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Category : All ; Cycle : August 2009
Report on Hernia Repair from SAGES 2008
Posted by Dr. Ashutosh Soni on Monday, 31st August 2009
"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.
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."
[ CLOSE WINDOW ]
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, R�ttgermann 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
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.
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.
RID - Recession Induced Depression & Homeopathy
Posted by Dr. Nigar Parveen on Monday, 31st August 2009
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'.
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
Category (Psychology, Stress & Mental Health) | Views (5761) | User Rating
PCNL
Posted by Mr. P A Joseph Anthony Purathur on Tuesday, 25th August 2009
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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Flexible URS (Ureteroscopy)
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.
Homeopathy and Chronic renal failure
Posted by Dr. Swapna Potdar on Saturday, 22nd August 2009
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
Irritated on being disturbed
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)
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!
Category (Eyes & Vision) | Views (21164) | User Rating
BEYOND ENTERTAINMENT: DR. SHRINIWAS KASHALIKAR
Posted by Dr. Shriniwas Kashalikar on Saturday, 22nd August 2009
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.
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.
NAMASMARAN & NEUROSIS: DR. SHRINIWAS KASHALIKAR
Indulgence and asceticism, atheism and theism, romance and renunciation; and such variety of apparently conflicting phenomena render completion to life. If you try to take away anyone of these, the life appears incomplete.
In fact even as I was convinced intellectually about the value of NAMSMARAN in life and wrote books on it right from 1992, one of the major hurdles in appreciating and experiencing the cosmic benevolence of NAMASMARAN was its depiction (or my erroneous perception of the depiction) as an activity of elderly, neurotic, inactive, pessimists, escapists and failed individuals. Even the books, movies, and dramas on saints and bhakti sangeet also (devotional music) made saintly life and the practice of NAMASMARAN appear miserable and pathetic. I never thought this was the A grade happiness, implied in spiritualism or self realization.
Partly because of this and partly because of the social justice and freedom implied in the atheism, which I cherish even today, I could not be involved completely in any particular theist tradition of NAMASMARAN.
But even as I, due to my repulsion for the pathetic life style (as depicted or interpreted by me) felt material pleasures could not be amputated arbitrarily from one�s life if one were to evolve healthily, I was not at ease even in the �best� of petty pleasures, which could at best give B grade pleasure, not A grade happiness implied in global justice.
Thus neither could I identify myself with the ascetics nor with the materialists. I kept on vacillating from one side to another like a pendulum.
But now it is more than clear, that NAMASMARAN is a panacea, it is an objective phenomenon and it can not be the monopoly of any one camp such as ascetic, indulgent, theist, atheist, scientific, religious and so on.
It is an objective phenomenon with cosmic benevolence for blossoming of one and all. It is as objective and as vital for human blossoming, as the oxygen is for human life.
It is beyond science, religion and philosophy. It is beyond human thought. It is a matter of practice and experience, not belief, feeling or imagination.
NAMASMARAN connects you to the center of life, time and cosmic consciousness, i.e. with your true self. NAMASMARAN (according to one�s tradition) is the privileged express highway to realize maximum potentials in every possible way, for one and all!


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text:
package com.simplegis.webservice.persistence.dao.impl;

import com.simplegis.webservice.persistence.dao.PhoneDao;
import com.simplegis.webservice.persistence.entity.Phone;
import com.simplegis.webservice.persistence.util.BatchUpdateWithGeneratedKeys;
import org.springframework.beans.factory.annotation.Autowired;
import org.springframework.jdbc.core.BatchPreparedStatementSetter;
import org.springframework.jdbc.core.BeanPropertyRowMapper;
import org.springframework.jdbc.core.JdbcTemplate;
import org.springframework.jdbc.support.GeneratedKeyHolder;
import org.springframework.jdbc.support.KeyHolder;
import org.springframework.stereotype.Repository;
import org.springframework.transaction.annotation.Transactional;

import java.sql.PreparedStatement;
import java.sql.SQLException;
import java.util.List;
import java.util.Map;

/**
 * Phone data access object.
 */
@Repository
public class PhoneDaoImpl implements PhoneDao {

    @Autowired
    private JdbcTemplate jdbcTemplate;

    @Autowired
    private BatchUpdateWithGeneratedKeys batchUpdateWithGeneratedKeys;

    @Override
    @Transactional(readOnly = true)
    public List<Phone> getAll() {
        String sql = "SELECT * FROM simplegisdb.phone p";

        return jdbcTemplate.query(sql, new BeanPropertyRowMapper<>(Phone.class));
    }

    @Override
    @Transactional(readOnly = true)
    public Phone getById(Long id) {
        String sql = "SELECT * FROM simplegisdb.phone p WHERE p.id = ?";
        Object[] args = {id};

        return jdbcTemplate.queryForObject(sql, args, new BeanPropertyRowMapper<>(Phone.class));
    }

    @Override
    @Transactional
    public Integer update(Phone phone) {
        String sql = "UPDATE simplegisdb.phone SET number = ?, organization_id = ?, version = ?"
                + " WHERE id = ? AND version = ?";

        return jdbcTemplate.update(sql,
                phone.getNumber(), phone.getOrganizationId(), phone.getVersion() + 1, phone.getId(), phone.getVersion());
    }

    @Override
    @Transactional
    public Phone insert(Phone phone) {
        String sql = "INSERT INTO simplegisdb.phone (number, organization_id, version)"
                + " VALUES (?, ?, ?)";

        KeyHolder keyHolder = new GeneratedKeyHolder();

        jdbcTemplate.update(connection -> {
            String[] columnNames = {"id"};
            PreparedStatement preparedStatement = connection.prepareStatement(sql, columnNames);

            int i = 0;
            preparedStatement.setString(++i, phone.getNumber());
            preparedStatement.setLong(++i, phone.getOrganizationId());
            preparedStatement.setLong(++i, 0);

            return preparedStatement;

        }, keyHolder);

        phone.setId(keyHolder.getKey().longValue());
        phone.setVersion(0);
        return phone;
    }

    @Override
    @Transactional
    public List<Phone> batchInsert(List<Phone> phones) {
        String sql = "INSERT INTO simplegisdb.phone (number, organization_id, version)"
                + " VALUES (?, ?, ?)";

        List<Map<String, Object>> generatedKeys;

        generatedKeys = batchUpdateWithGeneratedKeys.batchUpdate(
                sql,
                new BatchPreparedStatementSetter() {
                    @Override
                    public void setValues(PreparedStatement preparedStatement, int i) throws SQLException {
                        Phone phone = phones.get(i);

                        int index = 0;
                        preparedStatement.setString(++index, phone.getNumber());
                        preparedStatement.setLong(++index, phone.getOrganizationId());
                        preparedStatement.setLong(++index, 0);

                    }

                    @Override
                    public int getBatchSize() {
                        return phones.size();
                    }
                },
                new GeneratedKeyHolder());

        for (int i = 0; i < phones.size(); i++) {
            phones.get(i).setId((long) (int) generatedKeys.get(i).get("id"));
            phones.get(i).setVersion(0);
        }

        return phones;
    }

    @Override
    @Transactional
    public Integer delete(Phone phone) {
        String sql = "DELETE FROM simplegisdb.phone p WHERE p.id = ?";
        Object[] args = {phone.getId()};

        return jdbcTemplate.update(sql, args);
    }

    @Override
    @Transactional(readOnly = true)
    public List<Phone> getByOrganizationId(Long orgId) {
        String sql = "SELECT * FROM simplegisdb.phone p WHERE p.organization_id = ?";
        Object[] args = {orgId};

        return jdbcTemplate.query(sql, args, new BeanPropertyRowMapper<>(Phone.class));
    }
}

redpajama_set_name: RedPajamaGithub


text:
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The Suns made some significant dashes on the court by trading for Chris Paul and also authorizing a multitude of cost-free representatives that will certainly make them a significant playoff challenger this season, and they additionally released among the very best 'City' edition jerseys in the league. For several years, Phoenix has actually produced uninspiring city jerseys, however this moment around they took a vibrant swing as well as knocked it out of the park.
Comparable to the Hornets, the Suns have among the finest color combinations in the league, and also they ultimately made the ideal use purple and also orange to create a stylish modern jacket. Initially appearance, I had not been a follower of the Jean-Michel Basquiat jerseys, however after offering it a day, looking closer at the information, this attire is a hit for me.
It's different as well as unique from any kind of various other jersey but still remains tidy. Much more notably, the Nets are the only group in the organization that constantly utilizes its 'City' edition to really admire those from Brooklyn. Initially, it was Big deal Smalls, currently cutting-edge musician Basquiat. Yes, yes, yes. The Spurs gave the followers what they wanted after years of camo city jackets.
The NBA All-Star break has shown up as well as one of the most effective parts of the weekend is when the league reveals the game uniforms. Kohls Nba gear 2021. While this year's jackets have yet to be shown to the general public, we are honoring the weekend break with an appearance back at the very best looks from 1985 till now.
2015 (New York)These jackets obtained eliminated when the NBA unveiled them, as well as rightfully so. No wording on the front and also the complete names on the back of the jersey fizzled. I don't dislike them however if they would certainly have just put East/West on the front of the uniform, these would certainly be in the Leading 10 without a doubt – Kohls Nba gear 2021.
19861990 as well as 2003No one will seethe if the NBA made these the full-time All-Star attires going forward each year. There is simply also much background that happened in these jackets.
, still lead the means. The NBA released its jacket sales results from the very first fifty percent of the season based on sales as well as Le, Bron was on top, while his Los Angeles Lakers are the top group in merchandise sales.
The very first half of the NBA season is over, as well as we are heading towards the playoffs. The payoff in jacket sales sees one team with three gamers in the top 11. That could that be? If you rush, you might participate a bargain at Jimmy Butler and also the Warm lost versus the Lakers in The Finals, but his appeal climbed, specifically in South Beach.
77 will certainly be associated with the Mavericks' young star. The King regulations on as well as off the court (Kohls Nba gear 2021).
He was ranked fifth during the pre-COVID 2019-20 NBA period, and afterwards befalled of the leading 15 when the competitors restarted in Orlando. # 8 Kyrie Irving, Kyrie Irving with the Brooklyn Nets, Kyrie Irving placed on a show last period. He made a look in the unique 50-40-90 club, and he did so while balancing 26.
Irving is simply one of 4 players in NBA background to ordinary 25+ points as well as fire 50-40-90. Irving has seen a climb in his jacket sale numbers, which were 12th in the NBA in the last two periods.
Normally, we did. As the 2020-2021 normal season gets underway, we evaluated each franchise's most recent "City Edition" jackets, figuring out both the worst of the worst, as well as the most effective of the finest. There are several jerseys that can have taken the last spot on this listing, and it may be taken into consideration a "warm take" to some, but the Orlando Magic rest at the base of the barrel in our "City Edition" positions.
77 will be synonymous with the Mavericks' young star. The King policies on and also off the court.
He was rated fifth during the pre-COVID 2019-20 NBA period, and after that befalled of the leading 15 when the competition restarted in Orlando. # 8 Kyrie Irving, Kyrie Irving with the Brooklyn Webs, Kyrie Irving put on a show last season. He made an appearance in the unique 50-40-90 club, and also he did so while balancing 26.
Irving is simply one of four gamers in NBA background to ordinary 25+ factors as well as fire 50-40-90. Irving has seen a climb in his jacket sale numbers, which were 12th in the NBA in the last two periods. # 7 Stephen Curry, Stephen Curry of the Golden State WarriorsStephen Curry saw a dip in his jersey sales despite the amazing period he simply had.
Naturally, we did. As the 2020-2021 regular period gets underway, we evaluated each franchise business's latest "City Edition" jackets, identifying both the worst of the worst, as well as the most effective of the ideal. There are several jackets that might have taken the last place on this listing, and it might be thought about a "warm take" to some, however the Orlando Magic rest at the end of the barrel in our "City Edition" rankings.

redpajama_set_name: RedPajamaCommonCrawl


text:
package com.davidbracewell.apollo.linear;

import com.davidbracewell.apollo.linear.decompose.SingularValueDecomposition;
import lombok.NonNull;

import java.util.Collection;

/**
 *
Common vector compositions

 *
 * @author David B. Bracewell
 */
public enum VectorCompositions implements VectorComposition {
   /**
    * Averages the elements of the vectors
    */
   Average {
      @Override
      public NDArray compose(@NonNull Collection<NDArray> vectors) {
         return Sum.compose(vectors).divi(vectors.size());
      }
   },
   /**
    * Sums the elements of the vectors
    */
   Sum {
      @Override
      public NDArray compose(@NonNull Collection<NDArray> vectors) {
         if (vectors.size() == 0) {
            return NDArrayFactory.DEFAULT().empty();
         }
         NDArray toReturn = null;
         for (NDArray v : vectors) {
            if (toReturn == null) {
               toReturn = v.copy();
            } else {
               toReturn.addi(v);
            }
         }
         return toReturn;
      }
   },
   /**
    * Performs a point-wise multiply of the elements
    */
   PointWiseMultiply {
      @Override
      public NDArray compose(@NonNull Collection<NDArray> vectors) {
         if (vectors.size() == 0) {
            return NDArrayFactory.DEFAULT().empty();
         }
         NDArray toReturn = null;
         for (NDArray v : vectors) {
            if (toReturn == null) {
               toReturn = v.copy();
            } else {
               toReturn.mul(v);
            }
         }
         return toReturn;
      }
   },
   /**
    * Assigns the maximum element
    */
   Max {
      @Override
      public NDArray compose(@NonNull Collection<NDArray> vectors) {
         if (vectors.size() == 0) {
            return NDArrayFactory.DEFAULT().empty();
         }
         NDArray toReturn = null;
         for (NDArray v : vectors) {
            if (toReturn == null) {
               toReturn = v.copy();
            } else {
               toReturn.mapi(v, Math::max);
            }
         }
         return toReturn;
      }
   },
   /**
    * Assigns the minimum element
    */
   Min {
      @Override
      public NDArray compose(@NonNull Collection<NDArray> vectors) {
         if (vectors.size() == 0) {
            return NDArrayFactory.DEFAULT().empty();
         }
         NDArray toReturn = null;
         for (NDArray v : vectors) {
            if (toReturn == null) {
               toReturn = v.copy();
            } else {
               toReturn.mapi(v, Math::min);
            }
         }
         return toReturn;
      }
   },
   /**
    * Concatenates the vectors together and runs svd over them.
    */
   SVD {
      private final SingularValueDecomposition svd = new SingularValueDecomposition(1);

      @Override
      public NDArray compose(@NonNull Collection<NDArray> vectors) {
         if (vectors.size() == 0) {
            return NDArrayFactory.DEFAULT().empty();
         }
         return svd.decompose(NDArrayFactory.DENSE_DOUBLE.vstack(vectors))[2].getVector(0, Axis.ROW);
      }
   }

}//END OF VectorCompositions


text:
Kyoto: Perfect Harmony
Destinations / Asia
THERE ARE TWO JAPANS. We can visualize them both: the neon-lit, concrete and asphalt, high-tech, ultra-modern nation; and the land of geishas, tea ceremonies, Zen gardens and minimalist interiors.
How far apart are these two Japans? You could say they are separated by more than 70 years. The Japanese economic miracle since World War II propelled the country into the 21st century. Most of the major cities have radically transformed, often rising from bombed-out ruins. But one city, founded in 794 and for many centuries the imperial capital, survived unscathed and has remained largely preserved: Kyoto. In that respect, the two Japans are separated by the 35 miles between downtown Osaka and Kyoto's historical Gion district.
In fact, the demarcation is not as clear as that. Despite the architectural and cultural trappings of the past that form the popular view of Kyoto, both ancient and modern coexist within the city, often overlapping. The two Japans are so integrated here that with just a few strides or the merest flick of your gaze, you can move from one to the other.
Kyoto has long been a major center of higher education and is home to some of Japan's (and the world's) top-ranking universities. Academic excellence is one of the driving forces of Kyoto's advance into the future, with university research projects often spinning off to create commercial companies and sometimes entire industries.
For instance, under the auspices of Innovation Hub Kyoto, a facility founded in 2017, medical researchers pioneer new advances in regenerative medicine. Harnessing local expertise and providing the funds to enable young innovators to compete on the global stage, the facility aims to establish Kyoto as the Silicon Valley of regenerative medicine. It's a project that could potentially change all of our lives.
Kyoto Station © SEAN PAVONE | DREAMSTIME.COM
Many of us have already had our lives changed by a Kyoto-based company. In the 19th century, a local company was founded to make traditional hanafuda playing cards. The company's name translated as "leave luck to heaven."
In the 1950s, it began to expand into new areas, including the manufacture of laser shooting games, and was quick to embrace the possibilities of electronic gaming in the 1970s. It continues to dominate that sector. That modest card manufacturer is now one of the most recognizable brands on the planet: Nintendo. It continues to be based in Kyoto, in Minami-ku — South Ward — one of the city's 11 districts.
Other innovative companies based in Kyoto include GLM, a manufacturer of electric sports cars; Kyocera (which makes electronic components); and Omron (which makes medical equipment). These companies, and many others in the city, are modern manifestations of a traditional Japanese ethic: monozukuri, which translates as "thing making."
Here monozukuri has been repurposed into what is collectively referred to as "the wisdom industry," combining old philosophies with new technologies. In the process, Japan's tendency for insularity has been set aside. Foreign participation in Kyoto's wisdom industry is actively encouraged, both on the academic side and in the entrepreneurial realization of new products and concepts. The Kyoto Chamber of Commerce and Industry provides advice to foreign nationals wishing to work or invest in the city.
Kyoto Tower © SEAN PAVONE | DREAMSTIME.COM
If you arrive by train at the futuristic Kyoto Station (as the majority of visitors do, usually from Tokyo or Osaka), there is little sign of the quaint, traditional city you were expecting. This is modern Japan in all its gaudy, sci-fi glory. Step out of the vaulted interior and you're in no doubt you're at the heart of a city of 1.4 million people. The Kyoto Tower — an architectural cousin of Seattle's Space Needle — soars above you, presiding over busy streets.
A short distance to the north, in Gion District, it all changes, and your preconceptions are realized. Here, ramshackle wooden buildings fringe paved alleys. There are vistas that appear little changed in centuries. That impression is compounded if you're lucky enough to see a geisha walking to or from work in her white makeup, hair piled and pinned, garbed in a silk kimono and wooden shoes.
Along the alleys she looks perfectly in place, but at intersections she must mingle with everyone else at the crosswalks, waiting for the green light. In those moments, as so often in this beguiling city, the two Japans are one.
CHECKING IN WITH TOMOKO NAKAMURA
Owner, Ryokan Yoshida-Sanso
What opportunities does Kyoto offer Americans? Many Americans have already experienced Japanese culture at home. They will be familiar with some of the foods, with anime and manga and with many of our traditions. In Kyoto visitors can participate in the culture and learn many new things about it. They can study Zen, take part in calligraphy, learn the customs of Zen gardening, discover ceramics and pottery, and take part in a tea ceremony. They will not just see Japanese culture in Kyoto, they will be part of it.
What cultural differences should visitors be aware of when visiting Kyoto? There are many small cultural formalities they might not be familiar with. For instance, it is important to take your shoes off when entering a house. In some houses, slippers are provided. But always make sure your socks are clean and without holes. On visiting the bathroom, you will often switch to a separate pair of slippers for hygiene reasons.
How does Kyoto differ from other cities in Japan? Other cities lost their heritage, but in Kyoto it is preserved. The pace of life is slower and more relaxed. For the Japanese, Kyoto is a most important city. It is what and who we are.
What are the key developments to look for in the future? For me, Kyoto's future is also its past. Other Japanese cities are developing every year, so much and so quickly that soon they can't be recognized. In Kyoto we must save and protect what we have. It is important for us as a people to preserve such things as our traditional architecture, art and craft. My hope is Kyoto will develop without changing the things that make it special.
Which local attractions do you recommend? There are many more things to see and do here than can be experienced in one lifetime. Kyoto has beautiful, quiet surroundings, and I especially recommend taking a walk in the mountains on the east side of the city, particularly Yoshida-yama and Ginkaku-ji (the Silver Pavilion). The Philosopher's Path in Higashiyama district is a wonderful place for contemplation and is at its most beautiful in spring when the cherry blossoms are out. The most popular temples and shrines are always worth visiting, even though they can be busy. But we also have many other temples and shrines where not many people go, and you can enjoy them in peace.
Things to Do in Kyoto
Prepare to visit temples and shrines. With more than a thousand of them in Kyoto, they can't be avoided, and many are must-see attractions. Chief among them — and probably the most photographed spot in Kyoto — is Fushimi Inari-taisha, a mountainside complex of shrines. Anticipate some walking; the highlight of the complex is a 2.5-mile trail lined with some 10,000 vermillion-painted torii (wooden gates). The gates are the headline feature, breathtaking in design and sheer number. But also look out for hundreds of fox statues along the way. Inari is dedicated to the gods of both rice and business, and the fox is considered their messenger. A visit here is not just a tourist excursion, it's an auspicious pilgrimage for anyone seeking to do business in Kyoto.
Ginkaku-ji Silver Pavilion © SEAN PAVONE | DREAMSTIME.COM
The gods of rice are also the gods of one of the most popular by-products of rice, saké (rice wine). Fushimi, Kyoto's saké district, houses the majority of the city's 46 saké breweries. The waterways lacing the district provide the breweries with one of their key ingredients: soft water. In huge vats in picturesque wooden buildings, water and fermented rice combine to make the potent drink (which can have an alcohol content of up to 20 percent). The most famous brewery, Gekkeikan, opens to visitors every day 9:30 a.m.–4.30 p.m. The tour includes free tastings, so it's perhaps best not to schedule any business meetings immediately after your visit.
Other unmissable sacred sites include Kinkaku-ji, also known as the Golden Pavilion, an achingly beautiful temple covered in gold leaf seemingly floating on its own reflection within a placid pond. The temple has been rebuilt more than once since it was originally constructed in 1397, most recently in 1955 following a fire.
Another outstandingly photogenic temple is Kiyomizu-dera, where the wooden main hall, constructed on a scaffold, provides views of the city and the surrounding forested hills.
Kyoto Imperial Palace harks back to the city's long tenure as the capital of Japan. In common with many historical sites in Kyoto, you can only tour the exteriors of this complex of buildings; the interiors are too fragile to accommodate the volume of visitors.
Kyoto is renowned for its Zen gardens, the most famous of which is Ryōan-ji, in which an expanse of gravel carefully raked around several rocks creates a serene backdrop for quiet contemplation.
Gion district is the living manifestation of historical Kyoto. With its preserved streets and ancient teahouses, it's the part of the city that most visitors keep coming back to throughout their stay; there's always something new (or, more accurately, old) to discover here.
Kyoto Info to Go
Most visitors arrive at Kansai International Airport, situated on an island in Osaka Bay, 60 miles by road from downtown Kyoto. The fastest transfer is by Japan Railways Haruka express train; the journey takes about 75 minutes. From Tokyo's Narita International Airport catch the Airport Express train to Tokyo Station and then switch to the Shinkansen — bullet train — for the journey west to Kyoto. The total journey time should be around four hours.
Kyoto: Just the Facts
Phone code: Country code: 81 City code: 75
Currency: Yen
Key industries: Tourism, retail, higher education, medicine, IT, nanotechnology
All U.S. citizens require a passport valid for the duration of the visit to Japan and an onward/return ticket. U.S. citizens are eligible for visa-free entry on stays of up to 90 days. Visa-free entry does not permit you to work in Japan, and you cannot change to another visa status during your stay. If in doubt, contact the Japanese Embassy before embarking on your visit.
Where to Stay in Kyoto
HOSHINOYA KYOTO Just 15 minutes by riverboat shuttle from downtown, yet the hilly woodland setting beside the Oi River is authentically rural. Serene, traditional rooms. 11-2 Arashiyama Genrokuzan- cho, Nishikyo-ku $$$$
THE RITZ-CARLTON, KYOTO This new build opened in 2014 is already established as one of the best hotels in Japan, boasting a sophisticated blend of traditional and modern architecture and décor. Kamogawa Nijo-Ohashi Hotori, Nakagyo-ku $$$$
RYOKAN YOSHIDA-SANSO A ryokan is a traditional Japanese inn. This one is practically a palace; it was the residence of Emperor Akihito's uncle. Excellent location close to many attractions. 59-1 Yoshida Shimo-ojicho, Sakyo-ku $$$$
Restaurants in Kyoto
KIKUNOI Enjoy incredible local cuisine in a refined setting. Deserving of its three Michelin stars, Kikunoi's set menu comprises at least 10 courses. Reservations essential. 459 Shimokawara-cho, Higashiyama-ku $$$$
YAMAMOTOMENZO There's usually a line at this noodle bar par excellence — always a good sign. Menus in English are available. 34 Okazaki Minamigosho-cho, Sokyo-ku $$
YONEMURA Located in Gion, this fusion restaurant melds a Japanese grounding with European and Indian influences. Counter seating enables diners to watch the chefs at work. 481-1 Kiyoi-cho, Higashiyama-ku $$$$
Seoul Innovation
Transformation of a City


The article reports on the collaboration of the New Mexico State University (NMSU) and Texas Tech University for the use of remote sensing on peanut crops in New Mexico. It notes that remote sensing is capable of assessing the biophysical characteristics of the farm including leaf area index, yield, ground cover, and biomass production. Naveen Puppala, notes the effectiveness of the said remote sensing. The features of the remote sensing are also identified.
Focuses on the economic impact of the New Mexico State University on Las Cruces, New Mexico. Accommodation of the largest number of local employees; Production of a large number of Hispanic and Native American graduates.
Focuses on the New Mexico State University in Las Cruces. Involvement in daily community affairs; Technical expertise and cultural offerings; Direct spending in the county.
Looks at Lesley Stoune, a graphic designer at PrinTech, the printing division of Texas Tech University in Lubbock, Texas. Stounes' creations; Future outlook.
Reports that the advisory committee for Texas Tech University is considering whether to make changes to its endowments for investment policy.


Brand new on the Custom Covers' stand this year was the 9m Cruciform Roof. This allows hirers to join two 9m structures at 90 degrees without the use of gutters giving full ground to ridge clearance and a great interior space.
Custom Covers continued their practice of showcasing emerging talent by incorporating the designs of Southampton Solent University's Interior Design Course. The winning entry from Leisha Norman and Ashleigh Georgiou inspired a nautical themed area in keeping with Custom Covers' nautical heritage. The porthole walls were also successful commercially selling a number of units at the show.
An innovative addition to the existing door and entrance options.


text:
[Back to ToC](library.md)

# connected()

### Description

The method checks if the client is still connected to RAPIFIRE.

### Syntax

```c++
connected()
```

### Parameters

The method has no parameters.

### Returns

* __TRUE__ if the client is still connected to RAPIFIRE.

### Examples

```c++
#include <YunClient.h>
#include <PubSubClient.h>
#include <RapifireMqttClient.h>

YunClient client;
RapifireMqttClient rapifire("YOUR_THING_ID", "YOUR_THING_TOKEN", client);

void loop() {
	if (!rapifire.connected()) {
		rapifire.connect();
	}

	// The other code here
}
```