in patients presenting with unprepared bowel. METHODS: The cohort is composed of 103 patients, of these, 86 patients presented as emergencies (self- inflected and iatrogenic colon injuries, stab wounds and blast injury of the colon, volvulus sigmoid, obstructing left colon cancer, and strangulated ventral hernia). Another 17 patients were managed electively for other colon pathologies. During laparotomy, the involved segment was resected and the two ends of the colon were brought out via a separate colostomy wound. One layer of interrupted 3/0 silk was used for colon anastomosis. The exteriorized segment was immediately covered with a colostomy bag. Between the 5th and 7th postoperative day, the colon was easily dropped into the peritoneal cavity. The defect in the abdominal wall was closed with interrupted nonabsorbable suture. The skin was left open for secondary closure. RESULTS: The mean hospital stay (± SD) was 11.5 ± 2.6 d (8-20 d). The exteriorized colon was successfully dropped back into the peritoneal cavity in all patients except two. One developed a leak from oesophago- jejunostomy and from the exteriorized colon. She subsequently died of sepsis and multiple organ failure (MOF). In a second patient the colon proximal to the exteriorized anastomosis prolapsed and developed severe serositis, an elective ileo-colic anastomosis (to the left colon) was successfully performed. CONCLUSION: Exteriorized colon anastomosis is simple, avoids the inconvenience of colostomy and can be an alternative to routine colostomy. It is suitable where colostomy is socially unacceptable or the facilities and care is not available.

Cardiac cystic echinococcosis:Report of three cases

We present a retrospective analysis of three cases of cardiac hydatidosis,who underwent surgery between 2010 and 2012.Two patients had a lesion in the interventricular septum,whereas one patient had the lesion in apicoinferior wall of LV.The diagnosis was made by echocardiography,but magnetic resonance imaging was utilized to assess cyst activity and extend of disease.All patients were placed on cardiopulmonary bypass.No postoperative complication or death occurred.The patients discharged uneventfully and all of them were free from hydatid disease at two years follow-up.We concluded that cardiac hydatid cysts should be removed surgically regardless of their location or extent,even in asymptomatic patients.

The use of 5-fluorouracil in the prevention of tendon adhesions: A systematic review

Background:This systematic review aims to study the effectiveness of 5-fluorouracil(5FU)in the reduction of tendon adhesions postsurgical repair.Method:A systematic review was performed involving four databases,Cochrane,PubMed,MEDLINE,and Embase,looking for evidence of at least Level I or Level II(according to NHMRC)in the use of 5FU in tendon repairs in human or animal studies.Results:Across the four databases 546 articles were identified.Of these 12 were identified as relevant,with a further two being excluded after in depth review.Conclusions:Nine of the 10 studies showed that 5FU was effective at reducing tendon adhesions in their respective animal studies.One of the 10 studies showed no significant change compared to the control group.

Transverse Incision for the Management of Infected Non-Unions of Tibia

We are describing a transverse incision that we have found very useful in performing surgical procedures where the fractured site needs freshening, excision of the necrotic bones or shortening. Operative procedures using this technique have been extensively used by us since 1980 and we have registered 1187 cases with average follow up of 10 years. The incision is transverse and can be performed in any part of leg and extends from 1 cm lateral to anterior border of the tibia and runs medially till 1 cm medial to medial border of tibia. The incision allows adequate visualization of the interested area, less of periosteal stripping, ease of closure, no post operative wound dehiscence and cosmetically very much acceptable.

Assessment of Hand Hygiene Attitude, Knowledge and Practice among Health Science Students in Aden University

Background: A proper hand washing of community health care worker (CHCW) is universally accepted as an important factor in reducing Heath Care Associated Infections (HCAIs). This cross sectional study was done to assess the knowledge, the attitude and practice on hand hygiene among health science students in Aden University. Method: 329 participants from medical, dental and nursing schools completed the questionnaire (43.8% female and 56.2% males). 1st, 2nd and internship years were excluded from the study. The questionnaire is adapted from World Health Organization (WHO) tools for hand hygiene surveys. Epi info., an epidemiological software from the Centre of Disease Control (CDC), was used for data analysis. Results: Responses of the participants in the study indicated that the majority of the students were aware of Hand hygiene (>90%) and 60% have had some sort of training. There is an obvious lack of knowledge on hand movement i.e. my five moments of hand hygiene, particularly on the main source and route of cross contamination with pathogens in hospital setting. In hand hygiene practice, 95% of participants wash their hands before and after food intake, 85% of participants use soap and water, but 8% of participants use only water and very few use alcohol base cleansing agent. 84% of participants wash their hands after handling patient. There was no significant difference between males and females in hand hygiene practice. Conclusion: The study on assessment of knowledge, attitude & practice of students of medical sciences revealed that almost all participants were aware of hand hygiene. However, at this stage of assessment, knowledge and practice are below 100% score for the correct response in particular knowledge and practice.

A Concise Review of Surgical exposures for Revision Knee Arthroplasty

Revision knee arthroplasty is fraught with complications such as delayed wound healing, arthrofibrosis, increased chances of infection, instability and extensor mechanism disruption. The key to avoiding these complications is to handle the soft tissue with care and to have an adequate surgical exposure at the same time. As the number of revisions has gone up, there has been a renewed interest in getting the basics right to have an adequate surgical exposure. Numerous surgical approaches have been proposed and subsequently modified. We present a concise review of the various surgical approaches for a revision knee replacement.

Genuine Palestinian cabbage: Myth or fact. Comparison between Palestinian and Belgian coronary artery bypass grafting

Background: Outcomes post-CABG serves as an indicator of the quality and effectiveness of care given by health care providers. The primary aim of this study is to describe outcomes such as mortality, morbidity, length of hospitalization and hospital readmission post-CABG between Ramallah Ministry of Health Hospital and Ghent University hospital. Methods: A retrospective study is conducted on 200 matched patients who underwent isolated CABG in Ramallah hospital and Ghent University hospital between 2009 and 2011. Both groups were followed up in the post-operative period for minimum one year. Inferential statistics were performed to find the presence of relationship among variables. Kaplan-Meyer was performed to compare overall survival rates and freedom from adverse events. The logistic model was used to assess all factors that associated with readmission, mortality, morbidity and hospital stay. Findings: Both groups had comparable patient characteristics and operative data. Risk factors of diabetes (50%) and smoking (60%) were higher in Palestinian patients compared to (29%) and (31%) in Belgian patients. The mortality rate slightly, being higher among the Palestinian group, was 4% compared to 2% among the Belgium group. Occurrence of morbidity was less noted among Palestinian patients compared to Belgium patients (23%, 36%, P = 0.044 respectively). Palestinian patients had shorter hospital stay (IQR = 6 - 10,

Is de novo membranous nephropathy suggestive of alloimmunity in renal transplantation?A case report

BACKGROUND Post-transplant nephrotic syndrome(PTNS)in a renal allograft carries a 48%to 77%risk of graft failure at 5 years if proteinuria persists.PTNS can be due to either recurrence of native renal disease or de novo glomerular disease.Its prognosis depends upon the underlying pathophysiology.We describe a case of post-transplant membranous nephropathy(MN)that developed 3 mo after kidney transplant.The patient was properly evaluated for pathophysiology,which helped in the management of the case.CASE SUMMARY This 22-year-old patient had chronic pyelonephritis.He received a living donor kidney,and human leukocyte antigen-DR(HLA-DR)mismatching was zero.PTNS was discovered at the follow-up visit 3 mo after the transplant.Graft histopathology was suggestive of MN.In the past antibody-mediated rejection(ABMR)might have been misinterpreted as de novo MN due to the lack of technologies available to make an accurate diagnosis.Some researchers have observed that HLA-DR is present on podocytes causing an anti-DR antibody deposition and development of de novo MN.They also reported poor prognosis in their series.Here,we excluded the secondary causes of MN.Immunohistochemistry was suggestive of IgG1 deposits that favoured the diagnosis of de novo MN.The patient responded well to an increase in the dose of tacrolimus and angiotensin converting enzyme inhibitor.CONCLUSION Exposure of hidden antigens on the podocytes in allografts may have led to subepithelial antibody deposition causing de novo MN.

腹腔镜结直肠手术

腹腔镜结区肠手术技术一直逐年快速发展。第一例腹腔镜结肠切除术早在1991年首次报道，但英国在2008-2009年的一项医院统计显示，经腹腔镜完成的结肠切除术占其总数的22％。腹腔镜手术具备创伤小、恢复快的优势，

Morphometric Analysis of Maxillary Central Incisor to Determine its Crown Form: A Model‑based Cross‑sectional Study

The size and shape of tooth crowns are morphogenetically predetermined during embryogenesis.The maxillary central incisors have contributed to sexual dimorphism,and several classifications of the form of maxillary central incisors are available in the literature.We,in the present study,aimed to analyze the mesiodistal(MD)measurements at two levels of maxillary central incisor,to determine its crown form.The study was conducted on 100 dental plaster models(50 males and 50 females).The MD dimensions at the contact area level MD_incisal(MD_I)and at the gingival papilla level(MD_G)and the gingivo‑incisal height of the crown were measured in the dental models using digital Vernier caliper.The data were analyzed using SPSS version 16 statistical software.The mean values of all the three parameters measured were slightly greater for males and also for the left central incisors.There were no significant differences in all the three variables when the right and left incisors were compared.Significant differences were noted when the parameters are compared between genders.The height/width ratio of crown showed a significant difference between male and female.The value of the ratio between the two MD dimensions(MD_I and MD_G)was used to determine the crown form.The ratio between the MD dimensions at incisal and gingival area showed a significant difference between genders and no such significance was found between right and left central incisors.There is a significant difference in the form of maxillary central incisors between male and female samples and not between right and left.The MD dimensions at incisal and gingival thirds decide the form of crown.

Correlation between Maxillary Central Incisor Crown Form and Maxillary Dental Arch Form:A Model‑Based Morphometric,Cross‑Sectional Study

The crown form of maxillary central incisor tooth is one of the vital phenomenon for a person’s esthetics.Its crown form has been compared with other anatomical parameters such as arch form and facial form.Three different classes of tooth forms which relate to square,tapered,and ovoid forms are identified.The aim of this study was to morphometrically evaluate the correlation between maxillary dental arch form and the maxillary central incisor crown form.Dentate cast models of fifty male and fifty female normal occlusion controls in the age group of 18-23 years were analyzed.The mesiodistal(MD)dimensions of the maxillary central incisors were measured at incisal(MD_I)and at gingival(MD_G)levels.The transverse widths of maxillary casts were measured at the first molar and at the first premolar levels.The measured data were statistically analyzed using the SPSS software.The MD dimensions of maxillary central incisor were significantly greater in males than females.The ratio between the two MD dimensions also varied significantly among genders.The intermolar width(IMW)and interfirst premolar width(IPmW)between males and females were highly significant(P<0.05),whereas the ratio between these two parameters in males and females was not significant(P=0.43).Eighty‑eight percentage of the participants were found to have an ovoid type of maxillary arch,while only 45%of them had the ovoid form of maxillary central incisors.The MD_I and the IMW were found to be in the ratio of 1:5.5 in both genders.The MD_G and the IPmW were in the ratio of 1:4.7 in males and 1:4.5 in females.There was a weak positive correlation between MD_I and IMW(r^(2)=0.146)and between MD_G and IPmW(r^(2)=0.05).No significant concordance between the maxillary central incisor crown form and the maxillary arch form was found in this study.