Trans rectus sheath extra-peritoneal procedure (TREPP) for inguinal hernia repair under local anesthesia with sedation in the outpatient clinic: a feasibility study.

BACKGROUND: The Trans Rectus Sheath Extra-Peritoneal Procedure (TREPP) is an open procedure in which the mesh is placed in the preperitoneal space and is therefore associated with less chronic post-operative inguinal pain. TREPP is primarily performed under general or spinal anesthesia, however, it is also possible to perform under sedation and local anesthesia with potentially advantages. This retrospective feasibility pilot study investigates the safety and efficiency of TREPP under local anesthesia in the outpatient clinic in comparison with Lichtenstein. METHODS: Between 2019 and 2022, all patients who underwent an elective inguinal hernia repair under local anesthesia in the outpatient clinic operation theatre were assessed. 34 patients in the TREPP group and 213 patients in the Lichtenstein group were included. Outcomes were complications, operating time, theatre time, and early inguinal hernia recurrence within 8 weeks and 6 months post-operatively. RESULTS: No significant differences in complications such as wound infection, hematoma, seroma, urine retention and early recurrence between TREPP and Lichtenstein were found. Post-operative pain at 8 weeks was not significantly higher after Lichtenstein (8.8% vs. 18.8%, P = 0.22). Operating time (21.0 (IQR: 16.0-27.3) minutes vs. 39.0 (IQR: 31.5-45.0) minutes, P < 0.001) and theatre time (37.5 (IQR: 30.8-42.5) minutes vs. 54.0 (IQR: 46.0-62.0) minutes, P < 0.001) was significantly shorter for TREPP. CONCLUSION: This pilot study showed that TREPP appears to be feasible to perform safely under local anesthesia with comparable complication rates and substantially shorter operation time than Lichtenstein. These results justify further research with a larger study population and a longer period of follow up in order to provide firm conclusions.

Prospective randomized controlled trial: early weight bearing after conservative treatment of Weber B ankle fractures (pancake trial).

PURPOSE: Different studies have shown that weightbearing is safe in stable transsyndesmotic, isolated lateral simple ankle fractures. Despite this evidence, AO guidelines still recommend immobilization with above-the-knee cast for 4-6 weeks for these fractures. The objective of this study was to compare the outcomes of mobilization and weightbearing to those of immobilization and non-weightbearing in patients with stable transsyndesmotic, lateral isolated simple ankle fractures. METHODS: Fifty patients were randomly assigned to permissive weightbearing in a walking boot or non-weightbearing immobilization using a below-the-knee cast. Primary outcome was ankle functionality as scored by the Olerud-Molander Ankle Score (OMAS). Secondary outcomes were radiological displacement of fracture, range of motion (ROM), calf circumference, and RAND 36-item health survey. Patients were in follow-up for 24 months. RESULTS: Ankle functionality after six and twelve weeks was significantly higher for the intervention group, with respectively 30 points (p = 0.001) and 10 points (p = 0.015) of difference. ROM improved significantly in the intervention group after six weeks. All fractures showed radiological progression of fracture healing. RAND 36-item showed differences in both physical (60.3 vs. 46.3, p = 0.017) and mental (78.5 vs. 58.2, p = 0.034) components in favor of the intervention group. In 16% of patients who initially showed stable fractures on radiographic imaging, joint dislocation was identified on weightbearing radiographs prior to randomization, leading to exclusion. CONCLUSION: Weightbearing and mobilization using a walking boot may be a safe treatment for patients with stable Weber B fractures.

The first experience with the Dextile anatomical mesh in laparoscopic inguinal hernia repair.

BACKGROUND: The Dextile Anatomical mesh (Medtronic) is a polypropylene heavyweight mesh and has a 3D patented anatomical shape which adapts to the contours of the extra-peritoneal inguinal region without the need for fixation, potentially reducing the risk of hernia recurrence and chronic post-operative pain. This retrospective study will be the first study to assess the outcomes of the Dextile Anatomical mesh compared to another three-dimensional mesh, the 3DMax mesh (Bard). METHODS: Between 2019 and 2022, all patients who underwent an elective unilateral inguinal hernia repair were assessed. 416 patients in the Dextile Anatomical mesh group and 540 patients in the 3DMax mesh group were included. Outcomes were intra- and post-operative complications, inguinal hernia recurrence and chronic post-operative inguinal pain. RESULTS: No significant differences were found between the two groups regarding intra- and post-operative complications including wound infection, antibiotic use, hematoma, seroma, urinary retention and delayed wound healing. 1-year recurrence rate was comparable for the Dextile Anatomical mesh group and the 3DMax mesh group, respectively, 3.8% and 3.0%, P = 0.45. Chronic post-operative inguinal pain was similar for the Dextile Anatomical mesh (3.4%) and the 3DMax mesh (3.0%), P = 0.72. CONCLUSION: This retrospective study comparing the relatively new Dextile Anatomical mesh (Medtronic) with the 3D Max mesh (Bard) in unilateral inguinal hernia repair showed that both meshes are safe and effective to use. There were no significant differences in intra-operative outcomes, recurrence rates and chronic post-operative inguinal pain.

Using an E-Health Application for Post-operative Monitoring After Inguinal Hernia Repair: A Feasibility Study.

BACKGROUND: E-Health care is already well established in some (non-) surgical specialties and is considered as a means of improving patient-centred care. Considering the demand of remote health care changes, especially in the COVID-19 pandemic, it is essential to investigate the feasibility of e-Health care within one of the most performed surgery procedures: inguinal hernia repair. METHODS: A total of 60 patients used the e-Health application in this study compliant. Primary objectives were to investigate the accuracy of the "deviating post-operative course" alerting by the e-Health application. Secondary objectives included patient perspective and e-Health costs analysis. RESULTS: Forty-four patients reported no deviation in the post-operative course using the e-Health application of which 93.2% (n = 41) was in concordance with the findings during standard follow-up. Within 16 patients reporting a deviating post-operative course, a true complication was found in 25% (n = 4). Based on in-hospital costs, a hypothetical e-Health follow-up scenario was more expensive (€59.5 per patient) than current standard follow-up care (€28.2 per patient). Usage of the e-Health application showed a high perceived overall patient satisfaction: 4.2 (on a Likert-scale of 1-5). CONCLUSION: An e-Health application is a promising tool for identifying patients who require in-person or phone follow-up assessment. Patients' perspectives surveys revealed high potential and willingness of using this application. A hypothetical e-Health follow-up scenario showed to be more expensive compared to current standard follow-up. If the identified (dis)advantages can be improved, e-Health follow-up care appears to be promising in terms of safety and feasibility. Future studies can leverage on this study and further investigate the use of e-Health within the field of general surgery.

Safety and efficacy in inguinal hernia repair: a retrospective study comparing TREPP, TEP and Lichtenstein (SETTLE).

BACKGROUND: This pilot trial investigates whether the trans rectus sheath extra-peritoneal (TREPP) mesh repair is a safe and effective procedure compared to the currently most performed inguinal hernia repair techniques TEP and Lichtenstein. METHODS: Three hundred patients older than 18 years with unilateral inguinal hernia were included in this retrospective cohort study, of which 58 (19.3%) underwent TREPP, 190 (63.3%) TEP and 52 (17.3%) Lichtenstein. The primary outcome of this study was inguinal hernia recurrence rate within 1 year after surgery. Secondary objectives were chronic post-operative inguinal pain (CPIP) lasting more than 6 months, (major) complication rates and operating time. RESULTS: Recurrence rate within 1-year post-operative was low overall in the study population and did not differ significantly between TREPP, TEP and Lichtenstein, respectively 1.7, 2.1, 0.0% (P = 0.591). The rate of CPIP for which the patient contacted the hospital was similar in the study groups: TREPP: 1.7%; TEP: 1.6%; Lichtenstein: 1.9%; (P = 0.591). The mean operating time in minutes (SD) was significantly shorter in the TREPP group compared with the two other patient groups (TREPP: 22.2 (± 5.7); TEP: 38.7 (± 14.8); Lichtenstein: 49.3 (± 17.1), P < 0.001). No major complications occurred in any patient of the study groups. CONCLUSION: TREPP seems to be an effective and safe technique for unilateral primary inguinal hernia repair. It is found to be comparable to TEP and Lichtenstein in terms of recurrence rates, chronic post-operative inguinal pain, and clinically significant adverse events. This pilot study proves the need for future research into the TREPP technique.

An add-on training program involving breathing exercises, cold exposure, and meditation attenuates inflammation and disease activity in axial spondyloarthritis - A proof of concept trial.

OBJECTIVES: The primary objective of this trial was to assess safety and anti-inflammatory effects of an add-on training program involving breathing exercises, cold exposure, and meditation in patients with axial spondyloarthritis. METHODS: This study was an open-label, randomised, one-way crossover clinical proof-of-concept trial. Twenty-four patients with moderately active axial spondyloarthritis(ASDAS >2.1) and hs-CRP ≥5mg/L were included and randomised to an intervention (n = 13) and control group (n = 11) group that additionally received the intervention after the control period. The intervention period lasted for 8 weeks. The primary endpoint was safety, secondary endpoints were change in hs-CRP, serum calprotectin levels and ESR over the 8-week period. Exploratory endpoints included disease activity measured by ASDAS-CRP and BASDAI, quality of life (SF-36, EQ-5D, EQ-5D VAS), and hospital anxiety and depression (HADS). RESULTS: We found no significant differences in adverse events between groups, with one serious adverse event occurring 8 weeks after end of the intervention and judged 'unrelated'. During the 8-week intervention period, there was a significant decline of ESR from (median [interquartile range] to 16 [9-26.5] to 9 [5-23] mm/hr, p = 0.040, whereas no effect was found in the control group (from 14 [8.3-27.3] to 16 [5-37] m/hr, p = 0.406). ASDAS-CRP declined from 3.1 [2.5-3.6] to 2.3 [1.9-3.2] in the intervention group (p = 0.044). A similar trend was observed for serum calprotectin (p = 0.064 in the intervention group versus p = 0.182 in the control group), but not for hs-CRP. CONCLUSIONS: This proof-of-concept study in axial spondyloarthritis met its primary endpoint with no safety signals during the intervention. There was a significant decrease in ESR levels and ASDAS-CRP upon the add-on training program in the intervention group. These findings warrant full-scale randomised controlled trials of this novel therapeutic approach in patients with inflammatory conditions. TRIAL REGISTRATION: ClinicalTrials.gov; NCT02744014.

Progressive disseminated histoplasmosis mimicking a flare of systemic lupus erythematosus: a European case report.

INTRODUCTION: Diagnosing progressive disseminated histoplasmosis (PDH) in patients with systemic lupus erythematosus (SLE) is diagnostically challenging. Since PDH is lethal when untreated, awareness of this infection in patients with SLE is of utmost importance. To the best of our knowledge, this is the first description of a case of PDH in a patient with SLE in Europe. CASE PRESENTATION: A 56-year-old woman of Surinamese descent with a history of SLE, presented with fever and polyarthritis. Although a flare of SLE was suspected initially, cultures of bone marrow and broncho-alveolar lavage fluid grew Histoplasma capsulatum. CONCLUSION: This case report highlights that physicians should be aware of progressive disseminated histoplasmosis in patients with SLE treated with immunosuppressive agents. The signs and symptoms can easily mimic a SLE flare, which would then be treated with more aggressive immunosuppression. Failure to recognize the infection will therefore invariably lead to death of the patient. Progressive disseminated histoplasmosis is usually not recognized by doctors in non-endemic areas such as Europe. However, globalisation and more frequent intercontinental traffic of immunocompromised patients currently increases the incidence of histoplasmosis in these areas. It is therefore of life-saving importance that doctors are aware of the features of the infection in areas where H. capsulatum is not endemic.

Results of a questionnaire on the treatment of patients with Behçet's syndrome: a trend for more intensive treatment.

OBJECTIVES: To determine the preferred treatment for patients with Behçet's syndrome. METHODS: A questionnaire was given to all participants of the 2010 meeting of the International Society for Behçet's Disease. RESULTS: Forty-one respondents from 6 different subspecialties. In the case of a patient with (severe) posterior uveitis or parenchymal central nervous system (CNS) disease no consensus was seen. A diffuse spectrum of different schedules were given. In both uveitis and CNS disease the majority of respondents preferred treatment options consisting of combination systemic therapy and systemic corticosteroids. TNF was preferred as first line drug in uveitis in 7.5% and in severe uveitis in 32.5% of respondents. In parenchymal CNS disease TNF blockage was given by 17% of the respondents. EULAR guidelines regarding uveitis were followed by 12/40 physicians. In patients with a new deep vein thrombosis, 90% of respondents would intensify immunosuppression. More than half would also anticoagulate. CONCLUSIONS: Although consensus about how to treat patients with Behçet syndrome in different clinical situations is far from present, treatment has become more intensive when compared to 10-20 years ago. More uniformity should be sought for in the decision process in individual patients with Behçet's syndrome, regarding their treatment, as well as adhering to evidence, as presented in the EULAR guidelines, when present.

Two cases of near-fatal gamma-butyrolactone (GBL) ingestion and intoxication.

We present two cases of GBL intoxication. Patient A is a 45-year old man who lost consciousness after drinking a clear unknown liquid. He was brought to the Emergency Departement (ED) after he was intubated. His partner notified the liquid could be GBL, a prodrug for GHB. He regained consciousness 16 hours later in the intensive care unit (ICU) where he could be successfully extubated. Patient B is a 25-year old man who was found unconscious at home with next to him an empty bottle of GBL. He was intubated in the intensive care unit. He could be extubated after 12 hours. GBL intoxication is becoming a more frequent problem and overdosage of GBL can rapidly occur because of its rapid onset and high potency when compared to GHB. We discuss the clinical course and complications after GBL ingestion and intoxication.

Influence of routine computed tomography on predicted survival from blunt thoracoabdominal trauma.

INTRODUCTION: Many scoring systems have been proposed to predict the survival of trauma patients. This study was performed to evaluate the influence of routine thoracoabdominal computed tomography (CT) on the predicted survival according to the trauma injury severity score (TRISS). PATIENTS AND METHODS: 1,047 patients who had sustained a high-energy blunt trauma over a 3-year period were prospectively included in the study. All patients underwent physical examination, conventional radiography of the chest, thoracolumbar spine and pelvis, abdominal sonography, and routine thoracoabdominal CT. From this group with routine CT, we prospectively defined a selective CT (sub)group for cases with abnormal physical examination and/or conventional radiography and/or sonography. Type and extent of injuries were recorded for both the selective and the routine CT groups. Based on the injuries found by the two different CT algorithms, we calculated the injury severity scores (ISS) and predicted survivals according to the TRISS methodology for the routine and the selective CT algorithms. RESULTS: Based on injuries detected by the selective CT algorithm, the mean ISS was 14.6, resulting in a predicted mortality of 12.5%. Because additional injuries were found by the routine CT algorithm, the mean ISS increased to 16.9, resulting in a predicted mortality of 13.7%. The actual observed mortality was 5.4%. CONCLUSION: Routine thoracoabdominal CT in high-energy blunt trauma patients reveals more injuries than a selective CT algorithm, resulting in a higher ISS. According to the TRISS, this results in higher predicted mortalities. Observed mortality, however, was significantly lower than predicted. The predicted survival according to MTOS seems to underestimate the actual survival when routine CT is used.

A new technique in the treatment of distal radius fractures: the Micronail®.

OBJECTIVES: In 2006, an intramedullar titanium osteosynthesis for the stabilization of distal radius fractures was introduced in The Netherlands: the Micronail®. The Micronail® can be used in approximately 30% of distal radius fracture treatments. This article presents the introduction of this new treatment, and first clinical results. METHODS: In the first year after introduction of the Micronail® in our clinic, 10 patients have been treated with 11 Micronails® (eight 23-A2 radius fractures and three distal 22-A3 forearm fractures). Our patients were mainly woman (n=9) and had a mean age of 81 years (range 69-88 years). After re-alignment of the fracture, the Micronail® was placed into the medulla through a small incision over the styloid process of the radius. By using a guidance system, three locking buttress screws were placed in the distal radial fragment and two locking bolts were placed in the proximal radius. Postoperative treatment consisted of a splint for 5 days, after which full loadcarrying exercises can be started. RESULTS: After 6 weeks, six patients had a full range of motion. Two patients were still in a cast because of secondary dislocation and CTS, respectively. One patient had a cast because of newly sustained trauma, which resulted in a peri-osteosynthetic fracture. Pain was not recorded in these patients. All fractures healed without major loss of alignment. Patients experienced good to excellent results on an analog scale showing the wrist function. At 4 months, all patients had a good range of motion in the operated wrist; the difference between the two wrists was a maximum of 10 °. CONCLUSION: The first results of Micronail® are promising. It has the advantages of other operative techniques (minimally invasive, stable, intramedullar) without their known disadvantages. Short immobilization is sufficient, after which full load-carrying exercises are indicated.

Venous and arterial thromboembolic events in adalimumab-treated patients with antiadalimumab antibodies: a case series and cohort study.

OBJECTIVE: We observed 3 patients who developed severe venous and arterial thromboembolic events during treatment with adalimumab, 2 of whom had rheumatoid arthritis (RA) and 1 of whom had psoriatic arthritis. Antiadalimumab antibodies were detected in all 3 patients. We undertook this study to determine whether the development of antiadalimumab antibodies was associated with thromboembolic events during adalimumab treatment. METHODS: A retrospective search (with blinding with regard to antiadalimumab antibody status) for thromboembolic events was performed in a prospective cohort of 272 consecutively included adalimumab-treated RA patients. Incidence rates were calculated and hazard ratios (HRs) were estimated using Cox regression. None of the index patients were part of the cohort. RESULTS: Antiadalimumab antibodies were detected in 76 of 272 patients (28%). Eight thromboembolic events were found, 4 of which had occurred in patients with antiadalimumab antibodies. The incidence rate was 26.9/1,000 person-years for patients with antiadalimumab antibodies and 8.4/1,000 person-years for patients without those antibodies (HR 3.8 [95% confidence interval 0.9-15.3], P = 0.064). After adjustment for duration of followup, age, body mass index, erythrocyte sedimentation rate, and prior thromboembolic events, the HR was 7.6 (95% confidence interval 1.3-45.1) (P = 0.025). CONCLUSION: These findings suggest that the occurrence of venous and arterial thromboembolic events during adalimumab treatment is higher in patients with antiadalimumab antibodies than in those without antiadalimumab antibodies. Patient numbers were relatively small; therefore, validation in other cohorts is mandatory.

Local insulin-like growth factor I expression is essential for Purkinje neuron survival at birth.

IGF1, an anabolic and neuroprotective factor, promotes neuronal survival by blocking apoptosis. It is released into the bloodstream by the liver, or synthesized locally by muscles and neural cells, acting in an autocrine or paracrine fashion. Intriguingly, genetic studies conducted in invertebrate and murine models also suggest that an excess of IGF1 signaling may trigger neurodegeneration. This emphasizes the importance of gaining a better understanding of the mechanisms controlling IGF1 regulation and gene transcription. In the cerebellum, Igf1 expression is activated just before birth in a subset of Purkinje cells (PCs). Mice carrying a null mutation for HLH transcription factor EBF2 feature PC apoptosis at birth. We show that Igf1 is sharply downregulated in Ebf2 null PCs starting before the onset of PC death. In vitro, EBF2 binds a conserved distal Igf1 promoter region. The pro-survival PI3K signaling pathway is strongly inhibited in mutant cerebella. Finally, Ebf2 null organotypic cultures respond to IGF1 treatment by inhibiting PC apoptosis. Consistently, wild type slices treated with an IGF1 competitor feature a sharp increase in PC death. Our findings reveal that IGF1 is required for PC survival in the neonatal cerebellum, and identify a new mechanism regulating its local production in the CNS.

Fatal cerebral oedema in adult diabetic ketoacidosis.

In this report, a case of adult onset fatal cerebral oedema as a rare complication of diabetic ketoacidosis (DKA) is described and confirmed at post-mortem pathological examination. The pathogenesis of cerebral oedema due to DKA is still unknown. Potential mechanisms include the administration of sodium bicarbonate leading to intracellular acidosis, excessive fluid infusion causing swelling of brain tissue, or reduction of plasma osmolarity by a rapid fall in glucose levels causing osmotic swelling.

Management of hepatic trauma: a 9-year experience in 's-Hertogenbosch.

BACKGROUND: In patients who sustain abdominal trauma the liver is the most frequently injured organ. Although treatment for haemodynamically unstable patients remains urgent surgery, there has been a shift of management in haemodynamacally stable patients towards non-operative management. We performed an outcome assessment of traumatic hepatic injury. METHODS: A retrospective study was performed to assess incidence, mechanisms, management and outcome of traumatic liver injury in the region of 's-Hertogenbosch, The Netherlands, in the period 1999-2007. RESULTS: A total of 47 patients were identified. Thirty-six patients had blunt hepatic trauma, eleven sustained penetrating hepatic injury. In 67% (n = 24) of the blunt hepatic trauma patients the initial intention was to treat non-operatively. Yet, two patients underwent explorative laparotomy after one and two days. In the penetrating liver trauma patients, 91% (n = 10) underwent urgent surgery. In total, 31 of 47 patients were treated conservatively. CONCLUSION: Blunt hepatic trauma is the most common cause of hepatic trauma. Most patients sustaining hepatic trauma can be managed conservatively at a dedicated ICU and/or surgical trauma ward.

Treatment of dilated venous bypass grafts with an expanded polytetrafluoroethylene-covered nitinol endoprosthesis.

An above-knee femoropopliteal bypass graft constructed of great saphenous vein became dilated in 2 patients 12 and 25 years after surgery. Both patients had several concomitant disorders. The dilations were treated by insertion of an expanded polytetrafluoroethylene-covered nitinol endoprosthesis. There were no major procedural complications. One minor endoleak that developed immediately after endograft placement resolved within 6 weeks. The leg swelling subsided, and the endoprostheses have remained patent for 18 and 24 months, respectively. To our knowledge, these were the first cases in which an endoprosthesis was used to treat dilation of a venous bypass graft.

A 57-year-old man who developed arthritis during R-CHOP chemotherapy for non-Hodgkin lymphoma.

Rituximab is a chimeric human-mouse anti-CD20 monoclonal antibody, which is used in the treatment of both B-cell lymphomas and rheumatic diseases. We describe a case of a previously healthy 57-year-old man developing arthritis while being treated with rituximab-CHOP chemotherapy (R-CHOP) for a non-Hodgkin lymphoma. The remittant arthritis developed at successively shorter time-intervals after R-CHOP administration and only improved after rituximab was removed from the chemotherapy schedule, suggesting a rituximab-related phenomenon, as extensive diagnostic testing ruled out any other diagnosis.

Unexpected fatal neurological deterioration after successful cardio-pulmonary resuscitation and therapeutic hypothermia.

A 77-year-old woman was admitted to the intensive care unit after successful cardiopulmonary resuscitation for out-of-hospital cardiac arrest due to pulseless electrical activity. She was treated with mild therapeutic hypothermia to minimise secondary anoxic brain damage. After a 24 h period of therapeutic hypothermia with a temperature of 32.5 degrees C, the patient was rewarmed and sedation discontinued. Neurological evaluation after 24 h revealed a maximum Glasgow Coma Score of E4M4Vt with spontaneous breathing. However the patient developed a fever reaching 39 degrees C for several hours that was unresponsive to conventional cooling methods. In the subsequent 24 h patient developed apnoea, hypotension and bradycardia with deterioration of the coma score. Diabetes insipidus was confirmed. Cerebral CT was performed which showed diffuse brain oedema with herniation and brainstem compression. The patient died within hours. Autopsy showed massive brain swelling and tentorial herniation. Hyperthermia possibly played a pivotal role in the development of this fatal insult to this vulnerable brain after cardiac arrest and therapeutic hypothermia treatment. The acute histopathological alterations in the brain, possibly caused by the deleterious effects of fever after cardiac arrest in human brain, may be considered a new observation.