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Aug31
Essential Thrombocytosis & Myocardial Infarction
Abstract:

Essential thrombocytosis (ET) is a nonreactive chronic myeloproliferative disorder associated with sustained megakaryocyte proliferation that increases the number of circulating platelets. ET has been associated with an increase risk for thrombosis, hemorrhage, vasomotor symptoms and myelodysplastic disorder. Myocardial infarction (MI) is not typically associated with ET. We report a case where a patient with ET presented with an MI after stopping aspirin 4 days prior to a lipoma resection.

Case Report:

We present a 48 years old women with a past medical history of hypertension, hyperlipidemia, and essential trombocytosis. She was on medical treatment for ET with hydroxyurea and aspirin. On a routine exam, she was found to have a lipoma in her left thigh and she elected to have it resected. She was advised to stop her aspirin a week prior to her surgery. Four days after stopping her aspirin therapy, she noted a vague substernal discomfort associated with some breathing difficulty while walking. This sensation remitted spontaneously, but that evening she reported a poor appetite and intermittent chest discomfort. The next morning she started to feel fatigued and groggy with associated nausea. She presented to our emergency department with these symptoms.
On initial examination, she was found to have a blood pressure of 164/90 mmHg. Laboratory results revealed a platelet count of 873 x 103/mm3, Creatine Kinase- MB of 326.6 U/L, Creatine Kinase-MB Index of 13.5% and Troponin-T of 19.95 ng/ml. Admission electrocardiogram demonstrated lateral ST elevations. The patient was admitted with the diagnosis of acute Myocardial infarction with ST elevation of less than 6 hours duration, related to the aggravation of essential thrombocytosis presumed to be due to the aspirin cessation. An emergency coronary angiography revealed a right dominant system without a ramous intermedious branch. The left main artery and the right coronary artery had no significant stenosis, the left anterior descending artery had mild stenosis with possible myocardial bridge in the mid segment after the 1st diagonal and the left circumflex artery had a mid 100% thrombotic occlusion with TIMI 0 flow.
Based on the angiographic findings, an emergency Percutaneous Coronary Intervention with bare metal stenting of the left circumflex artery was preformed and TIMI III flow was restored. Post-procedure cardiac ultrasound reported an ejection fraction of 59%, mild mitral and aortic regurgitation and left ventricular dysfunction involving the inferior, inferoposterior and lateral territories. Patient was discharged four days later in good general condition and on treatment with aspirin, clopidrogrel, lisinopril and metoprolol. Follow up at 15 days and 1 month reported a patient in good health with an EKG negative for ischemia and a perfusion image showing moderately severe lateral wall scar associated with mild lateral ischemia.

Discussion:

ET is a nonreactive chronic myeloproliferative disorder of unknown etiology, associated with sustained haematopoietic stem cell and megakaryocyte proliferation that increases the number of circulating platelets, in the absence of definable cause. Although unknown, the prevalence of ET is believed to be about of 7 in 1 million [6, 8, 9]. ET is associated with an increased risk for thrombotic, hemorrhagic, vasomotor and myelodysplastic symptoms and complications [1-3].

The diagnosis of ET requires a platelet count over 600 x 103/mm3, megakaryocytic hyperplasia on bone marrow biopsy, and an absence of conditions associated with reactive thrombocytosis or other myeloproliferative disorders such as polycythemia vera, chronic myeloid leukemia, or myelofibrosis with myeloid metaplasia on clinical, laboratory, and bone marrow examination [1, 10, 11]. ET is differentiated from other myeloproliferative disorders by the presence of normal red cell mass, absence of the Ph chromosome and bcr-abl gene rearrangement and bone marrow absence of myelofibrosis.

The JAK2 V617F tyrosine kinase mutation is seen in majority of patients with Philadelphia negative myeloproliferative disorders such as polycythemia vera, and approximately half of the patients with ET and primary myelofibrosis [12, 13]. Present data supports that the JAK2 gene mutation is an important factor to determine the degree of myeloproliferation and myeloid metaplasia. Hence, a highly sensitive quantitative PCR assay has been developed for the quantification of the JAK2 V617F mutational load in these patients [12].

Around 26% of patients with ET are asymptomatic, 23% have hemorrhagic symptoms such as purpura, epistaxis and gingival bleeding and 40% have thrombotic symptoms such as erythromelalgia, cerebral infarction, myocardial infarction and deep venous thrombosis [14]. MI associated with this disease, although reported in the literature [1-8] is a rare complication with an estimated incidence of 9.4% [2]. ET is usually diagnosed in the fifth or sixth decade of life, but according to Turgut et al [7], of all the reported cases of ET associated MI, around 57% where below their fourth decade of life, as our patient was. This disease can also lead to pregnancy complications including recurrent abortions and fetal growth retardation [15].

Thrombosis is usually associated with endothelial injury and the activation of the coagulation cascade terminating in platelet activation and aggregation [4]. The pathophysiology of the thrombotic complications seen in ET is not well understood, although it is believed that the thrombus formation is more related to a platelet functional defect than to the increase in platelet count. Platelet abnormalities such as platelet membrane glycoprotein defects, decreased α- adrenergic receptors, loss of Prostaglandin D-2 receptors and increased thromboxane A2 production [4, 7] have been determined in patients with ET. More research is needed to determine the relation between these findings and the thrombus formation in these patients.

Thrombotic complications in both arterial and venous system usually occur in the cerebral, pulmonary and microvascular circulation [2, 3, 6, 7]. More uncommon locations are the coronary, renal, peripheral and digital arteries [2, 7].The average risk for thrombosis in ET has been determined to be of 6.6% patient years compared to 1.2% patient years observed in the control group [1, 3, 5]. The reported predicted factors for thrombosis in these patients are: past medical history of thrombosis, platelet count over 600 x 103/mm3, advanced age and laboratory demonstration of spontaneous megakaryocyte colony formation [1, 3, 7, 16]. Our patient although middle age without positive past medical history of thrombosis had a platelet count of 873 x 103/mm3.

MI associated with ET is usually related to thrombosis in the absence of a significant atherosclerotic lesion [1, 7]. In most of the reported cases, thrombosis has been found in the left anterior descending artery [7]. Multivessel thrombosis has also been reported usually involving both the left and right coronaries, including the left circumflex artery [1, 2, 3, 6]. There has not been any reported case of isolated thrombotic obstruction of the left circumflex artery as in our patient. Other risk factors for acute MI in ET are personal history of smoking and hypertension [6].

The accepted medical treatment for ET consist of hydroxyurea infusion to control platelet count below 600 x 103/mm [1, 2, 3, 8, 10] and α- interferon for the non responsive cases. The role of aspirin and other antiplatelet medications in the prevention of thrombotic complications haven’t been determined, but there are reported cases where MI has developed after aspirin treatment cessation [17], as we could see in our case. It is important to have a careful follow up of these patients antiplatelet treatment due to their higher risk of bleeding complications.

In the emergency treatment of an ET patient presenting with an acute MI, thrombolytic medical treatment, bypass surgery [1, 3] or Percutaneous Coronary Intervention and stenting can be used. PCI and stenting, is an effective, less invasive treatment option that has been used and reported in the literature [2, 5-8] , with successful results. Our patient’s clinical evolution and improvement after the procedure supports it. Complications post PCI, although not seen in our patient, usually involves bleeding from the femoral artery access point [7], epistaxis or ecchymoma [2] and in-stent thrombosis [7].

In our patient, and in others reported, aspirin cessation may have been related to the acute thrombosis and the consequent MI, but more data is needed to determine if there is a real relationship.

References:

1. Daya SK, Gowda RM, Landis WA, Khan IA. Department of Medicine, York Hospital, York, PA, USA. Essential thrombocythemia-related acute ST-segment elevation myocardial infarction. A case report and literature review. Angiology. 2004 May-Jun; 55(3):319-23.
2. Mizuta E, Takeda S, Sasaki N, Miake J, Hamada T, Shimoyama M, Tajima F, Igawa O, Shigemasa C, Hisatome I. Acute myocardial infarction in a patient with essential thrombocythemia: successful treatment with percutaneous transluminal coronary recanalization. Circ J. 2005 Aug;69(8):1000-2.
3. Nurkalem Z, Uslu N, Gorgulu S, Eren M. Cardiology Department, Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey. Left main coronary thrombosis with essential thrombocythemia. J Thromb Thrombolysis. 2006 Dec; 22(3):165-7.
4. Koh KK, Cho SK, Kim SS, Oh BH, Lee YW. Coronary vasospasm, multiple coronary thrombosis, unstable angina and essential thrombocytosis. Int J Cardiol. 1993 Sep; 41(2):168-70.
5. Michaels AD, Whisenant B, MacGregor JS. Multivessel coronary thrombosis treated with abciximab (ReoPro) in a patient with essential thrombocythemia. Clin Cardiol. 1998 Feb; 21(2):134-8.
6. Ozben B, Ekmekci A, Bugra Z, Umman S, Meric M. Multiple coronary thrombosis and stent implantation to the subtotally occluded right renal artery in a patient with essential thrombocytosis: a case report with review. J Thromb Thrombolysis. 2006 Aug; 22(1):79-84. Review.
7. Turgut T, Harjai KJ, Edupuganti R, Cole J, Jenkins JS, Ramee SR, Collins TJ. Department of Cardiology, Ochsner Medical Institutions, New Orleans, Louisiana 70121, USA. Acute coronary occlusion and in-stent thrombosis in a patient with essential thrombocythemia. Cathet Cardiovasc Diagn. 1998 Dec;45(4):428-33
8. Watanabe T, Fujinaga H, Ikeda Y, Higashi T, Murakami M, Kawahara K, Hayashi I, Niki T, Shigekiyo T, Wakatsuki T. Department of Cardiology, Tokushima Prefectural Central Hospital, Tokushima, Japan. Acute myocardial infarction in a patient with essential thrombocythemia who underwent successful stenting--a case report. Angiology. 2005 Nov-Dec; 56(6):771-4
9. McIntyre KJ, Hoagland HC, Silverstein MN, Petitt RM: Essential. thrombocythemia in young adults. Mayo Clin Proc 66:149-154, 1991.
10. Murphy S, Iland H, Rosenthal D, et al: Essential thrombocythemia: An interim report from the Polycythemia Vera Study Group. Semin Hematol 23:177-182, 1986.
11. Murphy S, Peterson P, Iland H, et al: Experience of the Polycythemia Vera Study Group with essential thrombocythemia: A final report on diagnostic criteria, survival, and leukemic transition by treatment. Semin Hematol 34:29-39, 1997
12. Larsen TS, Pallisgaard N, Møller MB, Hasselbalch HC. The JAK2 V617F allele burden in essential thrombocythemia, polycythemia vera and primary myelofibrosis--impact on disease phenotype. Eur J Haematol. 2007 Dec;79(6):508-15. Epub 2007 Oct 23.
13. Agarwal MB. Clinical applications of molecular haematology: JAK2 in myeloproliferative disorders. J Assoc Physicians India. 2007 Jul; 55:507-10.
14. Hattori A, Nagayama R, Kishi K, et al: Primary thrombocythemia in Japan: A survey of 225 patients. Leuk Lymph 4:177-186, 1991.
15. Falconer J, Pineo G, Blahey W, Bowen T, Docksteader B, Jadusingh I: Essential thrombocythemia associated with recurrent abortions and fetal growth retardation. Am J Hematol 25:345, 1987.
16. Passamonti F, Rumi E, Pungolino E, Malabarba L, Bertazzoni P, Valentini M, Orlandi E, Arcaini L, Brusamolino E, Pascutto C, Cazzola M, Morra E, Lazzarino M. Life expectancy and prognostic factors for survival in patients with polycythemia vera and essential thrombocythemia. Am J Med. 2004 Nov 15; 117(10):755-61.
17. Louwerenburg JW, Suttorp MJ, Herre Kingma J: Aspirin withdrawal in a patient with essential thrombocythemia: possible cause of myocardial infarction. Am J Med 83:1175, 1987.


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Aug31
Report on Hernia Repair from SAGES 2008
"If we could artificially produce tissue of the density and toughness of fascia and tendon, the secret of the radical cure of the hernia repair would be discovered."
Theodore Bilroth 1857
Although significant advances in herniorrhaphy have occurred since Bilroth's statement 150 years ago, hernia repair remains a challenge to the general surgeon. For many years, the field of hernia prosthetics was fairly static and options were limited. However, today when the operating room (OR) nurse asks you what mesh you would like for your patient, the choices can be overwhelming. With data to support or refute almost any material, and "reps" who are more than willing to offer their biased opinion, deciphering the data can be difficult. That being said, other than technique, choosing the correct mesh is one of the most critical factors in determining the risk of recurrence, infection, and chronic pain. While there is probably no universally superior material or manufacturer, understanding the characteristics of each type of prosthetic will enable the surgeon to maximize the results for their patients.
At this year's annual SAGES meeting in Philadelphia, a joint consensus panel with the American Hernia Society (AHS) was convened entitled: "The Explosion of Biomaterials for Hernia Repair; What Do I Do?" The panel was comprised of experts in the field of hernia repair including moderators Maurice Arregui, MD, and Guy Voeller, MD. It provided an excellent overview of the current state of mesh prosthetics for hernia repair. The following is a review of this consensus panel with additional comments from the author.
Synthetic Meshes: Types, Costs, Advantages, and Disadvantages
Bruce Ramshaw, MD, Chief of Surgery at The University of Missouri, began the session with a review of current options for synthetic hernia repair. He reviewed the modern history of mesh starting with Francis Usher's introduction of polypropylene (PP) in 1958.[1]
Mesh Types
Woven mesh. PP is a monofilament, hydrophobic, large pore mesh that has been one of the primary "work horses" in hernia surgery for the past 50 years. Currently PP comes in a variety of weaves including single strand, double strand, and multifilament. Ramshaw highlighted the recent development of lightweight (LW) PP, which utilizes a lighter PP strand with larger interstices or pores. He compared it to polyester, which was popularized in Europe in 1960 with the Rives-Stoppa technique.[2] PP and polyester are both woven, macroporous mesh; however, polyester is multifilamented and hydrophilic.
Nonwoven mesh. Expanded polytetrafluoroethylene (ePTFE), a derivative of Teflon®, is the second major class of synthetic mesh. Developed in the 1970s, ePTFE has a proven track record in herniorrhaphy. In contrast to the woven meshes, ePTFE has a microporous, smooth textured construct that minimizes tissue ingrowth. This is a critical factor in laparoscopic ventral hernia repair, where the mesh is placed in the peritoneal cavity in juxtaposition to the bowel and other viscera. Refinements in ePTFE have included a composite material that has a larger pore on the abdominal wall side to help promote ingrowth (Dual Mesh®) and antibiotic impregnation (Dual Mesh Plus®). In an effort to maximize mesh fixation, other manufacturers have coupled ePTFE with PP. (Composix®).
Costs and Advantages of Using Mesh Repair
After reviewing the common types of synthetic meshes, Dr. Ramshaw discussed cost and the advantages of using mesh for repair. In general the traditional synthetics are the least expensive, followed by the barrier meshes, with the biomeshes (discussed below) representing the most expensive group.
Although mesh repair has higher material costs compared to primary closure, bridging the hernia defect with a prosthetic enables a tension-free repair, which should reduce recurrence, lessen pain, speed recovery, and ultimately yield lower overall costs. This has been demonstrated in multiple clinical studies, including that of Burger and colleagues[3] who examined the recurrence rate in ventral hernia repairs. In this study, patients without mesh repair had a 62% recurrence compared to 32% with mesh.
Disadvantages of Mesh Repair
Despite the numerous advantages of mesh repair, implantation of a permanent prosthetic can have deleterious effects. Dr. Ramshaw presented numerous video clips demonstrating mesh-related fistulas and bowel adhesions, as well as prosthetics that had undergone extreme contraction, migration, and malformed rigid configurations. He reviewed some of his institution's data suggesting that host-related responses may oxidize the PP mesh, making it more brittle and less compliant. A similar end result may occur due to hydrolysis of the mesh. According to Dr. Ramshaw, ePTFE does not seem to be as susceptible to hydrolysis or oxidation; however, it is not immune to contraction.
In conclusion, Dr. Ramshaw emphasized the need for further development of biomeshes. He reminded the audience that some of the traditional synthetic hernia meshes were initially designed and tested for the textile industry and what may be a good material for household furniture may not necessarily be ideal for human abdominal wall reconstruction! He ended with a reference to a new class of "nano" meshes that combine a strong bio-scaffold with growth factors and inflammatory inhibitors. Perhaps 1 day Bilroth's dream will come true.
Barrier-Coated Meshes
The development and refinement of laparoscopic ventral hernia repair (LVHR) has been a major innovation in the field of herniorraphy. The benefits of LVHR include lower recurrence rates and wound complications, improved diagnosis of occult hernias, less morbidity, and fewer mesh-related infections. Many believe that LVHR now represents the gold standard for ventral hernia repair (VHR).
Surgeons performing open VHR with mesh have several options for mesh positioning:
• Intraperitoneal onlay mesh technique (IPOM);
• Preperitoneal or retro-rectus placement (Rives-Stoppa); and
• Primary closure with mesh onlay.
However, LVHR requires placement of mesh within the peritoneal cavity. Thus, it is imperative that any material used during LVHR has minimal impact on the adjacent intra-abdominal anatomy.
Traditionally, ePTFE has been the material of choice for IPOM or LVHR. Brent Matthews, MD, Associate Professor of Surgery at Washington University reviewed the emerging field of absorbable barrier-coated meshes that provide another material option for intraperitoneal mesh placement. Dr. Matthews began his presentation by highlighting the problems of placing unprotected macroporous mesh in the peritoneum. He sited a study by Halm and colleagues[4] that examined the impact of mesh position on the outcomes of 66 patients who had VHR and required a subsequent laparotomy.Compared to patients with preperitoneal mesh repairs, patients with intraperitoneal mesh had higher perioperative complications (76% vs 29%), more intra-abdominal adhesions (62% vs 26%) and fistulas (5% vs 0%), and required more bowel resections (20% vs 0%). It should be noted that 93% of these patients had unprotected PP placed at their initial VHR.
Dr. Matthews then reviewed the 4 currently available absorbable barrier-coated meshes (ABCMs) in the United States. These ABCMs all use either a PP or polyester mesh foundation that is coated with a temporary "barrier" designed to minimize tissue ingrowth into adjacent bowel or viscera. He added later, however, that ePTFE, whose microporous surface provides a permanent adhesive barrier, is, in his words, "the gold standard" to which other ABCMs must be compared.
The ABCMs exploit a natural process called neo-peritonealization. When a mesh is implanted in the peritoneal cavity, the host forms a new (neo) peritoneum over the material. This process, which can take several weeks, ultimately has the effect of placing the mesh in a more protected preperitoneal position, assuming the mesh barrier remains intact during this process. The specific properties of each ABCM are detailed in Table 1.
Table 1. Properties of Absorbable Barrier-Coated Meshes
Mesh Manufacturer Permanent Barrier Longevity (days) Weight (g/m2)*
ParietexTM Composite Covidien Polyester (RW) Atelocollagen Type 1, polyethylene glycol, glycerol 20 75
C-QurTM Atrium PP (LW) Omega-3 fatty acid 90-180 50
PROCEEDTM Ethicon PP (LW) Oxygenated regenerated cellulose + polydioxanone (PDS) within 30 days 45
SeprameshTM Davol PP (LW) Seprafilm within 30 days 102
*Weight is after absorption of barrier
Dr. Matthews explained that SeprafilmTM, PROCEEDTM, and Parietex CompositeTM all have barrier coatings that are completely absorbed within 30 days (according to the patent application data), while C-Qur'sTM omega-3 barrier coating lasts about 90 to 120 days
While it is unclear how each of these different barrier coatings translates to clinical outcomes in humans, there is evidence that ABCMs produce fewer intra-abdominal adhesions compared to uncoated macroporous (PP of polyester) mesh.
Dr. Matthews cited a study by Arnaud and colleagues,[5] demonstrating that the ParietexTM composite had fewer visceral adhesions when compared to unprotected polyester (18% vs 77%). In a similar study by Balique and colleagues,[6] ParietexTM demonstrated an ultrasonic adhesion-free abdomen in 86% of patients at 1 year. Both studies utilized a validated ultrasound technique to grade the extent of intra-abdominal adhesions. However, this technique (ultrasound) was not able to assess adhesion tenacity, which may be a more clinically important factor. Furthermore, none of the adhesion scores were confirmed with laparoscopy. Currently, a study is ongoing at Dr. Matthews' institution evaluating adhesion area, tenacity, and adhesiolysis time. According to Dr. Matthews, preliminary data has shown higher adhesions and tenacity with unprotected macroporous meshes.
Quality of Life With Different Meshes
Recurrence Rates
One of the primary goals in hernia surgery is to provide a secure repair with a low long-term recurrence rate. Surgical techniques that incorporate a mesh repair have undoubtedly helped to lower the recurrence rate of both inguinal and ventral hernias. The current generation of mesh products is far from perfect and recurrence rates after mesh repair can be relatively high. In fact, Dr. Ramshaw, in his review of synthetic hernia repair, raised the provocative question: does mesh only serve to delay the recurrence of hernias? He cited Flum and colleagues,[7] who concluded that long-term reoperative rates for ventral hernia, which presumably reflects recurrence, did not differ with mesh vs primary (no mesh) repair. However, this was a large population-based study that did not randomize patients or control for exact repair technique.
Alternatively, Scott Roth, MD, a surgeon at The University of Maryland argued that there are overwhelming data that mesh repairs significantly reduce hernia recurrence. He sited a landmark study[8] of incisional hernias in The New England Journal of Medicine that demonstrated a 48% recurrence rate at 3 years with a primary, suture repair compared to 20% recurrence rate with mesh.
Mesh-Related Complications
With the increased utilization of hernia prosthetics, the incidence of mesh-related complications has also risen. Although rare, mesh infections and enterocutaneous fistulas are a devastating complication that can have significant effects on long-term quality of life. Furthermore, a growing body of literature suggests that mesh can increase chronic pain and discomfort in the form of a foreign body sensation, excessive rigidity, and collateral nerve and tissue inflammation. Multiple high volume (> 1000 cases) studies have demonstrated a relatively high incidence of chronic pain after inguinal hernia repair. In an effort to improve post-herniorrhaphy quality of life, prosthetic manufacturers are increasingly focused on developing meshes that have a more favorable graft-host profile.
Dr. Roth discussed the influence of mesh on quality of life and chronic pain after hernia repair. He began by reviewing the growing trend of prosthetic hernia repairs. According to Dr. Roth, the adoption of the Lichtenstein technique, as well as laparoscopic approaches to inguinal hernias, has led to a significant increase in mesh repairs for these hernias. For example, in 2003 there were over 750,000 inguinal hernia repairs in the United States with over 90% of these procedures utilizing mesh. Similarly, in 2004 it is estimated that there were 300,000 incisional hernia repairs with more than 50% employing mesh.
Mesh Weights and Their Impact on Outcomes
Dr. Roth provided a brief history of the evolution of mesh beginning with the first description of silver coils in 1894 to the development of the current generation of meshes including PP, polyester, and ePTFE. The primary focus of his review was the differences in outcomes between the traditional heavyweight (HW) meshes and the newer lightweight (LW) materials.
LW meshes offer several theoretical advantages over HW materials. Because LW meshes have less foreign material (measured in g/m2), compared with HW meshes they produce a less rigid repair that more closely approximates native tissue compliance, with the end result being a more comfortable repair for the patient. Furthermore, reducing the concentration of material may lessen the inflammatory and foreign body response, which is thought to be a factor in pain and mesh contraction. Although the tensile strength of LW mesh is lower than that of HW mesh, it still exceeds bursting strength of native tissue.
While there have been reports of higher recurrence rates with LW mesh, it is thought that most recurrences are related to mesh migration and not mesh rupture. It has been postulated that the less aggressive ingrowth of LW mesh combined with composites that utilize absorbable weaves makes these materials more prone to migration. Dr. Roth reviewed 5 recent studies that examined the potential benefits of LW mesh.
In 2005 O'Dwyer and colleagues[9] examined the incidence of chronic pain after open inguinal hernia repair. This was a prospective study of 321 patients undergoing primary Lichtenstein repair. Patients were randomized to either LW mesh (32 g/m2) repair or HW PP (85 g/m2). At 1 and 3 months after surgery there was no difference in the incidence of pain or "return to activities." However, 1 year after surgery, patients with LW mesh had a statistically significant higher number of recurrences compared to HW patients (5.6% vs 0.4%; P = .037). Dr. Roth did not discuss the significantly higher incidence of "pain of any severity" in the HW group at 1 year postop (51.6% vs 39.5%, P = .033).
Akolekar and colleagues[10] examined the effect of LW vs. HW mesh on recurrence after laparoscopic total extraperitonal (TEP) inguinal herniorrhaphy. In their study, 371 hernias were repaired with LW mesh while 861 defects were repaired with HW mesh.[10] Overall, there was no significant difference in recurrence rates (4.3% for LW vs 2.8% for HW). However, the authors were concerned about the trend of higher recurrence rates for the LW group given the shorter follow-up time in this group (14 months vs 22 months for HW patients). As in the US laparoscopic VA trial,[11] this study's results were confounded by a high number of operating surgeons being trainees. In the O'Dwyer study,[9] 30% of the LW repairs were performed by residents vs 14% in the HW group. This included a "high activity" surgeon who only used HW mesh and had "no teaching responsibility." In a 2006 publication by Horstmann and colleagues,[11] PP weight was found to be proportional to the risk of postoperative complications in inguinal hernia patients. This study involved 632 patients undergoing laparoscopic transabdominal preperitoneal (TAPP) repairs with 3 varying weights of PP: (1) HW mesh, (2) LW mesh, and (3) extra-lightweight mesh (16 g/m2).Patients who received the HW mesh had a significantly higher incidence of postoperative complications including seroma and hematoma. At 12-month follow-up, the HW group also had a significantly higher incidence of foreign body sensation and "undue sensitivity to weather changes." Patients who had either moderate or severe impairment of quality of life (QOL) prior to surgery experienced a uniform improvement in QOL after hernia repair, regardless of the type of mesh. However it was concerning that patients who were asymptomatic or who had minimal QOL impairment preoperatively experienced a decrease in QOL in the HW and LW group; with only the extra-lightweight patients experiencing an improvement in QOL.
Post and colleagues[12] also examined the relationship between mesh weight and QOL in patients undergoing Lichtenstein repair.LW repairs yielded a significantly lower incidence of pain (with activity) and foreign body mesh sensations at 6 months postoperatively. As with most other studies, there was an improvement in overall QOL after repair that was independent of mesh weight. This study was limited in size (122 hernia repairs) and follow-up (6 months).
One of the higher volume single surgeon studies was published by Paajanem in 2007.[13] In his study of Lichtenstein repairs, Paajanem randomized 228 patients to either HW or LW mesh. At 1 year there was no difference in the incidence of pain, foreign body sensation, or recurrence rates between HW and LW groups. He did demonstrate that between the first and second year after surgery, patients have improvement in all of the above parameters. His results suggest that the nadir of adverse symptoms following inguinal repair may be at least 2 years after surgery. This is important because many of the studies examining mesh QOL have limited follow-up up (6 to 12 months).
Dr. Roth concluded with a brief discussion of ventral hernia repairs. He reviewed the commonly used permanent and absorbable barrier coated meshes and stated that they "all are associated with adhesions to a variable extent." According to Dr. Roth, the relevance of mesh-related adhesions to obstructions, fistulae, and quality of life are "absolutely unknown." Similarly, he stated that while it is assumed that HW meshes experience more contraction, it is unclear whether this translates to a higher risk of pain and recurrence.
In summary, Dr. Roth stated that there may be a trend toward less pain and foreign body sensation with LW mesh and this benefit may come at the expense of a higher recurrence rate. In addition, regardless of mesh weight, most patients seem to enjoy an improvement in QOL after hernia repair.
Yuri Novitsky, MD, Director of the Hernia Center at The University of Connecticut Health Center, Farmington, Connecticut, reviewed the clinical effect of aberrant inflammatory responses to mesh prosthetics, especially foreign body reactions that may increase mesh morbidity.
Picking up where Dr. Roth left off, he examined the histologic advantages of LW mesh while conceding that there is no clear definition of "lightweight mesh." For the purpose of his discussion, Dr. Novitsky defined HW mesh as > 95 g/m2 and reduced or LW mesh as < 70 g/m2.
Dr. Novitsky reviewed data from 3 animal studies[14-16] that confirmed the benefits of LW mesh. Klinge and colleagues[15] described the normal tissue healing process which involves an initial period of increased fibroblastic, macrophage and granulocyte activity that peaks after 7-14. After 90 days there is uniform collagen deposition and almost complete disappearance of inflammatory cells. In contrast, in the presence of a foreign body (ie, mesh) there is an exaggerated inflammatory response with maintenance of inflammatory cells even at 90 days and excessive fibrosis with formation of a "scar plate" around the mesh. Although LW mesh induces an abnormal inflammatory response, when compared to HW mesh it is more blunted, with less scar plate formation and foreign body reaction. This may translate to what is seen clinically (less contraction and more compliance). Compared to HW mesh, LW mesh also yielded lower levels of apoptosis and Ki-67 which are 2 markers of cell turnover and inflammation.
In a recent publication by Dr. Novitsky,[16] various prosthetics were implanted in rabbits and evaluated 1 year later.ePTFE and lightweight PP had significantly lower levels of apoptosis and Ki-67 compared to HW PP and the ePTFE/PP composite. Persistently elevated levels of apoptosis have also been observed in humans up to 5 years post implantation.[17-19]
Dr. Novitsky also reviewed some of the clinical data examining differences between LW and HW synthetic meshes. In addition to critiquing the Post and O'Dwyer studies (see above), he cited a 2006 study by Bringman and colleagues[20] where590 patients were randomized to Lichtenstein repair with either HW (80 g/m2) or LW (30 g/m2)mesh. The average follow-up interval was 3 years, with a minimum of 30 months. There was no significant difference in recurrence (3.7% vs 3.6%), testicular atrophy, pain with activity, or long-term postoperative narcotic use. In fact, on their 20-point questionnaire, there were only 3 areas of significant difference; groin tenderness on palpation (HW: 3.3% vs LW: 0.8%, P = .49); pain with positional change (HW: 13.6% vs LW: 7.6, P = .29) and mesh sensation (HW: 22.6% vs LW: 14.7%, P = .025). However, there was no difference in the number of patients reporting a "normal sensation" or "discomfort" in the groin.
The Ideal Synthetic Mesh -- Has it Arrived?
Dr. Novitsky began with an emphatic "no" when answering the question above. According to Dr. Novitsky, the ideal synthetic mesh would have all of the following properties:
• Durable tensile strength;
• No physical alteration by host tissue (contraction);
• Hypoallergenic;
• Noncarcinogenic;
• Resistance to infection;
• Effective tissue ingrowth without excessive inflammation or foreign body reaction; and
• Cost effectiveness.
Other important factors include: compliance, ease of handling, and reduced risk of fistula and seroma formation.
In summary Dr. Novitsky emphasized the equivocal clinical data pertaining to synthetic meshes. He stated that there is "insufficient evidence" to establish superiority of PP vs polyester; monofilament vs multifilament; and pore size (controlling for weight). While arguing that there is a "vast" body of evidence supporting the immunohistochemical benefits of LW mesh, he conceded that there are no clear data demonstrating clinical benefits of LW mesh other than mild-to-moderate reductions in groin pain.
Biologic Meshes -- Sources, Advantages, and Cost
One of most recent trends in hernia prosthetics has been the development of the biologic meshes, aka "biomeshes." Human and porcine acellular dermal matrices, which where introduced in the mid 1990s,[21] were initially used for coverage of burn wounds. Recently the biomeshes have established a higher profile in hernia and abdominal wall reconstruction, especially in the arena of infected wounds and "damage control" surgery.
Dr. Scott Helton, Chairman of Surgery at The Hospital of St. Raphael in New Haven, concluded the session with a review of the status of biomeshes in hernia repair. He began by highlighting the dramatic growth in the field. According to Dr. Helton, in the last 2 years, the number of available biomeshes in the United States has grown from 3 to 13. However, he pointed out that 6 of these products have no peer-reviewed published animal or human data.
There are 3 biomesh categories: human acellular dermis, xenogenic acellular dermis (porcine and bovine), and acellular porcine small intestinal submucosa (Table 2). All of these constructs use a matrix of proteins, including collagen, elastin, glycoproteins, and growth factors, which provide a scaffold for ingrowth of host cells and deposition of mature collagen, with ultimate resorption of the biomesh. Dr. Helton also briefly mentioned bovine pericardium, which is primarily used for staple line reinforcement.
He then discussed the key components that vary between each biomesh product:
• The process for extracting donor cells and contaminant (ie, viral) material;
• Removing potentially deleterious xenogenic proteins that may promote abnormal host inflammation; and
• Hydration and freeze-drying, which alter the operating room "prep time" of the product.
In addition, there are also numerous host factors, such as anatomical position of the biomesh, the degree and type of local wound infection, and local inflammatory mediators that affect mesh strength, longevity, and the ability to resist infection. In Dr. Helton's words, it is often a race between mesh "incorporation, integration, and remodeling" and infectious forces attempting to degrade the biomesh.
Table 2. Biomeshes
Biomesh Type Products, Manufacturers
Human acellular dermis AlloDerm®, LifeCell

Flex HDTM, J&J

AlloMaxTM, Davol
Xenogenic acellular dermis PermacolTM (porcine), Tissue Science Laboratories

SurgiMendTM (bovine,calf), TEI Biosciences

CollaMendTM, (porcine) Davol

XenMatriX® (porcine), Brennen Medical LLC; Brennenmed.com

StratticeTM, LifeCell
Porcine small intestine submucosa Surgisis®, Cook Medical

FortaGen®, Organogenesis

Dr. Helton summarized the unique and advantageous properties of the biomeshes. He explained that the biomeshes are especially well suited for coverage and protection of exposed viscera (ie, the open abdomen). When compared to the polyglactin 910 absorbable woven mesh (VicrylTM), Dr. Helton stated that there is accumulating data that the biomeshes reduce the risk of fistula formation and accelerate vascularization and wound contracture. He also addressed the high cost of the biomeshes, but justified their use if it avoids an enterocutaneous fistula, which can cost "hundreds of thousands" of dollars. The biomeshes also appear to be more resistant to infection, which makes them an ideal choice for repair of infected hernias or repairs that are done during contaminated procedures, such as colectomy, ostomy closure/reinforcement, hysterectomy, or gastric bypass. Finally, there are data to support the use of biomeshes in hiatal repair and the concept of having an absorbable material in juxtaposition to the esophagus is appealing. However, the efficacy and safety of biomeshes in elective, clean, ventral or inguinal herniorrhaphy is unknown. There are concerns about long-term tensile strength and recurrence with the biomeshes.[22,23] For this reason, as well as cost, most surgeons continue to use a permanent synthetic material for clean ventral and inguinal herniorrhaphy.
Because the biomeshes are derived from transplanted animal tissue there have been concerns related to transmission of infectious agents. Although no case of an infection has been reported with a xenogenic biomesh, there is the theoretical possibility of viral or prion (notably, bovine spongioform encephalopathy) transmission. The risk of infection with human allogenic biomeshes is slightly higher with the primary concern being HIV and viral hepatitis. According to 2005 Centers for Disease Control (CDC) data, the risk of "disease transmission" with cadaveric grafts is 4 per million with most of these cases involving solid organ transplantation. Despite several well-publicized cases of improper organ procurement, the processing of biomeshes is extremely stringent and there have no reports of transmission with xenogenic or allogenic hernia biomeshes. There are also medical/legal issues related to utilizing animal grafts for hernia repair in patients who have religious or personal objections to implantation of animal tissue. Dr. Helton stressed the importance of informed consent before using any animal derived biomesh. Specifically, Islamic and Jewish faiths may prohibit porcine-derived biomesh, and these patients should be encouraged to consult with their religious leaders prior to surgery. Furthermore, the Jehovah's Witness' faith forbids receipt of any animal or human tissue or fluid.
Summary
Hernias will continue to be a common and vexing challenge to the general surgeon. While minimally invasive techniques and modern prosthetics have bolstered the surgeon's armamentarium, we have yet to realize the ultimate goal of recurrence free repairs that are free from any morbidity. Furthermore, despite a wealth of published data, many of the fundamental questions in herniorraphy remain unanswered. However, if the past is any predictor, the scientific and medical community will continue their march forward in search of Bilroth's "secret of the radical hernia repair."
________________________________________
References
[ CLOSE WINDOW ]
References
1. Usher FC, Ochsner J, Tuttle LL. Use of Marlex mesh in the repair of incisional hernias. Am Surg. 1958;24:969-974. Abstract
2. Rives J. Surgical treatment of the inguinal hernia with Dacron patch. Int Surg. 1967; 47:360-361. Abstract
3. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004;240:578-583. Abstract
4. Halm JA, DeWall LL, Steyerberg EW, Jeekel J, Lange JF. Intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery. World J Surg. 2007; 31:423-429. Abstract
5. Arnaud JP, Hennekinne-Mucci S, Pessaux P, Tuech JJ, Aube C. Ultrasound detection of visceral adhesion after intraperitoneal ventral hernia treatment: a comparative study of protected versus unprotected meshes. Hernia. 2003;7:85-88. Epub 2003. Erratum in: Hernia. 2003;7:164.
6. Balique JG, Benchetrit S, Bouillot JL, et al. Intraperitoneal treatment of incisional and umbilical hernias using an innovative composite mesh: four year results of a prospective multicenter clinical trial. Hernia. 2005; 9:68-74. Abstract
7. Flum D, Horvath K, Koepsell T. Have outcomes of incisional hernia repair improved with time?: A population-based analysis. Ann Surg. 2003; 237:129-135. Abstract
8. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343:392-398. Abstract
9. O'Dwyer PJ, Kingsnorth AN, Molloy RG, Small PK, Lammers B, Horeyseck G. Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair. Br J Surg. 2005 ;92:166-170. Abstract
10. Akolekar D, Kumar S, Khan LR, de Beaux AC, Nixon SJ. Comparison of recurrence with lightweight composite polypropylene mesh and heavyweight mesh in laparoscopic totally extraperitoneal inguinal hernia repair: an audit of 1,232 repairs. Hernia. 2008 ;12:39-43. Epub 2007 Sep 13.
11. Langenbach MR, Schmidt J, Zirngibl H. Comparison of biomaterials in the early postoperative period. Polypropylene meshes in laparoscopic inguinal hernia repair. Surg Endosc. 2003; 17:1105-1109. Abstract
12. Horstmann R, Hellwig M, Classen C, Röttgermann S, Palmes D. Impact of polypropylene amount on functional outcome and quality of life after inguinal hernia repair by the TAPP procedure using pure, mixed, and titanium-coated meshes. World J Surg. 2006;30:1742-1749. Abstract
13. Post S, Weiss B, Willer M, Neufang T, Lorenz D. Randomized clinical trial of lightweight composite mesh for Lichtenstein inguinal hernia repair. Br J Surg. 2004 ;91:44-48. Abstract
14. Paajanen H. A single-surgeon randomized trial comparing three composite meshes on chronic pain after Lichtenstein hernia repair in local anesthesia. Hernia. 2007 ;11:335-339. Epub 2007 May 10.
15. Klinge U, Klosterhalfen B, Birkenhauer V, Junge K, Conze J, Schumpelick V. Impact of polymer pore size on the interface scar formation in a rat model. J Surg Res. 2002 ;103:208-214. Abstract
16. Harrell AG, Novitsky YW, Peindl RD, et al. Prospective evaluation of adhesion formation and shrinkage of intra-abdominal prosthetics in a rabbit model. Am Surg. 2006;72:808-813; discussion 813-814.
17. Novitsky YW, Harrell AG, Cristiano JA, et al. Comparative evaluation of adhesion formation, strength of ingrowth, and textile properties of prosthetic meshes after long-term intra-abdominal implantation in a rabbit. J Surg Res. 2007 ;140:6-11. Abstract
18. Junge K, Klinge U, Rosch R, Klosterhalfen B, Schumpelick V. Functional and morphologic properties of a modified mesh for inguinal hernia repair. World J Surg. 2002;26:1472-1480. Epub 2002 Sep 26.
19. Klinge U, Junge K, Stumpf M, Klosterhalfen B. Functional and morphological evaluation of a low-weight, monofilament polypropylene mesh for hernia repair. J Biomed Mater Res. 2002;63:129-136. Abstract
20. Klosterhalfen B, Junge K, Hermanns B, Klinge U. Influence of implantation interval on the long-term biocompatibility of surgical mesh. Br J Surg. 2002;89:1043-1048. Abstract
21. Bringman S, Wollert S, Osterberg J, Smedberg S, Granlund H, Heikkinen TJ. Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia. Br J Surg. 2006 ;93:1056-1059. Abstract
22. Buinewicz B, Rosen B. Acellular cadaveric dermis (AlloDerm®): a new alternative for abdominal hernia repair. Ann Plast Surg. 2004 ;52:188-194. Abstract
23. Blatnik J, Jin J, Rosen M. Abdominal hernia repair with bridging acellular dermal matrix -- an expensive hernia sac. Am J Surg. 2008;196:47-50. Epub 2008 May 7.
24. Bluebond-Langner R, Keifa ES, Mithani S, Bochicchio GV, Scalea T, Rodriguez ED. Recurrent abdominal laxity following interpositional human acellular dermal matrix. Ann Plast Surg. 2008;60:76-80. Abstract


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Aug31
Lichtenstein or Mesh Plug Hernia Repair -- Is There a Difference in Recurrence?
Lichtenstein or mesh plug repair: Which is superior for inguinal hernias? To answer this question the study authors randomly assigned 595 patients to one of the 2 operative procedures and looked at outcomes after 1 year. Follow-up was complete for 85% of the study group and revealed no significant differences with respect to recurrence rates or immediate postoperative complications. Operations were shorter, and reoperations within the first year were less frequent in the mesh plug group (4 vs 14), but seromas were more frequent (P = .02) than with Lichtenstein repair.
Viewpoint
The important finding in this large randomized trial shows that these 2 widely used procedures give comparable results with respect to recurrence -- the main outcome of concern. However, the follow-up period in the study is only 1 year, so it will be important to determine whether these findings hold up over longer time periods. The study authors promise to provide 5-year follow-up results when available. Younger patients (< 40 years) were excluded from the study, so we cannot generalize the results to all age groups.


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Aug31
RID - Recession Induced Depression & Homeopathy
A new pandemic has crept into our society and friends its not the swine flu.....its something which no one seems to take notice of.It causes insomnia, anxiety,anorexia , guilt, envy, shame, headaches and in some grave cases even suicidal thoughts. Most of us might have experienced some form of this sickness atleast mild anxiety or insecurity. Ever wondered what is causing all this? No, its not some alien bacteria or virus............ the culprit is the 'R' word which has become a household name by now. Guessed it right its the RECESSION and I would call this spectrum of symptoms as Recession Induced Depression or in short 'RID'.

THE EVOLUTION

Daily news of people losing jobs has stirred anxiety and insecurity among many. The ones who have lost their jobs are facing pangs of guilt for not saving enough and shame for being jobless. There have been many suicides and a surge in crime rate following recession.

THE REMEDY

At this juncture HOMOEOPATHY comes to your rescue. Homoeopathy is a holistic treatment which believes in eliminating the disease from its roots. It has treated many psychological illnessess successfully.Homoeopathy has more than hundred drugs which act on the mental and emotional level and establishes a cure. A detailed case-taking is done by taking account of the patient's psychological state in comparision to his or her usual self.Recent changes in the general state of the patient like appetite, thirst, bowel movements, sleep,food cravings etc are take into account. Physical RID symptoms like headaches,chest pain etc are considered and a prescription is made.

TIPS TO COMBAT RID

• STOP WORRYING - Worry worsens symtoms and anyways tomorrow is not in our hands.
• SOCIALISING - Interact with near and dear ones and avoid the R word in your conversations.
• BUILD YOUR CONFIDENCE - Believe in yourself is the mantra. A positive aura keeps negativity at bay.
• RELAXATION TECHNIQUES - Prayers,meditation and evening walks do help a lot in calming a hyper mind.

Courtesy:www.homeoforall.com


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Aug25
PCNL
MULJIBHAI PATEL UROLOGICAL HOSPITAL, NADIAD
JAYARAMDAS PATEL ACADEMIC CENTRE


NO STONE LEFT UNTURNED – INSTRUCTION COURSE ON PCNL

'German Doctor praises Nadiad Kidney Hospital for pioneering work'

Jayaramdas Patel Academic Centre (JPAC) at the Muljibhai Patel Urological Hospital (MPUH), Nadiad organised yet another Instruction Course on PCNL (Percutaneous nephrolithotripsy) during 2 -4 July, 2009.

Stone management occupies a major portion of our clinical practice. Basically most of the stone cases are either neglected or diagnosed late. Very often they complicate other health problems like diabetes, hypertension, obesity, pregnancy, neurological diseases, CRF, Bleeding Diathesis, etc. This increases complication or failure to clear all stones. Though PCNL (Percutaneous nephrolithotripsy), URS (Ureteroscopic lithotripsy) and ESWL (Extracorporeal shock wave lithotripsy) are still indicated, their applications have been modified. It requires special attention.

International faculty who participated in the Course included Peter Alken from Germany and Adrian Joyce from UK, while Samir Rai and Anil Bradoo will be among the National faculty members. Mahesh Desai, Director, JPAC and Chairman, Dept. of Urology; and R.B. Sabnis, Vice Chairman, Dept. of Urology will also be present, among others, from MPUH.

Dr. Peter Alken told DNA "I invented the PCNL technique in 1980s, but the doctors here (in MPUH Nadiad) perfected it. I am really very glad to see good use of the technique here. I admire the hospital and its doctors for making a great success of the technique".

The main aim of the Course was to focus on complicated situations. There will be ‘hands on’ facilities to increase the skill. Around 50 Urologists participated in the programme.

Muljibhai Patel Urological Hospital, who are the pioneers in the field of nephro-urology in India, has handled more than 16000 stone cases so far.

Kidney Stones Overview
The kidney acts as a filter for blood, removing waste products from the body and helping regulate the levels of chemicals important for body function. The urine drains from the kidney into the bladder through a narrow tube called the ureter. When the bladder fills and there is an urge to urinate, the bladder empties through the urethra, a much wider tube than the ureter.
In some people, the urine chemicals crystallize and form the beginning, or a nidus, of a kidney stone. These stones are very tiny when they form, smaller than a grain of sand, but gradually they can grow to a quarter inch or larger. The size of the stone doesn't matter as much as where it is located.
When the stone sits in the kidney, it rarely causes problems, but should it fall into the ureter, it acts like a dam. The kidney continues to function and make urine, which backs up behind the stone, stretching the kidney. This pressure build up causes the pain of a kidney stone, but it also helps push the stone along the course of the ureter. When the stone enters the bladder, the obstruction in the ureter is relieved and the symptoms of a kidney stone are resolved.

Kidney Stones Causes
There is no consensus as to why kidney stones form.
Heredity: Some people are more susceptible to forming kidney stones, and heredity certainly plays a role. The majority of kidney stones are made of calcium, and hypercalciuria (high levels of calcium in the urine), is a risk factor. The predisposition to high levels of calcium in the urine may be passed on from generation to generation. Some rare hereditary diseases also predispose some people to form kidney stones. Examples include people with renal tubular acidosis and people with problems metabolizing a variety of chemicals including cystine (an amino acid), oxalate, (a type of salt), and uric acid (as in gout).
Geographical location: There is also a geographic predisposition in some people who form kidney stones. There are regional "stone belts," with people living in the stone belts having an increased risk. This is likely because of the hot climate, since these people can get dehydrated, and their urine becomes more concentrated, allowing chemicals to come in closer contact and begin forming the nidus of a stone.
Diet: Diet may or may not be an issue. If a person is susceptible to forming stones, then foods high in calcium may increase the risk, however if a person isn't susceptible to forming stones, nothing in the diet will change that risk.
OTC products: People taking diuretics (or "water pills") and those who consume excess calcium-containing antacids can increase the amount of calcium in their urine and increase their risk of forming stones. Patients with HIV who take the medication indinavir (Crixivan) can form indinavir stones.
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Aug25
Flexible URS (Ureteroscopy)
MULJIBHAI PATEL UROLOGICAL HOSPITAL, NADIAD
Jayaramdas Patel Academic Centre

www.mpuh.org

Flexible Ureteroscopy

Muljibhai Patel Urological Hospital (MPUH), Nadiad organised a 3-day Instruction Course on Flexible URS (ureteroscopy), during 20th to 22nd August 2009. Flexible Ureteroscopy has become increasingly popular in the management of stone disease. It is more nephron saving than PCNL and ESWL.

During the past two decades, URS has dramatically changed the management of ureteral calculi and is extensively used in many urological centres all over the world, including the Nadiad Kidney Hospital (MPUH). Major improvements have taken place especially in the area of flexible URS that offers minimally-invasive removal of stones from the proximal ureter and the kidney. Flexible URS has demonstrated its efficacy for small or mid-sized stones. Further technical advancements, more experience and better skills of the urologists will expand its indications, making flexible URS a preferred treatment option for renal calculi. The three-day Instruction Course at MPUH was attended by more than 100 urologists from all over India and abroad.

The star faculty included Drs. Michael Grasso, S V Kandasami and Pradeep P Rao. From MPUH, Dr. Mahesh Desai, Director, JPAC and Chairman, Department of Urology; and Dr. R B Sabnis, Vice-Chairman, Department of Urology will also be participating in the Programme and sharing their experience. There were ‘hands-on’ training on simulators and a model.

*****


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Aug22
Homeopathy and Chronic renal failure
A Case Of Chronic Renal Failure:

It was a precious opportunity for me to treat few cases of chronic renal failure.
I am discussing here one such case of interest.

On the 12 th June 2003 a gentleman aged 73 years came to my office with his wife and daughter.
He was a man of short thin built, with a yellowish complexion and looking pale and withered. He had a calm and composed expression. It was characteristically fearless, showing no anxiety or concern of any kind.

He had been a professor of language for 17 years and had composed many poems. He had taught literary criticism to students of Masters in Arts.

His wife and daughter were doing all the talking. He reprimanded them right at the beginning of the interview and asked them whether they were going to let him talk.

He started as, ‘I have absolutely no complaints. I am a diabetic since 20 years. That was detected in a routine blood examination before my operation for cataract. I am a hypertensive since 15 years. That was detected in a routine medical check up.
Since a few weeks I had slight nausea and aversion for food. So I had a check up done when high urea and creatinine was found in my blood.’

He has been on anti-hypertensive allopathic drugs and Insulin injections for about 15 years.

The levels were Blood Urea level 220 mg/dl (normal range being 15-40 mg/dl)
and Serum creatinine at 3.9 u/dl (Normal range being 0.5-1.5)

His Renal Doppler suggested diffuse renal parenchymal disease. An atrio-ventricular fistula had been made in his right arm, and he was to go for a dialysis the following week.

2 years back he had a toe amputation for an intractable infection.
So it is quite evident that he is suffering from complications of diabetes.

Let us take note here that there is a major problem in his body, but the only symptoms the vital force has expressed is slight nausea and aversion for food.

The relative lack of subjective symptoms was striking.
This brought to mind the syphilitic miasm so definitely.

The syphilitic miasm is of a deep destructive nature, which hardly shows up in the form of subjective symptoms. Its very nature is like the silent killer.

The relative lack of subjective symptoms gives us the clue that psora is more or less latent at this point of time.
Psora in its very essence means expression; psora needs to express as it needs to communicate its primary anxiety of separation. Psora expresses to connect with others so that they may feel less separated; less lonely. The mental ‘itch’ may thus somewhat be relieved.

So we find that his economy only communicates minimally, in the form of two symptoms, nausea and an aversion for food. That is quite unlike an active psora.

He has a low appetite, and nausea. Empty retching.
He likes spicy pickles and sweet meats when well. Let us note here that it is not a craving, a mere preference. So we cannot really put it high up in the hierarchy.
He drinks less water as his chest seems to fill up with it. His stools are sometimes dry and hard.
He passes about 1 litre of urine per day.

He is a man of few words. And they are precious ones.
Quite unlike an active psora!

He has a small friends’ circle of renowned writers and poets. He used to read a lot, but is not happy with the present shallow writing, and thinking. So now, he generally does not read much, nor does he write anymore.
He had a huge collection of books all of which he donated to a library.
We understand this as a need to collect and retain followed by a total discharge, probably out of a growing indifference.
It means he is tuning away from the things he ardently loved before.

He has stopped his expression- his writing and teaching, and become indifferent now. He has a feeling that it is not worth it anymore.

The symptoms I could gather were-

Absence of symptoms where expected
Reserved
Philosophical
Indifferent
Irritated on being disturbed
Renal failure

But to summarize the observations made before,
He was in psora and tubercular miasm initially.
Psora because it being a basic ‘ mother miasm’, is always present, though varying in its active influence or activity during the lifetime of a person.
And psora, also because he was very expressive, teaching, writing.
The tubercular miasm shows itself by his creativity and innovative ideas;

Only creative persons can write poems. And those who think and feel deeply and can express it in verse.
The Syphilitic miasm seems to have been present in the past, but had been latent in his constitution. This conclusion is on the basis of his mentioning that he did not have any ‘subjective symptoms’ of diabetes or of hypertension. These had been detected during routine blood tests.

That means there was hardly any expression of the inner disturbance; which means not much activity of psora although psora is always there.

Now at this point of time, when the patient is in chronic renal failure, the syphilitic miasm seems more dominant as it has brought about a silent irreversible organ damage and the little activity of a largely latent psora seems to have brought up the nausea and aversion for food, which are the only subjective symptoms, or expressions in his case.

If psora had remained almost completely latent, he would have had no symptoms, no nausea or food aversion. He would probably have straight away gone into uraemic coma.

Besides this miasmatic analysis we see a prominent theme in the case.
‘Retention.
He used to collect- ‘retain’ a large number of books, which he has now given away- discharged. We see a polarity of need and aversion here.
He is reserved- ‘retains’ emotions. Initially he expressed them in verse, now he does not. He ‘retains’.
He is a deep, sensitive thinker.


The theme of retention, his depth of thinking and his past tryst with verse, brought to mind Natrum and the radical chloride.
So one dose consisting of 2 pellets of Natrum mur 6X were given to him. The rest was plain Sac lac.

In organ damage, I have observed great benefit with the low potencies. Here I have often used the X potencies instead of the C. The C correspond more to the higher frequencies of disturbance as they are more potent than the X potencies.

The frequency of energy of a disturbance is a relative term, by which I mean that—the higher the frequency, the more is the ‘energy’ of expression of the symptoms.
The symptoms will be sharp, strong, marked, and violent.
The ‘higher’ potencies correspond to these sublimated forms of expression.

The lower the frequency of energy of a disease, the lower is the intensity of expression of symptoms.
Like it is in our patient. So the lower potencies are more similar here. Though certainly not a material dose!

The low potencies correspond to the more physical aspects of disease; to the disturbances of a lower frequency so to say.

The problem with him right now, is- his failing kidneys.
I could not have given him a higher potency as his constitution would have been overwhelmed by it. They would just not correspond to him! It would bring about aggravation.
So he had one dose of Natrum Mur 6X.

He reported back about a month later on 17th July 2003, with his BUL and S. Cr. Levels.

BUL was 136 mg/dl……which had been 220 mg/dl before.
S .cr was 3.15 ug/dl……which was 3.9 ug/dl before.


He said ‘I feel more energetic’ and he looked less yellow for sure. He looked more interested than before. This means the syphilitic miasm has reduced in its activity a little.

Placebo was continued up to 29/09/03. His allopathic medications continued as before.

Now his BUL was 166 mg/dl
S.cr 3.9 ug/dl

During this period, he had an episode of vertigo.
He also had fluctuations in Blood sugar levels in the last one week.
He seemed to be more irritated this time. His wife said he seemed to want to cast off all the restrictions put upon him by doctors.
He decided that he wanted to travel to Canada, to his daughter. ‘I need to travel. It is a tonic for me. I always wanted to travel. But my wife’s osteoarthritis never let us go anywhere. My kidneys feel better now. Please give me something that I can travel without a problem with them’.

Do we see here the rebellious Tubercular miasm coming up! Let us recall that he was a thinker, poet and teacher, the creative Tubercular.

These statements were quite startling as compared to his first visit. He seemed to have come out of the Natrum Mur phase. He wanted to go out, travel, connect back with his distant relatives, and even risk his health for that.

This brought to mind another member of the Natrums, Natrum Phos.

The outgoing, communicating effervescent Phosphate radical, who can burn himself by his own warmth if he is not able to give it out.

Now Natrum Phos 12X was given.

I chose the 12X now, as we see that the ‘energy’ of his symptoms have increased to a higher level. The frequency is higher than a 6X.

Nat phos has known to have an affinity for the pancreas and hence diabetes; says the Biochemistry man Schussler.
Nat phos is irritated. And incidentally our patient had a deep yellow coated tongue which confirmed my choice of Natrum Phos!

2 months later, his BUL was 97 mg/dl….(previous reading – 166mg/dl)
S.cr 2.2 ug/dl ……….(previous reading- 3.9 ug/dl )

His allopathic anti-hypertensive and insulin shots continued, but he needed only half the initial dose now!

This was encouraging.

He went on well for about 3 years. He did travel abroad to Canada to visit his daughter, and enjoyed his stay there for a period of six months. After Natrum phos, he did not rebel against medical advice regarding diet and regimen, and so did not ‘burn’ himself, or I mean land himself into trouble, like he would have without our Natrum Phos 12 X.
He was independently going about his routine activities and even went out alone for a short walk.
He visited every month and was quite stable. As symptoms came up he got a single dose of the indicated remedy. Natrm sulph 30 X one dose on one occasion and Nux vomica 30 one dose on another.

3 years later he started deteriorating. He complained of breathlessness, and disorientation.
He died of cardiac arrest peacefully at the ripe age of 76 years.

We do understand here that it was a case with irreversible renal damage. But the medicine seemed to have accentuated the functioning of the remaining healthy renal cortical tissue for a fairly good period of time. He did not require dialysis except on the last day of his life, as his condition had been stable, and his blood biochemistry was fairly good.

Homeopathy could give him a better quality of life. I can say that it was probably even considerably prolonged with Homeopathy.


Dr. Swapna Potdar
BHMS (Pune, INDIA)
D. (Hom)Devon, (UK)


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Aug22
CHORIORETINITIS treated with Homeopathy
CHORIORETINITIS Dt 28-3-07

Hello readers! Here is another gem from homeopathic healing.
A gentleman aged 51 years came with blurring of vision of the left eye, in spite of correction of refractory with spectacles. He had been to several ophthalmologists, and a number of tests had been carried out.
Namely, VDRL, Toxoplasmosis, HIV, Tuberculin test, and orbital sonography. All except the sonography yielded nothing.
Orbital sonography showed post inflammatory chorio-retinal thickening with floating bands in the posterior vitreous chamber.
One ophthalmologist advised him to have an orbital angiography, another advised him to try steroid injections. No one could be sure of why he had the problem, and whether it would go for good or not.
His wife wanted him to take homeopathy. He was reluctant, even defiant; but his wife was sure. She said, “Don’t risk your eyes with invasive methods. Homeopathy can surely help you, never harm. And at worse if it fails, I can take are of a blind husband for life!”
Cheers! To the followers of Homeopathy!
So there he was in my clinic, a short thin man with spectacles, a pointed chin curly hair, and a strikingly ‘wild’ looking face. (This strikes some miasmatic bells in mind!).
He showed me his reports and was very anxious about his eyes and the treatment suggested.
He had been a sickly child. Always ill with whatever disease was going around. (Psora, Tub). He had diphtheria when he was 5 years old, and had been quite ill then. His family doctor warned of dangerous consequences if he became violent or mentally upset. So he had his way in everything since then.
His wife described him as an impulsive, whimsical person. He always fell into trouble with someone or another. Yelling, shouting and fighting his way on useless matters. He was like a difficult child! I once saw him overtake a truck on his bike, dangerously, just to bad mouth the driver.
He analyzed and theorized, until one’s hair would split! He had a lecture to give on everything under the sun, including the sun. It was as if he wanted to prove that he was a genius to the sheer exasperation of listeners. His brothers were very sure he was mad, and all he needed was a psychiatrist!
Once he understood that I would listen to all that he had to say, he felt comfortable nay, elated! He spoke to me like a teenager, laughing and jesting and cracking silly jokes!
But this was one aspect which was another pole to his quarrelsome nature.
He quickly shifted from one to another.

The main point that struck me was his ‘wild face’ and wild talk, and his peculiar physiognomy. It was a ‘delayed milestone’ for me.
Kent lists Calcarea phos in ‘wildness’ amongst other drugs.
Sulphur definitely came very close, being the great ragged philosopher.
But he spoke more than he could analyze or think. He wanted to sound learned, but lack the capacity to really analyze in detail like Sulphur.
Tuberculinum was another drug close on heel considering his susceptibility in childhood to all illnesses, his appearance, and attitude. But at the present state he was not in the pathogenesis of, or the ‘uncompensated’ state of Tuberculinum. In short he did not ‘need’ Tuberculinum as the pathology did not match now.

The miasm was psora and tubercular, and the jigsaw puzzle fitted most closely into Calcarea Phos.
So Calcarea Phos 1CM one single dose was given on 8th November 2004.
He came 15 days later, looking calmer, more ‘tame’.
“I can now see clearly with both my eyes, even in dim light” he said. And worth mentioning here is that he didn’t split my hair with his incessant talk!
Placebo was given for a fortnight.
Orbital sonography was repeated as promised 1 month later. The report was:
Significant improvement in chorio-retinal swelling, with regression of floating bands seen in posterior vitreous chamber.

In this case we have considered the evolution of the pathology from his childhood, as early as he can remember, or we can gather, and have formed a timeline to understand his present state in order to prescribe as accurately as possible.

Cheers to Homoeopathy the absolutely amazing healing art!


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Aug22
BEYOND ENTERTAINMENT: DR. SHRINIWAS KASHALIKAR
Everywhere people seem to be engrossed in some or other kind of entertainment; under the garb of spiritualism.

Spiritualism never was and certainly is not anti entertainment. But spiritualism is not the same as entertainment.

Spiritualism has never been and is certainly not against pleasures. But spiritualism is not the same as getting immersed in visual, olfactory, aural, gustatory, tactile or such pleasures.

This glorified escapism is NOT spirituality. It is at best; and in physiological terms, premature emotional and intellectual ejaculation.

NAMASMARAN is said reach you to the center of the internal and external universe. It is said to enable you to see the truth. Seeing and experiencing the reality is enlightenment. Reorienting and restructuring the perspective, plans, laws, rules and regulations around the enlightenment and conducive to enlightenment; have no alternative.

DR.
SHRINIWAS KASHALIKAR


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Aug22
DREAM & VISION: DR. SHRINIWAS KASHALIKAR
What is use of the scriptures, mythology and other variety of religious and philosophical literature?

What is the value of creative poetry incorporating sublime dreams for the society?

What is the relevance of magnum opus such as Benhur or Dr. Ziwago, in terms of social development?

What is the use of bombardment of sermons in schools, colleges and on other pulpits?

The violence and crimes do not seem to reduce! Violence in Germany was replaced by violence in Hiroshima. Violence in Hiroshima was replaced by violence in Vietnam. Thereafter violence kept on erupting in Cambodia (Kampuchea), Iraq, Afghanistan, Ethiopia, Uganda, Rwanda and so on.

Are the expressions depicting justice, peace, brotherhood and so on, mere emotional outbursts of illusory or subjective nature of some sensitive individuals?

This question can come in any one’s mind.

The answer is neither unrealistically optimistic nor unrealistically pessimistic.

The realization of justice, peace and brotherhood (to a greater extent than what is prevalent) is equivalent to objective process of consistent and conscious evolutionary transformation, in billions, through generations through unhesitant, single minded, simultaneous and consistent commitment to and practice of NAMASMARAN by billons of people in the world through generations (analogous to generations working for the construction of Belur temple and sculpting of Ajanta).

Artistic, scientific and even prophetic expressions are periodic harbingers of this mega process of global nature; which keeps on eluding you at any given time, because, it can at best be apparent in bits at a time, as it involves many generations all over the world!

Thus neither the scriptures are false, nor our faith futile. A process that spreads over millennia is a reality, but not comprehensible by limited individual capacity.

It is our privilege that we are aware of and linked with this all encompassing cosmic superprocess, superstate and superpower viz. NAMASMARAN. This fact itself is a matter of ultimate assurance, and rejoices.

Dr. Shriniwas Kashalikar


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