Predictors of long-term mortality in octogenarian veterans following inguinal hernia repair.

BACKGROUND: While elective inguinal hernia repair (IHR) in octogenarians carries a low 30-day mortality rate, long-term outcomes are uncharted. If on average, veteran octogenarians are expected to succumb to pre-existing cardiopulmonary disease within a year of diagnosis, watchful waiting might be advisable. This study interrogated long-term mortality and its predictors following elective IHR in veteran octogenarians. MATERIALS AND METHODS: This is a retrospective analysis of 109 veterans (≥ 80 years of age), ten of which were nonagenarians who had an elective IHR. Data were dichotomized between deceased vs. non-deceased patients for univariable and multivariable analyses. Patient characteristics were also assessed in patients undergoing general (GA) vs. local (LA) anesthesia and corrected for unilateral repair and age. Kaplan-Meier curves were generated in corrected and uncorrected cohorts receiving GA vs. LA. RESULTS: At the time of analysis, 46 (45.0%) octogenarians were deceased. The average time to death following IHR was 3.7 ± 2.9 years [range (37 days-12.4 years)]. Univariable analysis showed renal disease (19.9% vs. 5.3%), operative time (67.9 ± 29.0 vs. 56.1 ± 14.4 min) and use of GA (73.0% vs. 34.8%) associated with long-term mortality (all p < 0.01). Renal disease [odds ratio (95% confidence intervals) 4.1 (1.2-13.8)] and use of GA [5.0 (2.0-10.0)] were independent predictors of mortality. Patients undergoing LA (n = 62) were older, were more likely to have cardiac disease, and had a higher ASA compared to patients receiving GA (n = 47). After correcting for age, cardiac disease and higher ASA remained more common in patients submitting to LA. Long-term mortality was significantly higher in both matched and unmatched octogenarians undergoing GA. CONCLUSION: Octogenarian veterans with a high burden of comorbid conditions are unlikely to experience short-term mortality because of their pre-existing conditions. Inguinal hernia repair should be offered to octogenarian veterans, but GA should be avoided whenever possible.

Outcomes of obese compared to non-obese veterans undergoing open inguinal hernia repair: a case-control study.

BACKGROUND: The optimal approach for inguinal hernia repair in the obese remains elusive. Minimally invasive techniques show equivocal results compared to the open method. None of the current analyses include a non-obese control group because the differences in factors leading to complications vary widely between these two cohorts. MATERIALS AND METHODS: In the present study, we matched (1:1) obese to non-obese patients undergoing an open inguinal hernia repair. Matching was performed by age, hernia type (bilateral, inguinal, femoral, recurrent, primary, direct, pantaloon, and scrotal component), type of repair (tissue repair vs. mesh), concurrent umbilical hernia repair, current smoking, ASA Class, a history of DM and COPD. RESULTS: Demographics in the unmatched cohorts demonstrated significantly (p < 0.05) wide differences between obese (n = 319) and non-obese (n = 1137) veterans: age (58.0- vs. 63.4-year-old), indirect hernia (37.7% vs. 45.5%), scrotal component (14.4% vs. 9.9%), current smoking (23.5% vs. 34.4%), DM (20.8% vs. 13.1%), OSA (13.2% vs. 3.6%), COPD (12.2% vs. 18.5%), and BPH (16.9% vs. 23.3). After matching, there were 300 obese and 300 non-obese patients available for analysis. There was no difference in 30-day morbidity between obese and non-obese patients in the unmatched (11.0% vs. 7.9%; p = 0.09) and matched (10.7% vs. 8.1%, p = 0.27) cohorts. Similarly, no differences in inguinodynia and recurrence were observed in either matched or unmatched cohorts. CONCLUSION: Obese patients pose no further risk in outcomes compared to non-obese veterans undergoing open inguinal hernia repair. The best technique for an inguinal hernia repair in obese patients should rest on the comfort and the experience of the surgeon.

Nueva mutación en el canal HCN4 en paciente pediátrico con bloqueo auriculoventricular de 2º grado / New mutation in the HCN4 channel in a pediatric patient with 2nd atrioventricular block

La presencia de un bloqueo AV de primer y segundo grado tipo Mobitz I se considera un hallazgo benigno en gente joven y en periodos nocturnos. Presentamos el caso de una niña de 3 años de edad en la que se detectó de forma casual un bloqueo AV de primer y segundo grado tipo I, portadora de una mutación probablemente patogénica en el gen que regula la actividad de marcapasos del corazón

The presence of a first and second degree type Mobitz I AV block is considered a benign finding in young people and at night periods. We report a case of a 3 year-old girl in whom a type I first and second degree AV block was detected, carrying a probably pathogenic mutation in the gene that regulates the pacemaker activity of the heart

Emergent groin hernia repair at a County Hospital in Guatemala: patient-related issues vs. health care system limitations.

BACKGROUND: The rate of emergent groin hernia repair in developing countries is poorly understood. MATERIALS AND METHODS: A retrospective analysis of groin hernia repairs performed at a county hospital in Guatemala [Hospital Nacional de San Benito (HSNB)] was undertaken and compared to a literature review in developed countries. Patients with incarcerated hernias were interviewed to determine factors related to late presentation. RESULTS: Twenty-five percent of patients with groin hernias in this analysis presented at HNSB emergently (vs. 2.5-7.7% in developed countries). Most patients were male in their fifth decade of life. Ten percent of hernias were femoral. There was no delay in scheduling patients for surgery presenting for elective repair. Most patients lived within 20 miles of the hospital, but only 50% of patients returned for their follow-up appointment. Most patients with an incarcerated inguinal hernia (56%) did not seek medical attention because of family obligations, but when they did, this decision was influence by their children (66%). None of the patients presenting with an incarcerated hernia had education past secondary school. In fact, most (56%) did not have any form formal education. Nearly 90% of patients who had an incarcerated hernia repaired thought that the hospital provided good-to-excellent care. CONCLUSION: A high number of patients present emergently for groin hernia repair at a county hospital in Guatemala compared to developed countries. Our data suggest that emergent hernias are likely the result of patient-related issues rather than health care system limitations.

Mesh migration following abdominal hernia repair: a comprehensive review.

PURPOSE: This study reviewed the literature regarding mesh migration in abdominal hernia repair. The aim of this study is to interrogate incidence, common type of abdominal hernia repair leading to migration, patterns of mesh migration, and materials associated with migration. METHODS: A comprehensive literature review was conducted. PubMed and MEDLINE were searched for relevant articles in the English literature. We employed Ovid syntax from 1949 to January 2010, the Cochrane Library, Google and Google Scholar. The clinical trial database Clinicaltrials.gov was reviewed. Letters to the editor were reviewed to extract cross-references. Multiple keywords were used alone and in combination to extract all relevant articles. RESULTS: In total, 287 unique English citations were reviewed. Of these, 84 articles were selected and consisted of 3 case series, 77 case reports, 2 literature reviews, 1 retrospective study, and 1 prospective, observational study. In an analysis of available cases, the average age was 59.8 ± 13.8 years with a male predominance (76.2%). The index hernia repair was inguinal in 62.9%, incisional/ventral in 28.1%, umbilical in 6.7%, and other in 2.2%. Within the inguinal hernia group, 51.8% were open repairs, 42.9% were laparoscopic, and 1.8% were robotic. Implicated mesh materials included polypropylene, PTFE, and composite mesh. Migration commonly affected multiple organs (31.5%). CONCLUSIONS: It is likely that more cases of mesh migration will appear in the literature. Reports are heterogeneous and highlight the diversity of this complication. A standardized method of reporting is needed to develop guidelines and recommendations for this presentation.

Right ventricular ejection fraction obtained from TAPSE / Fracción de expulsión del ventrículo derecho obtenida a partir del TAPSE

Abstract: Introduction: American guidelines for echocardiographic evaluation from 2015 determine an abnormal TAPSE value below 17 mm; a right ventricle ejection fraction (RVEF) below 45% measured by a three-dimensional method (3D) is considered abnormal, it's widely validated by Magnetic Resonance Imaging (MRI). Kawel-Boehm et al, through MRI has established the reference parameters for adults and children. For men between 20-68 years the minimum normal RVEF value is 52% (52-72% range, 61% medium); in women from the same age range the minimum normal RVEF value is 51% (51-71% range, medium 61%). Objective: To make a comparison between the RVEF obtained by an echocardiographic method as the result of multiply the 2.9 constant * TAPSE against the MRI´s volumetrically measured RVEF. Material and methods: The TAPSE measuring was made in M mode; the MRI RVEF was determined by a standardized method in steady-state free precession cinematic sequences. Results: We analyzed 32 consecutives patients; 18 were men and 14 were women. The calculated TAPSE was 19.2 ± 4.8; the RVEF with the 2.9*TAPSE formula was 55.7 ± 13.8% and through MRI (p 0.67) 53.2 ± 14.8%. The RVEF measured by the testing method in comparison with the reference method does not show significant statistically difference; there is a good correlation with both methods through the Bland-Altman method. Conclusions: The RVEF can be echocardiographically measured by multiplying the TAPSE value with the 2.9 constant.

Resumen: Introducción: Las Guías Americanas para la evaluación ecocardiográfica de 2015 determinan un valor TAPSE anormal inferior a 17 mm; una fracción de eyección del ventrículo derecho (FEVD) por debajo de 45% medido por un método en tres dimensiones (3D) se considera anormal, es ampliamente validado por imagen de resonancia magnética (RM). Kawel-Boehm et al, a través de la resonancia magnética ha establecido los parámetros de referencia para adultos y niños. Para los hombres entre 20-68 años, el valor normal mínimo de FEVD es 52% (rango 52-72%, 61% promedio); en mujeres de la misma franja etaria el valor normal mínimo de FEVD es 51% (rango 51-71%, promedio 61%). Objetivo: Hacer una comparación entre la FEVD obtenida por un método ecocardiográfico como el resultado de multiplicar la constante FEVD 2.9 * TAPSE, contra la medición volumétrica por RM. Material y métodos: La medición TAPSE se realizó en modo M; La FEVD por RM se determinó mediante un método estandarizado en secuencias cinemáticas de precesión libre en estado estacionario. Resultados: Se analizaron 32 pacientes consecutivos; 18 eran hombres y 14 eran mujeres. La TAPSE calculada fue de 19.2 ± 4.8; la FEVD con la fórmula 2.9 * TAPSE fue de 55.7 ± 13.8% y por medio de resonancia magnética (p 0.67) 53.2 ± 14.8%. La FEVD medida por el método de prueba en comparación con el método de referencia no muestra diferencia significativa estadísticamente; existe una buena correlación con ambos métodos a través del método de Bland-Altman. Conclusiones: La FEVD se puede medir ecocardiográficamente multiplicando el valor TAPSE por la constante 2.9.