The impact of comorbidities on postoperative outcomes of ventral hernia repair: the patients' perspective.

INTRODUCTION: Ventral hernia repair (VHR) outcomes can be adversely affected by modifiable patient co-morbidities, such as diabetes, obesity, and smoking. Although this concept is well accepted among surgeons, the extent to which patients understand the significance of their co-morbidities is unknown, and a few studies have sought to determine patient perspectives regarding the impact of their modifiable co-morbidities on their post-operative outcomes. We attempted to determine how accurately patients predict their surgical outcomes after VHR compared to a surgical risk calculator while considering their modifiable co-morbidities. METHODS: This is a prospective, single-center, survey-based study evaluating patients' perceptions of how their modifiable risk factors affect outcomes after elective ventral hernia repair. Pre-operatively, after surgeon counseling, patients predicted the percentage of impact that they believed their modifiable co-morbidities (diabetes, obesity, and smoking) had on 30-day surgical site infections (SSI) and hospital readmissions. Their predictions were compared to the Outcomes Reporting App for CLinicians and Patient Engagement (ORACLE) surgical risk calculator. Results were analyzed using demographic information. RESULTS: 222 surveys were administered and 157 were included in the analysis after excluding for incomplete data. 21% had diabetes, 85% were either overweight with body mass index (BMI) 25-29.9 or obese (BMI ≥ 30), and 22% were smokers. The overall mean SSI rate was 10.8%, SSOPI rate was 12.7%, and 30-day readmission rate was 10.2%. ORACLE predictions correlated with observed SSI rates (OR 1.31, 95% CI 1.12-1.54, p < 0.001), but patient predictions did not (OR 1.00, 95% CI 0.98-1.03, p = 0.868). The correlation between patient predictions and ORACLE calculations was weak ([Formula: see text] = 0.17). Patient predictions were on average 10.1 ± 18.0% different than ORACLE, and 65% overestimated their SSI probability. Similarly, ORACLE predictions correlated with observed 30-day readmission rates (OR 1.10, 95% CI 1.00-1.21, p = 0.0459), but patient predictions did not (OR 1.00, 95% CI 0.975-1.03, p = 0.784). The correlation between patient predictions and ORACLE calculations for readmissions was weak ([Formula: see text] = 0.27). Patient predictions were on average 2.4 ± 14.6% different than ORACLE, and 56% underestimated their readmission probability. Additionally, a substantial proportion of the cohort believed that they had a 0% risk of SSI (28%) and a 0% risk of readmission (43%). Education, income and healthcare employment did not affect the accuracy of patient predictions. CONCLUSIONS: Despite surgeon counseling, patients do not accurately estimate their risks after VHR when compared to ORACLE. Most patients overestimate their SSI risk and underestimate their 30-day readmission risk. Furthermore, several patients believed that they had a 0% risk of SSI and readmission. These findings persisted regardless of level of education, income level, or healthcare employment. Additional attention should be directed toward setting expectations prior to surgery and using applications such as ORACLE to assist in this process.

Short-term outcomes and healthcare resource utilization following incisional hernia repair with synthetic mesh in patients with Crohn's disease.

PURPOSE: While the use of synthetic mesh for incisional hernia repair reduces recurrence rates, little evidence exists regarding the impact of this practice on the disease burden of a Crohn's patient. We aimed to describe the post-operative outcomes and healthcare resource utilization following incisional hernia repair with synthetic mesh in patients with Crohn's disease. METHODS: A retrospective review of adult patients with Crohn's disease who underwent elective open incisional hernia repair with extra-peritoneal synthetic mesh from 2014 to 2018 at a single large academic hospital with surgeons specializing in hernia repair was conducted. Primary outcomes included 30-day post-operative complications and long-term rates of fistula formation and hernia recurrence. The secondary outcome compared healthcare resource utilization during a standardized fourteen-month period before and after hernia repair. RESULTS: Among the 40 patients included, six (15%) required readmission, 4 (10%) developed a surgical site occurrence, 3 (7.5%) developed a surgical site infection, and one (2.5%) required reoperation within the first 30 days. The overall median follow-up time was 42 months (IQR = 33-56), during which time one (2.5%) patient developed an enterocutaneous fistula and eight (20%) experienced hernia recurrence. Healthcare resource utilization remained unchanged or decreased across every category following repair. CONCLUSION: The use of extra-peritoneal synthetic mesh during incisional hernia repair in patients with Crohn's disease was not associated with a prohibitively high rate of post-operative complications or an increase in healthcare resource utilization to suggest worsening disease during the first 4 years after repair. Future studies exploring the long-term outcomes of this technique are needed.

Outcomes of redo-transversus abdominis release for abdominal wall reconstruction.

BACKGROUND: Transversus abdominis release (TAR) is increasingly used to address complex ventral hernias; consequently, associated complications are seen more frequently. Our hernia center has a growing experience with redo-transversus abdominis release (redo-TAR) to address large, complex hernia recurrences after failed TAR. Here, we describe our outcomes after abdominal wall reconstruction with redo-TAR. STUDY DESIGN: Adults undergoing elective open, redo-TAR at our institution from January 2015 to February 2021 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. The primary outcome was 30-day wound morbidity. Secondary outcomes were long-term composite hernia recurrence and patient-reported quality of life. RESULTS: Sixty-five patients underwent redo-TAR. Median age was 60 years, 50.8% were female, and median BMI 31.8 kg/m2. Median recurrent hernias were 16 cm wide by 25 cm long. Frequent mechanisms of recurrence included linea semilunaris injury (27.7%), mesh fracture (18.5%), infection (16.9%), and posterior sheath disruption (15.4%). Wound complications occurred in 33.8% and 16.9% required procedural intervention. With median clinical and PRO follow-up of 12 and 19 months, respectively, the composite hernia recurrence rate was 22.5% and patients reported significantly improved quality of life (HerQLes: median + 36.7, PROMIS: median - 9.5). CONCLUSION: Redo-TAR may be performed as a salvage procedure to reconstruct complex defects after failed TAR, however, in our center, it is associated with increased wound morbidity and fairly high composite recurrence rates. Despite this, patients report improvements in quality of life and pain. Tracking outcomes after TAR will facilitate understanding how to manage its failures.

How to recognize and treat acute HIV syndrome.

The diagnosis of acute human immunodeficiency virus (HIV) syndrome requires a high index of suspicion and proper laboratory testing. Patients with the syndrome may have fever, fatigue, rash, pharyngitis or other symptoms. Primary HIV infection should be considered in any patient with possible HIV exposure who presents with fever of unknown cause. The diagnosis is based on a positive HIV-1 RNA level (more than 50,000 copies per mL) in the absence of a positive enzyme-linked immunosorbent antibody assay (ELISA) and confirmatory Western blot antibody test for HIV. Early diagnosis permits patient education as well as treatment that may delay disease progression. Triple-combination antiretroviral therapy should be started immediately and continued indefinitely. Compliance with medication regimens is essential to maximize benefit and discourage the development of viral resistance.

New recommendations for prophylaxis after HIV exposure.

Early prophylaxis after exposure to human immunodeficiency virus (HIV) can reduce the risk of HIV infection 10-fold and should be recommended or offered after all parenteral exposures. The current recommendations from the Centers for Disease Control and Prevention call for the use of two nucleoside antiretroviral drugs (zidovudine and lamivudine) with or without a protease inhibitor. The use of interferon alfa-2b has not been extensive but may be of benefit in cases of massive exposure. Both the HIV-source patient and the person exposed to HIV should be tested for hepatitis B and C and syphilis, as well as HIV antibody.

HIV disease: a review for the family physician. Part II. Secondary infections, malignancy and experimental therapy.

The first part of this two-part article included recommendations for the initial evaluation of patients suspected of having HIV infection, the Centers for Disease Control's classification scheme for HIV disease and current recommendations for the use of zidovudine. In this second part, secondary infections and malignancy are reviewed, and various experimental therapies are briefly discussed.

HIV disease: a review for the family physician. Part I. Evaluation and conventional therapy.

Family physicians will be challenged with caring for increasing numbers of patients infected with human immunodeficiency virus. After confirming the presence of the infection, the physician must follow a logical sequence of evaluation, counseling and treatment. The current Centers for Disease Control classification and a series of evaluation and treatment protocols form the basis for prescribing zidovudine to delay or mitigate involvement of T lymphocytes and neuronal cells.

Effects of norepinephrine on BAY K-8644-induced contraction in porcine coronary artery.

BAY K-8644 is a dihydropyridine calcium agonist which produces contraction in several isolated vascular preparations--including porcine coronary artery. This study examined the ability of norepinephrine to relax porcine coronary artery previously contracted with BAY K-8644 and compared this to effects on preparations contracted with histamine. Norepinephrine relaxed BAY K-8644 and histamine-treated preparations to approximately base line developed tension. The ED50 value for norepinephrine was the same in the presence of increasing concentrations of either BAY K-8644 or histamine.

Delinquency and learning disabilities: Evidence for compensatory behaviors and adaptation.

There has been a great deal of debate as to whether or not there is a direct relationship between learning disabilities and delinquent behavior. While the relationship was well established for adjudicated youth, it was more uncertain for adolescents not actively involved with the juvenile justice system. There are indications, however, that the relationship is more complex, with learning disabled (LD) adolescents more likely to develop severe delinquent behaviors than are their nondisabled peers, but unlikely to exhibit a middle ground between delinquent and nondelinquent behavior. It is hypothesized that this difference is due to the ability of most LD children and adolescents to adapt through developing skills that allow them to compensate for their handicapping conditions. Implications for future research are discussed.

Protection of myocardial function during endotoxin shock by ibuprofen.

We have concluded that Ibuprofen, a cyclooxygenase inhibitor with high specificity for the preferential blockage of thromboxane synthetase, significantly improves arterial blood pressure, cardiac index, and arterial pH during endotoxin shock in dogs (J. Clin. Invest. 70:536, 1982). This study was undertaken to determine whether Ibuprofen (25 mg/kg i.v.) administered 20 min prior to endotoxin (2 mg/kg i.v.) is able to overcome the depressed ability of cardiac microsomes to actively sequester calcium after 2 hrs of endotoxin shock. Results indicate that microsomes isolated from hearts of animals pretreated with Ibuprofen and then given endotoxin are able to sequester calcium at rates similar to microsomes isolated from control hearts. Microsomes isolated from hearts of animals in endotoxin shock without Ibuprofen show the anticipated depression of calcium sequestering ability. The improved ability of microsomes from the hearts of animals pretreated with Ibuprofen to sequester calcium is the result of normal Ca+2-Mg+2 ATPase activity in the microsomal membrane. We conclude that Ibuprofen protects against the detrimental hemodynamic derangements of endotoxin induced shock in the dog, and thereby also improves cardiac subcellular calcium transport; the factor regulating contractility. Ibuprofen may warrant evaluation as a protective agent to be used prophylactically in high risk cases of endotoxemia.

The role of prostaglandins E2 and F2 alpha on canine arterial in vitro lipid biosynthesis from 14C-acetate.

This study was designed to investigate the influence of prostaglandin on in vitro incorporation of 14C acetate into canine aortic lipid. Aortae were excised from pentobarbital-anesthetized dogs, stripped of their adventitial layer and incubated four hours in the presence of labeled substrate alone or labeled substrate plus prostaglandin. The tissue was subsequently homogenized and the lipid phase extracted. Thin layer chromatography was used to separate lipid subfractions. Incorporated 14C was measured by liquid scintillation. PGE2 (0.05-0.10 microgram/ml) significantly decreased (p less than 0.01) incorporation of 14C acetate into phospholipid. Other lipid subfractions were not affected. PGF2 alpha (0.01-0.05 microgram/ml) significantly increased (p less than 0.01) incorporation of 14C acetate into phospholipid, triglyceride and FFA. Other subfractions were not affected. Studies conducted on intimal and medial layers separately failed to alter the extent to which 14C was incorporated into these tissue layers. Tissue "blanks" performed following destruction of enzymatic activity failed to demonstrate any significant background uptake of 14C. Therefore, in vitro effect of PGE2 is to decrease aortic wall lipid synthesis from acetate, while the effect of PGF2 alpha is to increase aortic lipid synthesis from acetate.