Biologic Mesh
From SAGES Surgical Wiki
1 Introduction
2 Basic science of biologic meshes
3 Indications for use
3.1 Non contaminated setting
3.2 Bridging the gap
3.3 Reinforcement of the repair
3.4 Contaminated Setting
3.5 Prophylaxis during stoma creation
3.6 Hiatal Hernias
4 Conclusion
5 References


Introduction
Biologic mesh development resulted from a search for a biomaterial that could address the problems associated with permanent synthetic mesh, including chronic inflammation and foreign body reaction, stiffness and fibrosis, and mesh infection. Since the introduction of biologic mesh, the market has been rife with new biologic materials attached to largely unsupported claims of superiority and safety. With data comprised mainly from animal studies and Level III evidence, there has been little science regarding these materials, yet surgeons have been using these materials with increasing frequency driving a multi-million dollar market.

Basic science of biologic meshes
Most often derived from human or porcine dermis, these materials have been processed to acellular, porous extracellular matrix scaffolds of collagen and elastin. Some source growth factors remain and attract endothelial cells and subsequent fibroblasts into the mesh. These host cells release additional chemoattractants that signal the migration of other structural cells. The three-dimensional nature of the mesh and porosity allow cells to enter the mesh and adhere. What happens from there is a cycle of remodeling consisting of degradation of the biologic mesh and regeneration of the collagen scaffold with host tissue. The balance of this degradation and rebuilding process, and the speed with which it occurs, influences the ultimate strength and structure of the biologic mesh hernia repair.
The processing of the biologic mesh for production is by and large a proprietary procedure, making it difficult for surgeons to access information and answer several questions about the final products. These uncertain areas include decellularization, the sterilization process, the source of human dermis in terms of donor age and body part, and the crosslinking process. The cells are removed from the grafts in different ways: physical means such as dessication, chemical processes, or enzymatic reactions. Some of the products are terminally sterilized while others are not, resulting in variations in storage and pre-use hydration requirements. Sterilization options include gamma radiation, ethylene oxide, or hydrogen peroxide. Some companies instill chemicals, such as gluteraldehyde, into the biologic graft to induce additional crosslinking bonds in the graft to slow down the degradation process in the hope of leading to a stronger host collagen framework. However, this is a not a natural feature of the donor tissue and there is concern about the lack of remodeling in too heavily crosslinked grafts. This unintended feature could result in a poorly integrated graft and foreign body reaction, similar to some permanent synthetic meshes.
The advantage of crosslinked mesh versus non-crosslinked mesh remains a controversial area. Early investigation at Washington University presented at the 2009World Hernia Congress and the 2010 American Hernia Society Meeting showed increased stiffness for two crosslinked biologic mesh products (porcine dermis and bovine pericardium) compared to the non-crosslinked bovine pericardium mesh. 1-2 Greater cell infiltration was seen in the non-crosslinked mesh. Future investigation is warranted as to whether these characteristics are clinically important or if the crosslinked mesh poses an increased risk for infection by preventing collagen breakdown and macrophage migration.

Indications for use
The theoretical advantage of biologic mesh over synthetic mesh has appealed to surgeons, mostly in the United States. These meshes are not widely favored nor used in Europe and elsewhere due to the high cost of the biologic mesh over its cheaper and more widely applicable synthetic mesh counterpart. Over the last decade, surgeons have utilized biologic mesh in a variety of cases ranging from primary ventral and inguinal hernia repair in non-infected fields, recurrent hernias, reinforced hernia repair, hernia prophylaxis, and the most widely used application, hernia repair in the contaminated or potentially contaminated field.

Non contaminated setting
The use of biologic mesh in primary or recurrent ventral or inguinal herniorrhaphy in the noncontaminated and previously uninfected field is difficult to justify due to the high material cost without added benefit. There is very little data regarding the performance of biologic mesh in these settings.

Bridging the gap
The poor performance of the mesh in terms of laxity in a bridging repair makes this an unacceptable repair in the noncontaminated setting. Blatnik et al documented a recurrence rate of 80% for bridging repair with acellular dermal matrix at an average cost of $5,100 per patient, comparing the repair to an “expensive hernia sac.”3 The laxity associated with biologic mesh has been documented in other series.4

Reinforcement of the repair
The use of allograft or xenograft as reinforcement of a primary ventral hernia repair is felt to be a more sound approach. This fits with what we know of the science of biologic meshes in that placement in well-vascularized tissue is favorable for the ingrowth and remodeling process. Rosen’s group at Case Western investigated this and found a reduction in ventral hernia recurrence rate with a components separation midline repair reinforced with acellular dermal matrix (20%) compared to the 80% recurrence after bridging allograft repair.5

Contaminated Setting
The presence of contamination may limit the applicability of permanent synthetic mesh in some hernia repairs. Biologic mesh may be acceptable for this purpose or for placement in open wounds as a staged closure in complex abdominal wall reconstruction. There is limited data in both of these areas, with some noting a high risk of hernia recurrence and associated infection. The data is mostly limited to animal models and case series. 6,7 However, the lack of suitable alternatives has made biologic mesh attractive for contaminated field hernia repair.

Prophylaxis during stoma creation
The role of biologic mesh has been explored in prevention of parastomal hernias. An ongoing study of human dermis allograft placed at the time of construction of ileal conduits after cystectomy shows promising results with a decreased risk of hernia occurrence (30.4% v. 6.3%).8 Biologic mesh has also been used in the treatment of parastomal hernias where infection is a concern.9 With increasing reports of prophylactic synthetic mesh placement at the time of ostomy construction, the use of biologic mesh in this preventative setting may decline.

Hiatal Hernias
Biologic mesh has been utilized in the reinforcement of paraesophageal hernia repair. The randomized controlled trial of mesh repair for paraesophageal hernia lead by Oelschlager is the only Level I human study of biologic mesh.10 This study showed a decreased risk of hernia recurrence with mesh repair, from 24% to 9%. The recommendation for mesh reinforced hiatal repair is made with some caution; significant mesh complications, ranging from mesh erosion to esophageal stenosis and fibrosis, were documented in a follow-up study.11

Conclusion
In summary, biologic grafts represent a major advancement in complex hernia repair. Further investigation regarding the appropriate indications, performance of the grafts based on individual properties such as crosslinking, and potential complications is needed. Given the high cost of most of these materials and the limited available data, biologic mesh should be used judiciously and only when permanent synthetic mesh is inappropriate, such as in the contaminated field. The FDA reported complications of these materials warrant caution and sound surgical judgment.12,13




Biologic/bioresorbable graft comparison




Brand Name
Company
Type


AdditionallyCrosslinked?
Sterilized?

Alloderm®
LifeCell
Dermis
Human
No
No

Allomax™
CR Bard
Dermis
Human
No
Yes

Collamend™
CR Bard
Dermis
Porcine
Yes
Yes

FlexHD™
MTF
Dermis
Human
No
No

Periguard®
Synovis
Pericardium
Bovine
Yes
Yes

Permacol™
Covidien
Dermis
Porcine
Yes
Yes

Strattice®
LifeCell
Dermis
Porcine
No
Yes

Surgimend®
TEI
Dermis
Bovine fetal
No
Yes

Surgisis®
Cook
Intestinal submucosa
Porcine
No
Yes

Tutopatch®
Tutogen

Pericardium
Bovine
No
Yes

Veritas®
Synovis
Pericardium
Bovine
No
Yes

XenMatrix TM
CR Bard
Dermis
Porcine
No
Yes

BioA®
WL Gore
Synthetic bioabsorbable

N/A
Yes

TIGR®
Novus Scientific
Synthetic bioabsorbable


N/A
Yes





References
1. Melman L et al. Proceedings of World Hernia Congress. Berlin, Germany. 2009
2. Melman L et al. Histologic Evaluation of Crosslinked and Non-crosslinked Biologic Mesh Materials in a Porcine Model of Mature Ventral Incisional Hernia Repair. Proceedings of American Hernia Society: Hernia Repair 2010. Orlando, FL. 2010
3. Blatnik J, Jin J, Rosen M. Abdominal hernia repair with bridging acellular dermal matrix--an expensive hernia sac. Am J Surg. 2008 Jul;196(1):47-5
4. 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 Jan;60(1):76-80.
5. Jin J, Rosen MJ, Blatnik J, McGee MF, Williams CP, Marks J, Ponsky J. Use of acellular dermal matrix for complicated ventral hernia repair: does technique affect outcomes? J Am Coll Surg. 2007 Nov;205(5):654-60.
6. Saettele TM, Bachman SL, Costello CR, Grant SA, Cleveland DS, Loy TS, Kolder DG, Ramshaw BJ. Use of porcine dermal collagen as a prosthetic mesh in a contaminated field for ventral hernia repair: a case report. Hernia. 2007 Jun;11(3):279-85.
7. Candage R, Jones K, Luchette FA, Sinacore JM, Vandevender D, Reed RL 2nd. Use of human acellular dermal matrix for hernia repair: friend or foe? Surgery. 2008 Oct;144(4):703-9.
8. Harold KL, et al. Early Results of a Prospective Randomized Study Using Acellular Human Dermal Matrix (Alloderm) to Prevent Parastomal Herniation. Proceedings of American Hernia Society: Hernia Repair 2010. Orlando, FL. 2010
9. Lo Menzo E, Martinez JM, Spector SA, Iglesias A, Degennaro V, Cappellani A. Use of biologic mesh for a complicated paracolostomy hernia. Am J Surg. 2008 Nov;196(5):715-9.
10. Oelschlager BK, Pellegrini CA, Hunter J, Soper N, Brunt M, Sheppard B, Jobe B, Polissar N, Mitsumori L, Nelson J, Swanstrom L. Biologic prosthesis reduces recurrence after laparoscopic
paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006 Oct;244(4):481-90.
11. Stadlhuber RJ, Sherif AE, Mittal SK, Fitzgibbons RJ Jr, Michael Brunt L, Hunter JG, Demeester TR, Swanstrom LL, Daniel Smith C, Filipi CJ. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc. 2009 Jun;23(6):1219-26.
12. Rosen MJ. Biologic mesh for abdominal wall reconstruction: a critical appraisal. Am Surg. 2010 Jan;76(1):1-6.
13. Harth KC, Rosen MJ. Major complications associated with xenograft biologic mesh implantation in abdominal wall reconstruction. Surg Innov. 2009 Dec;16(4):324-9.
14. Gina Adrales, M.D. Biological Meshes – Indications and Shortcomings. Challenging Hernias Post-Graduate Course. 12thWorld Congress of Endoscopic Surgery. April 15, 2010

Getting out from the departmental store with my shopping bag, i was loading them in my car when i noticed a motorbike parked nearby. A crow was sitting on the petrol tank of the bike, and with a surreptitious look around, he delved into a pouch that was fixed on the bike and pulled out a goodie; a pistachio shell!. He looked around again, noticed another crow nearby, and quickly put the nutshell back again and nonchalantly started to look elsewhere. I am almost sure he also caught my eye!. With another look at the other crow, he seemed to be debating what to do, and then decided to carry the war right into the enemy camp. He flew to the place the other crow was sitting, and chased it away. The poor chap did not know what was happening and with a furious caw, flew away, probably cursing the chaser but deciding to leave the battle scene!.
I did not stop to see whether the crow came back for the nut shell (ironic isn’t it, all this was for not even the nut, just the shell!), but was thinking about how we humans and crows are so similar in our interpersonal relationships. I have seen this happening so often in the corporate jungle. People vie with each other for positions and power, and very often than not, the rules of the game are not followed; if they at all are, they are conveniently bent to suit the needs of the few who know how to win. The winning is all that matters. So these games are played out, in board rooms, in conferences, at meetings, and in cabins behind closed doors. The chase is subtle but it is persuasive. The victim either decides, like the crow in our story, to leave the scene but carries with it anger and resentment and even feelings of being victimised and being a scapegoat. Or he decides to give it a fight, and then the real battle ensues.
These feelings, if not handled constructively, become the emotional baggage that the person carries; and this feeling of having lost out may permeate into his other areas of living, sometimes making relationships also very dysfunctional. See the whirlpool effect?
I think it all boils down to fighting right: even in personal relationships. Squirrels have to bury food: so they do. But it is not seen as ‘hiding’ it away. It is acting in character to its species. But on second thoughts, i think the crow also acted in its nature? Don’t they say crows are supposed to thieve?? But do we humans act in our true nature? Are we not essentially supposed to be ‘good’ ? Then why do we deliberately push down, degrade other fellow beings, all for money, power, position? If we let go of the need for greed for power and control, i think a lot of our interpersonal conflicts can also resolve itself. Most of them start with power struggle: If the need for being in control: of others, not of self, is examined, and saturated not by controlling another human being, but by renouncing the need by itself, then i am sure life would be so much more fulfilling.
Mohana Narayanan

GLOBAL STRESS
THE
POSSIBLE
ROLE
OF
NAMASMARAN
IN
TOTAL
STRESS MANAGEMENT

DR.SHRINIWAS KASHALIKAR
The ascent of our petty self and its merger into the true self i.e. cosmic self is hypothesized to be possible through the practice of NAMASMARAN.

The term cosmic self refers to the source of cosmic conscience, thoughts, ideas and their execution.

The entanglement in the petty self leads to total inertia or perverted and fanatic activities. This is characterized by indiscriminate violence, destruction of nature and brazen exploitation of others. This may be termed TAMAS.

The entanglement in the petty self; can also lead to intelligent, skilled, but sectarian and hence selfish activity aimed at the petty gains of few. This is characterized by subtle, disguised and cunning exploitation, deception, cheating, frauds, lies, hypes, through a variety of tactics and technologically advanced means. The cruelty is concealed and hence majority fall prey to it; willingly or unknowingly but readily!
This may be termed RAJAS.

The entanglement of petty self may also lead to otherwise innocuous, harmless, egalitarian activities such as involvement in the study (though inadequate) of various sciences, arts, and technology. This self contented attitude associated with kindness (though insufficient and restricted to personal favors and certain philanthropic activities) is SATVA.

More practice of NAMASMARAN by more people; is hypothesized to help more people; in the ascent of petty self and merging with the cosmic self (The source of the holistic perspective, ideas, feelings and actions i.e. superliving); and lead to commensurate rectification of everything governed by the TAMAS, RAJAS and SATVA and achieve Total Stress Management!

STRESS
RESERVATIONS
AND
COMMUNALISM


DR.
SHRINIWAS
KASHALIKAR

Merely belonging to different castes, different religions or merely following certain customs, which are running through the generations in a family and a community etc. do not make us discriminatory, unjust, prejudiced and communal; and does not produce STRESS of communalism!

According to the world book dictionary, communalism refers to self-governance of a commune or communes and this is a kind of federalism. Communal means related to commune.

In Sanskrit there is a SUBHASHITA

PINDE PINDE MATIH BHINNAH
KUNDE KUNDE NAVAM PAYAH
JATO JATO NAVACHARAH
NAVA VANEE MUKHE MUKHE

The meaning of this SUBHASHITA is simple and enlightening. It boosts the spirit of tolerance.

It implies, every individual has different intellectual capacity, every source of water contains water with different characteristics and composition, every community has different tradition; and different linguistic expression is present in every individual mouth!

But in India this word has different connotation. In India, communalism implies disproportionate pride, concern about one’s caste, tribe, religion or any such group and disproportionate contempt, hatred and prejudice about those of others.

This is almost always associated with practices harmful to others. Communalism has become an everyday problem. It has infiltrated every walk and every stratum of life; like a cancer. Thus political parties, a variety of unions, various organizations etc and associations are diseased with communalism. Similarly, policies regarding employment, promotions, admission to different educational careers, competitive examinations in almost every sphere of life have been infiltrated by communalism.

To understand and overcome the menace of communalism and bring about harmony and justice in society effectively; we have to understand the caste system and the caste specific job distribution that has come into existence and remained for centuries and the emergence of religions and their impact on social life. In this article; we will consider the development of caste system.

In my view, (my theory of the emergence of caste system that disapproves the conspiracy and exploitation theories) the caste system in India was based on the physiological principle of homeostasis where many different type of cells perform different functions so as to maintain constancy of internal environment and thereby health of the organism.

Secondly it was based on the principle of variety, complementarity and harmony in nature. Thus the emergence of caste system was based on the observation that neither in body nor in nature the individual components perform the same work or job. In fact this kind of “equality” is dangerous. Complementarity of components is important and conducive to health. This entailed distribution of different jobs. This distribution of the jobs initially depended on the capacity.

However the distribution of jobs gradually became independent of the capacity and started depending on one’s caste. How could have this happened?

Firstly, it appears to me that this took place because of the observation; that the tissues performing a particular function in body; give rise to the cells with the same functions.

Secondly; there is heredity in nature. The mango tree gives mango fruits, banana tree gives banana and coconut tree gives coconuts. The offspring of a tiger is tiger and offspring of a cat is a cat.

Thus the fact the tissues give rise to daughter cells performing the same function and the plants and animals reproduce their own replicas; was probably extrapolated to the human society.

It must have been thought that such heredity must be working in human beings also. In fact, such extrapolation must have been buttressed by the observations that children do carry the traits of their parents which may include, from mathematical talents to musical skills, besides physical constitution and looks. In fact even today we use expressions such as “There is music in his blood”, “There is acting in his blood” “There is business in his blood” and so on. These expressions are based on observations of centuries. So every community was seen or perceived as a particular organ or tissue, which would give rise to specific type of cells; and subserve the homeostasis in the organism viz. holistic welfare or blossoming of the mankind!

The second reason for this change must have been due one of the most prevalent concepts viz. KARMA PHALA SIDDHANTA. In Marathi this is expressed as KARAVE TASE BHARAVE. In English this is expressed through “As you sow, so you reap”.

This concept gives a basis for why a particular child is born in a particular community or caste. This led to the notion that those who are born in a particular caste are born according their deeds in the past life. This lent a conceptual foundation for the stability and continuance of the caste dependent job distribution. So every individual in a particular community, caste, subcaste; was conceived as a particular individual cell in a tissue.
Now it can be appreciated why there were restrictions on all the communities (analogous to organs or tissues) to do a particular job.

Obviously this was to achieve social homeostasis (analogous to homeostasis in an organism). Clearly this was to avoid competition based on petty selfishness and unabated personal ambitions, which could, jeopardize the welfare of a society (analogous to endangering the homeostasis and life of an organism because of different tissues competing to perform the same functions).

The caste system also had one more and important aspect and that was punishment at local level. This punishment depended on the nature of “crime” or “sin” and the verdict of the traditional beliefs, conventions and consensus. This particular system included the punishment of outcasting.

Outcasting means; removing out of the community. The person or a family could not live in; and get any facilities from their community. There was total noncooperation. This was a kind of imposition of sanctions.

It is well known in India that the father and mother of the world famous saint of 12th century, saint Dnyaneshwar were outcasted and forced to commit suicide; for their “crime” of going against the then prevalent conventions.

Those who were outcasted were condemned to live as the outcaste. This system of giving “justice” by consensus; apparently did not have any provision for the upward traffic of the outcasted “lower” castes, who actually were not merely the conquered people or slaves. They included the “upper” castes individuals and families, which had to enter into “lower” castes because of what was then considered a “crime”.

However one does not know with certainty whether there were any ways of absolving from those so called “crimes” and promoting to “upper castes”.

Today most of these “crimes” may not be considered as crimes, blunders or even mistakes; because of the individualism, superficiality, pettiness as well as ideas of (right as well as wrong) freedom.

It appears that these castes, which were forced to live outside the villages, were declared untouchable. Due to the same notion of heredity, which consolidated caste system, their progeny was also considered inferior and forced to stay out of the village border, was made to accept dirty jobs and were declared untouchable. This is why; many villages in India used to have and still have; in many regions, the formerly untouchable people staying beyond the boundaries of the villages.

The caste system has been primarily a result of all that has been said above and NOT A CONSPIRACY; though it became unjust and perverted; through the subsequent influence of other factors such as vested interests, misuse of cultural superiority and authority, emotional blackmailing, exploitation of gullibility, religious persecutions, outright sadism, brutality, foreign invasions, forcible conversions, fear of the unknown, fear of the society, etc.

It can be clearly understood from the foregoing that the caste system in India which deteriorated into increasingly unjust and grave perversion; was to start with; NOT A CONSPIRACY; as is made out to be by many misguided individuals.

The theory that it was a conspiracy; can prejudice and mislead; the young and innocent people; and can create division, hatred and strife; amongst different castes. But since it does not go to the root cause; it can not solve the burning problems of the billions. In fact this has been vindicated by the history of many ad hoc measures; such as; reservations and other caste-caste interactions in India in last several decades.

The fact that the caste system did not develop as conspiracy can be clearly evident if following points are considered.

1) Caste system to be the conspiracy has not primarily been a result of political wars or religious wars also. The subsequent influence of such factors; however; can not be entirely denied.

2) Political, dictatorial, oppressive, exploitative reasons appear too simplistic to explain the phenomenon of casteism and untouchability, which has spread all over India and in every nook and corner of even the interior most aspects of country (which were ruled by extremely different rulers with extremely diverse backgrounds).

3) Caste system to be a conspiracy has not been primarily a result of winner-loser relationship. If that had been the case then there would not have been as many restrictions on certain “upper” castes as have been there in India.

4) If there had been winner loser relationship between two groups then one would have found fairly uniform characteristics amongst “upper” and “lower” castes. This is not so. Everyone would agree that there are people with very low capacity in so called “upper” castes and there are people with far greater capacity in so called “lower” castes. In fact almost all types of people are seen in all the castes. This applies not only to capacity but also to morality and social commitment.

5) The skin complexion of the individuals from “upper” castes and “lower” castes is also not uniform. Thus brahmins are not uniformly fair in complexion and the “lower castes” are not uniformly dark in complexion.

6) Caste system was not based on equality. But it was basically and to start with not based on inequality, injustice and exploitation also. It was based on; as is said earlier; the interpretation of homeostasis, heredity and complementarity, and its extrapolation to society, social harmony, social stability, social order and optimal social blossoming in holistic health.

7) In the ancient times; most of the rulers and great scholars were NOT brahmins and the scriptures were the products of consensus and any particular community.

It has to be appreciated that because of this, even as most of the saints did not practice caste discrimination, religious discrimination or any kind of discrimination for that matter, they did not condemn or allege the Indian scriptures with malicious and vicious intentions.

These scriptures (MANU SMRUTI, PARASHAR SMRUTI, VASISHTHA SMRUTI, NARADA SMRUTI, YAJNAVALKYA SMRUTI) were codes of conduct for different age groups, different professionals, different members of the family etc; such as and so on.

This was because they knew that by condemning them, the old wisdom of social homeostasis would be lost and by supporting and practicing it; the exploitative, coercive and inhuman element would be justified and would continue.

For this reason they chose the middle way. The saints did not make any disruptive and provoking statements; because they knew that this was not the solution to the evils of caste system. They knew that the solution to the evils of caste system lied in the opening of the floodgates of enlightenment and empowerment for one and all.

This is why, without making any stunts and gimmicks they spent their lives in trying to open the floodgates of enlightenment and empowerment for one and all.

They suffered during their lifetime because of the harassment from callous, rigid, orthodox and inhuman conservative elements; and centuries after their death; still continue to be misunderstood, misquoted, condemned and ridiculed by many misguided elements.
From the work of the saints it appears that the saints had diagnosed the flaw in the caste system; and hence foreseen and predicted; the end of caste system (without losing the essential concept of social homeostasis) through generalized enlightenment and empowerment; irrespective of caste, religion, region etc, which is of paramount importance and inevitable and indispensable (but neglected) in really annihilating the castes even today.

The major flaw; in the caste system that rendered it extremely exploitative, coercive and inhuman; is the omission or ignorance of i) Human beings are different from tissue cells; by virtue of greater freedom and flexibility ii) mango, coconut, tiger and cat do not have the choice and freedom to transcend their mango-ness, coconut-ness, tiger-ness and cat-ness. In contrast human beings have this potential and hence must get choice and freedom to transcend their caste characteristics, the process which is called enlightenment or self-realization.

The saints seem to have realized that the children are not of the parents (to get exactly the same characteristics or to be blamed for the “sins” of their parents), but they come through the parents.

The saints also seem to have realized that it is a great fallacy to condemn some one as sinful; merely because of being born in a particular caste; and punish him/her for the so called sins/crimes of the past generations or past lives.

The purpose of this article is not to glorify or to condemn anybody, or to describe the detailed history of caste system but only to i) conceptualize the theory of the mergence of caste system based on the understanding physiology and ii) having gone to the root of the caste system and the main determinants of the caste system; take it to its logical end by blossoming everybody; at individual and global levels in every possible way!

This implies that everything coercive in caste system would come to an end and the wisdom of harmony and complementary would continue.

This is because, we must remember that while evolving out of the caste system, and annihilating it; mankind has already begun to be plagued by and suffer from; individualism, pettiness and superficiality.

Those, who attribute all the evils to the caste system in India; must be explained; that; in rest of the world; where there was no caste system like that in India, individualism, pettiness and superficiality are playing havoc and proving to be malignant and fatal!
We must learn from the saints; the importance of opening the floodgates of self realization to people irrespective of caste, creed, race, religion, nations and study, practice and promote; the Total Stress Management (the core of which is NAMASMARAN), which embodies holistic perspective, policies, plans, programs and actions; for individual and global blossoming; through international laws, rules and conventions; in holistic healthcare, holistic productive education, and every field of life!

As and when this begins, everybody would become self reliant, independent, empowered, self sufficient, and enlightened; and the ad-hoc steps such as reservation policy, free education, concessions, free food, subsidies, loan wavers etc; would become redundant and unnecessary. Moreover; majority would begin to realize that in absence of this; even 100 percent reservations in parliaments, assemblies, jobs and everywhere; for that matter; would NOT solve the problems of the suffering billions.

There is a longstanding and eternal debate concerning the type of fluid (crystalloid or colloid) that is most appropriate for volume resuscitation. Each fluid has its army of loyalists who passionately defend the merits of their fluid. It was believed that a major consequence of acute blood loss was an interstitial fluid deficit and that replenishing this deficit with a crystalloid fluid will reduce mortality. Thus crystalloid fluids were popularized for volume resuscitation because of their ability to add volume to the interstitial fluids. Later studies using more sensitive measures of interstitial fluid revealed that the interstitial fluid deficit in acute blood loss is small and is unlikely to play a major role in determining the outcome from acute hemorrhage. This refuted the importance of filling the interstitial compartment with crystalloids, yet its popularity did not wane.
The most convincing argument in favor of colloids for volume resuscitation is their superiority over crystalloid fluids for expanding the plasma volume. Colloid fluids will achieve a given increment in plasma volume with only one quarter to one third the volume required of crystalloids. This is an important consideration in patients with brisk bleeding or severe hypovolumia, where rapid volume resuscitation is desirable . Crystalloids can also achieve the same increment in plasma volume as colloids but then three to four times more volume is required to achieve this goal !This adds fluid to the interstitial space and can cause unwanted edema. THE PRINCIPLE EFFECT OF CRYSTALLOID INFUSIONS IS TO EXPAND FLUID VOLUME, NOT THE PLASMA VOLUME. Since the goal of fluid resuscitation is to support the intravascular volume , colloids fluids are the logical choice over crystalloids.
FILLING A BUCKET- The following example illustrates the problem with using crystalloids to expand the plasma volume. Assume that you have two buckets, each representing the intravacular compartment, and each bucket is connected by a clamped hose to an overhanging reservior that contains fluid. One reservior contains a colloid fluid in the same volume as the bucket, and the other reservior contains a crystalloid fluid in a volume that is three to four times greater than the colloid volume. Now release the clamp on each hose and empty the reserviors; both buckets will fill with fluid, but most of the crystalloid fluid will spill over on to the floor. Now ask yourself which method is better suited for filling the buckets; the colloid method with the right amount of fluid and no spillage, or the crystalloid method with too much fluid, most of which spills on to the floor.The biggest disadvantage of colloid resuscitation is the higher cost of these fluids.
Thus there is too much chatter about which type of resuscitation is most appropriate in critically ill patients , because it is unlikely that one type of fluid is best for all patients. A more logical approach is to select the type of fluid that is best designed to correct a specific problem with fluid balance. For example, crystalloid fluids are designed to fill the extracellular space(interstitial space plus intravascular space) and would be appropriate for use in patients with dehydration. Colloids on the other hand are designed to expand plasma volume and are appropriate for patients with hypovolumia due to blood loss, while albumin containing colloid fluids are appropriate for patients with hypovolumia associated with hypoalbuminemia. Tailoring fluid therapy to specific problems of fluid imbalance is the best approach to volume resuscitation !