Incisional hernia rates following midline laparotomy in the obese patient: a retrospective review.

PURPOSE: Incisional hernia is the most common complication of midline laparotomy. Although obesity is a known risk factor, the incidence of hernia formation in obese patients is not well defined. We sought to define the rate of incisional hernia formation in obese patients undergoing primary midline laparotomy in a large academic medical center. METHODS: Obese patients (BMI ≥ 30 kg/m2) who underwent an elective or urgent primary midline laparotomy from 2017 to 2021 at our institution were retrospectively identified. A blinded hernia surgeon reviewed imaging to assess for incisional hernia formation, defined as a midline fascial defect with intra-abdominal contents herniated outside of the peritoneal cavity. RESULTS: A total of 2241 patients met inclusion criteria. Cross-sectional imaging was available for 914 (41%) of these patients. The median BMI for all patients was 34.3 kg/m2 (range 30.0-59.1). Median time to follow-up imaging was 316 days (181-957, IQR = 185) for all patients and 316 days (201-903, IQR = 184) for patients with incisional hernia. In total, 474 (51.9%) had radiographic evidence of an incisional hernia. Colorectal and General Surgery demonstrated the highest rate of incisional hernia (p < 0.001). During the study period, 138 patients (15.1%) underwent surgical repair of their hernia at our institution, with the highest percentage being Colorectal Surgery patients. CONCLUSION: There is a high rate of hernia formation and subsequent hernia repair in obese patients undergoing midline laparotomy. Most importantly, these findings demonstrate an immediate and pressing need to identify the patient risk factors and technical issues related to this rate of hernia formation.

Role of the community pharmacist in detecting frailty and spatio-temporal disorientation among community-dwelling older people in France.

BACKGROUND: Many older community-dwelling subjects may be frail and/or disoriented, putting them at risk of adverse outcomes. We investigated the prevalence of frailty and spatiotemporal disorientation among patients aged > 65 years collecting regular medication at a community pharmacy. METHODS: Prospective, cross-sectional study of geriatric evaluation in 218 community pharmacies in France. Regular customers aged > 65 years attending the pharmacy to receive ≥ 1 prescription drug were eligible. Spatio-temporal disorientation was assessed using a 4-item screening test; subjects were considered disoriented if they had ≥ 1 incorrect answers. Frailty was evaluated using the Short Emergency Geriatric Assessment (SEGA) grid. Subjects were considered as not frail (score < 8), or frail/very frail (score of 8 or more). RESULTS: 4090 subjects were included, average age 77.5 ± 7.6 years, 60.1% females. Overall, 1025 (25%) were frail/very frail, and 384 (9.4%) were disoriented in space or time. On average, subjects were taking 5.4 ± 3.5 medications per day. Among non-frail patients, 116/3065 (3.8%) were disoriented, of whom 87 (87/116, 75%) managed their medication alone. Among frail/very frail patients, 268/1025 (26.1%) were disoriented, of whom 46 (46/268, 16.8%) managed their medication alone. The majority of patients (77.9%) collected their medication alone at the pharmacy, but significantly fewer frail patients came to collect their drugs alone (p < 0.001). CONCLUSION: It is feasible for community pharmacists to detect disorientation and frailty among older patients. A quarter of subjects were frail/very frail, and 3.2% were disoriented yet managing their drugs alone. Additional social support should be envisaged for these subjects.

Only one nemo-like kinase gene homologue in invertebrate and mammalian genomes.

The nemo-like kinase (Nlk) connects the MAP kinase and Wnt signalling pathways. We have found that invertebrate (Caenorhabditis elegans, Drosophila melanogaster) and mammalian genomes (Mus musculus and Homo sapiens) each contain only a single functional Nlk gene. The mouse genome also harbours a transcriptionally silent processed Nlk pseudogene residing on chromosome 2. Thus, while genes encoding upstream (such as Wnts and frizzelds) and downstream (such as TCF/LEF) components of the Wnt signalling pathway have been extensively diversified during evolution, genes encoding components of the common core of the connecting signalling structure (such as beta-catenin, GSK beta and Nlk) have been maintained in single copies.

Wnt/(beta)-catenin signaling regulates the expression of the homeobox gene Cdx1 in embryonic intestine.

During mammalian development, the Cdx1 homeobox gene exhibits an early period of expression when the embryonic body axis is established, and a later period where expression is restricted to the embryonic intestinal endoderm. Cdx1 expression is maintained throughout adulthood in the proliferative cell compartment of the continuously renewed intestinal epithelium, the crypts. In this study, we provide evidence in vitro and in vivo that Cdx1 is a direct transcriptional target of the Wnt/(beta)-catenin signaling pathway. Upon Wnt stimulation, expression of Cdx1 can be induced in mouse embryonic stem (ES) cells as well as in undifferentiated rat embryonic endoderm. Tcf4-deficient mouse embryos show abrogation of Cdx1 protein in the small intestinal epithelium, making Tcf4 the likely candidate to transduce Wnt signal in this part of gut. The promoter region of the Cdx1 gene contains several Tcf-binding motifs, and these bind Tcf/Lef1/(beta)-catenin complexes and mediate (beta)-catenin-dependent transactivation. The transcriptional regulation of the homeobox gene Cdx1 in the intestinal epithelium by Wnt/(beta)-catenin signaling underlines the importance of this signaling pathway in mammalian endoderm development.

Cardiovascular risk and use of estrogens or estrogen-progestagen combinations. Stanford three-community study.

Cardiovascular risk factors were assess in 986 women residing in three northern California communities. Women who reported current use of oral contraceptives had higher plasma triglyceride levels and systolic and diastolic blood pressures compared with women not using these agents, after adjusting for age and for the greater relative leannes of oral contraceptive users. Similar increases, albeit of lesser magnitude, were observed in women who used pure estrogens. Mexican-American women appeared to be more susceptible to the effects of estrogens, perhaps as a consequence of their greater degree of obesity.