Closing the gap: medialization of fascia with laparoscopic incisional hernia repair.

PURPOSE: Laparoscopic incisional hernioplasty (LIH) bridges the fascial gap between the rectus muscles with a posteriorly placed mesh, and is a low recurrence alternative to other reconstructions. It is unclear if this repair optimizes the function of the abdominal wall. We hypothesize that significant medialization of the fascial edges occurs in patients who undergo LIH. METHODS: Two hundred fifty-eight patients underwent LIH by a single surgeon between 2004 and 2012. 44 of these had pre- and postoperative CT scans that illustrated the gap between the rectus muscles. All 44 patients underwent LIH with polyester composite mesh, with suture and tack fixation. The distance between the fascial edges on the pre- and postoperative CT scans was compared. Percent medialization was calculated for each defect. RESULTS: Average fascial separation reduction was 0.8 cm (6.56-5.76 cm, 12.2 % medialization, p < 0.0001). 36 of 44 patients demonstrated a reduction in hernia defect width (81.8 %): these defects reduced 1.09 cm (6.47-5.38 cm, 16.9 % medialization, p < 0.0001). In defects wider than 5 cm, the width reduced by 0.94 cm (8.48-7.54 cm, n = 26, 10.6 % medialization, p = 0.004). The use of meshes ≥500 cm(2) reduced the defect by 0.95 cm (8.42-7.47 cm, 11.23 % medialization, n = 22, p = 0.005). CONCLUSIONS: Significant medialization of the rectus muscles is evident in most patients undergoing LIH. Although the rectus muscles are not ideally approximated, this may help improve the function of the anterior abdominal wall. Further technical refinements and material improvements may improve the reconstructive results of the LIH.

Nonsteroidal anti-inflammatory drug use in collegiate football players.

OBJECTIVE: To determine prevalence of nonsteroidal anti-inflammatory drug (NSAID) use in college football players and whether positions sustaining the most contact would use NSAIDs more frequently. DESIGN: Prospective cross-sectional study. SETTING: American college football programs. PATIENTS: An anonymous survey was given to 211 college football players before the season. INDEPENDENT VARIABLE: Use of NSAIDs. MAIN OUTCOME MEASURES: The dependent variables are the different patterns in NSAID usage among positions and the frequency of NSAID use before and after the season. RESULTS: Of the athletes surveyed, 95.7% had or were using NSAIDs. Athletes first used NSAIDs in junior high school (45.6%), high school (48.5%), or college (5.8%). Athletes were separated into high (daily or weekly) or low (monthly or rarely) utilizers of NSAIDs. High utilization of NSAIDs was more frequent during the season (50.0%) than in the off-season (14.6%), P < 0.001. High NSAID utilization among all players was more prevalent after than before games (32.7% vs 10.9%, P = 0.002). Players with a higher body mass index (BMI; >28) were significantly higher utilizers of NSAIDs, reporting higher rates of use in season compared with other players (57.4% vs 39.5%, P = 0.011, OR = 2.06). CONCLUSIONS: Use of NSAIDs in collegiate football players is common. It is concerning that those athletes with the highest cardiovascular risk (ie, elevated body mass index) use greater amounts of NSAIDs. Further investigation is needed to delineate the short-term and long-term consequences of NSAID utilization in young athletes.

Construct validity for the LAPSIM laparoscopic surgical simulator.

BACKGROUND: The skills required for laparoscopic surgery are amenable to simulator-based training. Several computerized devices are now available. We hypothesized that the LAPSIM simulator can be shown to distinguish novice from experienced laparoscopic surgeons, thus establishing construct validity. METHODS: We tested residents of all levels and attending laparoscopic surgeons. The subjects were tested on eight software modules. Pass/fail (P/F), time (T), maximum level achieved (MLA), tissue damage (TD), motion, and error scores were compared using the t-test and analysis of variance. RESULTS: A total of 54 subjects were tested. The most significant difference was found when we compared the most (seven attending surgeons) and least experienced (10 interns) subjects. Grasping showed significance at P/F and MLA (p < 0.03). Clip applying was significant for P/F, MLA, motion, and errors (p < 0.02). Laparoscopic suturing was significant for P/F, MLA, T, TD, as was knot error (p < 0.05). This finding held for novice, intermediate, and expert subjects (p < 0.05) and for suturing time between attending surgeons and residents (postgraduate year [PGY] 1-4) (p < 0.05). CONCLUSIONS: LAPSIM has construct validity to distinguish between expert and novice laparoscopists. Suture simulation can be used to discriminate between individuals at different levels of residency and expert surgeons.

Comparison of two composite meshes using two fixation devices in a porcine laparoscopic ventral hernia repair model.

INTRODUCTION: Laparoscopic ventral hernia repair uses tacks to secure mesh. The mesh is designed to maximize tissue ingrowth while minimizing adhesions. We hypothesized: (1) a collagen-coated polyester mesh (PCO) will form fewer adhesions than an ePTFE-polypropylene composite (BC) and (2) absorbable tacks are equivalent to metal tacks. METHODS: In a porcine model of adhesion formation, three pieces of 10x15-cm mesh were placed on the anterior abdominal wall. PCO was secured with absorbable (PLA) or metal tacks (PT), BC with PT. At 28 days, adhesion formation, abdominal-wall adherence, and tissue ingrowth were analyzed. RESULTS: PCO induced fewer adhesions (14.5% vs 53.4%, P = 0.007). On an adhesion scale (0 5), BC scored 3.6 vs 1.75 for PCO (P < 0.03). There was no difference in adhesion strength, tack adhesions, or abdominal-wall peel force. Histology showed equal ingrowth. CONCLUSIONS: PCO induces fewer adhesions than BC. There is no difference in the ingrowth of the two mesh types. The PLA achieves equivalent mesh incorporation to the PT.

Inhibition of alveolar neutrophil immigration in endotoxemia is macrophage inflammatory protein 2 independent.

BACKGROUND: Altered transendothelial migration and delayed apoptosis of neutrophils (PMN) have been implicated as contributing to infection in patients with gram-negative sepsis. Macrophage inflammatory protein 2 (MIP-2) signals PMN immigration and may alter other PMN functions. We tested the hypothesis that sequential endotoxin challenge in vivo alters PMN apoptosis and chemotactic responses. MATERIALS AND METHODS: Endotoxemia was induced in male Wistar rats (250 g) via intraperitoneal (IP) administration of LPS (4 mg/kg). After 18 h, intratracheal (IT) injection of LPS (400 microg/kg) was performed. Control animals received saline injections. Four hours after IT-LPS, circulating and bronchoalveolar lavage (BAL) PMN were isolated. PMN yields were calculated, and apoptosis was quantified after 18 h in culture by annexin V-fluorescein isothiocyanate FACS analysis. BAL MIP-2 concentrations were determined by ELISA. PMN chemotaxis to MIP-2 and IL-8 was determined using a fluorescent in vitro migration assay. RESULTS: Endotoxemia (IP-LPS) significantly decreases BAL PMN yield in response to an in vivo IT-LPS challenge. IT-LPS inhibits BAL PMN apoptosis to the same extent as sequential IP/IT-LPS. Alveolar MIP-2 concentrations are similar in the two groups. In vitro migration to IL-8 and MIP-2 was inhibited in PMN from endotoxemic versus control animals. CONCLUSIONS: These data demonstrate that endotoxemia inhibits PMN migration despite similar MIP-2 concentrations in the alveolus. Sequential insults do not affect the inhibition of apoptosis. In vitro, PMN from endotoxemic animals display impaired chemotaxis to MIP-2 and interleukin-8. This may result in an inadequate host defense that contributes to increased ICU-acquired pneumonia in septic patients.

Sodium salicylate inhibits proliferation and induces G1 cell cycle arrest in human pancreatic cancer cell lines.

The mutations most common in pancreatic cancer decrease the ability to control G1 to S cell cycle progression and cellular proliferation. In colorectal cancer cells, nonsteroidal anti-inflammatory drugs inhibit proliferation and induce cell cycle arrest. We examined whether sodium salicylate, an aspirin metabolite, could inhibit proliferation in human pancreatic cancer cell lines (BxPC3 and Panc-1). Quiescent cells were treated with medium containing 10% fetal calf serum, with or without salicylate. Cellular proliferation was measured by MTT assay and bromodeoxyuridine incorporation. The fractions of cells in G0/G1, S, and G2/M phases of the cell cycle were quantitated by fluorescence-activated cell sorting. Results were compared between groups by two-tailed t test. Cyclin D1 expression was determined by Western blot analysis and prostaglandin E2 expression by enzyme-linked immunosorbent assay. Serum-starved cells failed to proliferate, with most arrested in the G1 phase. Salicylate significantly inhibited serum-induced progression from G1 to S phase, cellular proliferation, and the expression of cyclin D1. The concentrations at which 50% of serum-induced proliferation was inhibited were 1.2 mmol/L (Panc-1) and 1.7 mmol/L (BxPC3). The antiproliferative effect of sodium salicylate was not explained by inhibition of prostaglandin E2 production. This study provides further evidence in a noncolorectal cancer model for the antineoplastic effects of nonsteroidal anti-inflammatory drugs.

Effect of aging on myocardial adenosine production, adenosine uptake and adenosine kinase activity in rats.

Adenosine levels present in the interstitial fluid and coronary effluent of the aged heart exceed those of the young adult heart. The present study investigated mechanisms in the Fischer 344 rat heart which may be responsible for the observed differences. (1) Total production of adenosine was determined in isolated perfused hearts by measuring coronary effluent adenosine content while inhibiting adenosine deamination and rephosphorylation with erythrohydroxy-nonyladenosine (EHNA) and iodotubercidin (ITC), respectively. Total adenosine production was similar in both young (3-4 month) and aged (20-21 month) hearts at 31.8 +/- 6.6 and 38.4 +/- 3.3 nmol/min/g dry wt, respectively. However, stimulation with the beta-adrenergic agent, isoproterenol, elicited a significantly greater increase in adenosine production in the young vs. aged heart. (2) Adenosine transport was evaluated in isolated perfused hearts by determining 14C uptake by the myocardium after 20 min of 14C-adenosine perfusion. Adenosine uptake in the agent-free heart was found to be decreased 17 to 25% in aged compared to young adult hearts. (3) Adenosine transport characteristics were determined with nitrobenzylthioinosine saturation-binding studies in ventricular membrane preparations. The Bmax values were significantly lower in aged than young adult hearts (140.2 +/- 1.5 fmol/mg and 191.9 +/- 2.3 fmol/mg in aged and young hearts, respectively) indicating a decreased number of transporter sites in the aged heart. However, the values for Kd were decreased with aging, suggesting an increase in the affinity of the transporter for adenosine in the aged vs. young adult heart. (4) The activities and kinetics of adenosine kinase were determined in homogenates of aged and young adult ventricular myocardium. No statistical difference was found between the two activities. Taken together these results suggest that increased interstitial adenosine levels in the aged heart result from decreased uptake of adenosine by the ventricular myocardium.

Knowledge and Attitudes of Certified Athletic Trainers in Pennsylvania Toward HIV/AIDS and Treating HIV-Positive Athletes.

OBJECTIVE: As the number of people infected with the Human Immunodeficiency Virus (HIV) continues to increase so does the likelihood that athletic trainers will treat HIV-positive athletes. The purposes of this study were to determine how knowledgeable certified athletic trainers in Pennsylvania are about HIV/ AIDS and their attitudes toward treating the injuries of HIV- positive/AIDS athletes. Another purpose of this study was to determine what effect the athletic trainers' HIV/AIDS attitudes had on their HIV/AIDS knowledge level. DESIGN AND SETTING: A questionnaire was mailed to 807 NATA-certified athletic trainers who resided in the state of Pennsylvania. A total of 410 (50.8%) athletic trainers participated in the study: 241 (58.8%) males and 169 (41.2%) females. SUBJECTS: NATA-certified athletic trainers who resided in the state of Pennsylvania as of March 19, 1994. MEASUREMENTS: A questionnaire was developed by the investigators after reviewing the appropriate literature and in consultation with a panel of experts that consisted of athletic trainers, physicians, and a health educator who specialized in HIV/AIDS education. The questionnaire consisted of three sections: demographic information, HIV/AIDS knowledge, and HIV/AIDS attitude. Returned questionnaires were analyzed via descriptive (frequencies, percentages, and means) and inferential statistics. Univariate analysis consisted of independent t tests to determine what effect the athletic trainers' HIV/AIDS attitudes had on their HIV/AIDS knowledge level. RESULTS: NATA-certified athletic trainers in Pennsylvania are moderately knowledgeable about HIV/AIDS and have constructive attitudes in treating the athletic injuries of HIV-positive/ AIDS athletes. Their major concern, however, is fear of HIV transmission. It was further determined that differences in HIV/AIDS attitudes had no effect on HIV/ AIDS knowledge level. CONCLUSIONS: The likelihood that athletic trainers will treat HIV-positive athletes is ever increasing. HIV/AIDS education and appropriate clinical precautions are paramount in protecting the clinician and athlete alike.