Use of local anesthesia for inguinal hernia repair has decreased over time in the VA system.

PURPOSE: In 2003, randomized trials demonstrated potentially improved outcomes when local instead of general anesthesia is used for inguinal hernia repair. Our study aimed to evaluate how the use of local anesthesia for this procedure changed over time following the publication of the trials' level 1 evidence. METHODS: We used the 1998-2018 Veterans Affairs Surgical Quality Improvement Program database to identify adults who underwent open, unilateral inguinal hernia repair under local or general anesthesia. Our primary outcome was the percentage of cases performed under local anesthesia. We used a time-series design to examine the trend and rate of change of the use of local anesthesia. RESULTS: We included 97,437 veterans, of which 22,333 (22.9%) had hernia surgery under local anesthesia. The median age of veterans receiving local anesthesia remained stable at 64-67 years over time. The use of local anesthesia decreased steadily, from 38.2% at the beginning year to 15.1% in the final year (P < 0.0001). The publication of results from randomized trials (in 2003) did not appear to increase the overall use or change the rate of decline in the use of local anesthesia. Overall, we found that the use of local anesthesia decreased by about 1.5% per year. CONCLUSION: The utilization of local anesthesia for inguinal hernia repair in the VA has steadily declined over the last 20 + years, despite data showing equivalence or superiority to general anesthesia. Future studies should explore barriers to the use of local anesthesia for hernia repair.

Prospective, multicenter, pairwise analysis of robotic-assisted inguinal hernia repair with open and laparoscopic inguinal hernia repair: early results from the Prospective Hernia Study.

PURPOSE: To evaluate and compare peri-operative outcomes through 30 days, including pain and quality of life (QOL) through 3 months across three cohorts of inguinal hernia repair (IHR) patients (robotic-assisted, laparoscopic, and open IHR). METHODS: The Prospective Hernia Study is an ongoing, multicenter, comparative, open-label analysis of clinical and patient-reported outcomes from robotic-assisted surgery (RAS) versus open and RAS versus laparoscopic IHR procedures. Patient responses to the Carolinas Comfort Scale (CCS) questionnaire provided QOL outcomes. RESULTS: 504 enrolled patients underwent unilateral or bilateral IHR (RAS, n = 159; open, n = 190; laparoscopic, n = 155) at 17 medical institutions from May 2016 through December 2018. Propensity score matching provided a balanced comparison: RAS versus open (n = 112 each) and RAS versus laparoscopic (n = 80 each). Overall, operative times were significantly different between the RAS and laparoscopic cases (83 vs. 65 min; p < 0.001). Fewer RAS patients required prescription pain medication than either open (49.5% vs. 80.0%; p < 0.001) or laparoscopic patients (45.3% vs. 65.4%; p = 0.013). Median number of prescription pain pills taken differed for RAS vs. open (0.5 vs. 15.5; p = 0.001) and were comparable for RAS vs laparoscopic (7.0 vs. 6.0; p = 0.482) among patients taking prescribed pain medication. Time to return to normal activities differed for RAS vs. open (3 vs. 4 days; p = 0.005) and were comparable for RAS vs. laparoscopic (4 vs. 4 days; p = 0.657). Median CCS scores through 3 months were comparable for the three approaches. Postoperative complication rates for the three groups also were comparable. One laparoscopic case was converted to open. CONCLUSION: This study demonstrates that IHR can be performed effectively with the robotic-assisted, laparoscopic, or open approaches. There was no difference in the median number of prescription pain medication pills taken between the RAS and laparoscopic groups. A difference was observed in the overall number of patients reporting the need to take prescription pain medication. Comparable operative times were observed for RAS unilateral IHR patients compared to open unilateral IHR patients; however, operative times for RAS overall and bilateral subjects were longer than for open patients. Operative times were longer overall for RAS patients compared to laparoscopic patients; however, there was no difference in conversion and complication rate in the RAS vs. laparoscopic groups or the complication rate in the RAS vs. open group. Time to return to normal activities for RAS IHR patients was comparable to that of laparoscopically repaired patients and significantly sooner compared to open IHR patients.

Use of a Pfannenstiel incision in minimally invasive colorectal cancer surgery is associated with a lower risk of wound complications.

BACKGROUND: The Pfannenstiel incision, widely used in gynecological surgery, has been reported to be associated with lower rates of wound complications than midline incisions in open surgery. However, its effect on wound complications in minimally invasive surgery (MIS) is not well understood. We hypothesize that use of a Pfannenstiel incision in MIS colorectal cancer resections would be associated with fewer short-term wound complication rates. METHODS: A retrospective cohort study was performed on 171 patients who had undergone MIS colorectal cancer surgery requiring a specimen extraction/hand-access site, divided into a Pfannenstiel and a midline group depending on the type of incision used. Wound complications compared included disruption, infection, dehiscence, evisceration, and fistula formation. The Mann-Whitney U and Fisher's exact tests were used to analyze differences in risk factors between the groups. Logistic regression was performed to determine factors associated with prevention of wound complications. RESULTS: Patients in the Pfannenstiel group had significantly lower rates of wound disruption (0 vs. 13%, p = 0.02), superficial surgical site infection (7 vs. 22%, p = 0.03), and overall wound complications (13 vs. 30%, p = 0.04). Using multivariate logistic regression, Pfannenstiel incisions and colon rather than rectal resections were significant predictors of prevention of wound complications. CONCLUSIONS: The use of a Pfannenstiel incision in MIS colorectal cancer resections is associated with a decreased risk of short-term wound complications.

Improving ground beef safety and stabilizing color during irradiation using antioxidants, reductants or TSP.

The objective of this research was to extend ground beef retail display life using antioxidants, reductants, and/or TSP treatments combined with electron beam irradiation. Ground beef was produced with added butylated hydroxyanisole (BHA) plus butylated hydroxytoluene (BHT) with the following combinations; (1) ascorbate; (2) trisodium phosphate(buffer); (3) erythorbate; (1) and (2); (1) and (3); (1), (2), and (3); and an untreated control, C. Half of the treated samples were irradiated (I) at 2.0kGy-absorbed dose under a nitrogen atmosphere, half remained non-irradiated (N). Samples were displayed under atmospheric oxygen and evaluated for total aerobic plate count (TPC), thiobarbituric acid reactive substances (TBARS) and instrumental color during 9d of simulated retail display (SRD). Controls had the highest (P<0.05) TBARS value and the lowest (P<0.05) redness (CIE a∗), proportion of oxymyoglobin and vividness. Treated irradiated samples were just as red and vivid on SRD day 9 as the non-irradiated untreated control at day 0. Treatments stabilized color and lipids of ground beef after irradiation and during SRD.

The pre- and post-grinding application of rosemary and its effects on lipid oxidation and color during storage of ground beef.

The timing of the application of rosemary extract was evaluated as one-way of minimizing myoglobin and lipid oxidation in ground beef. In experiment 1, rosemary extract was added to beef at four different stages namely trim, cube, coarse, and fine ground beef. The beef was evaluated for color and TBARS values during 144h of storage (4°C). Results showed that when rosemary was added to the pre-grinding treatments of trim and cube, ground beef had the highest a(∗) values (redness), oxymyoglobin content, and lowest TBARS values at 144h. In experiment 2, the effect of rosemary extract was evaluated on the color quality of case ready ground beef inoculated with 10(7)CFU/g Escherichia coli. Microbial counts, color, and TBARS values were measured during 144h of simulated storage. The results showed that both the rosemary treated samples that were inoculated and uninoculated remained redder longer and had lower TBARS values than the untreated inoculated and uninoculated controls. There was no significant inhibition of E. coli by the rosemary extract.

Human and murine CD4 T cell reactivity to a complex antigen: recognition of the synthetic random polypeptide glatiramer acetate.

The capacity of glatiramer acetate (GA), a random copolymer of alanine, lysine, glutamic acid, and tyrosine to stimulate primary in vitro human and murine T cell proliferation was examined. PBMCs isolated from healthy humans and relapsing remitting multiple sclerosis patients and spleen cells from inbred strains of mice, expressing different H-2 haplotypes, were used as sources of non-GA-primed lymphocytes. GA functioned as a universal Ag, inducing dose-dependent proliferation of all non-GA-primed human and murine T cell populations tested. Moreover, GA stimulated PBMCs derived ex vivo from human cord blood, strongly suggesting that GA can activate both naive and memory T cells. The human T cell proliferative responses to GA were HLA class II DR-restricted by virtue of the ability of anti-class II Ab to inhibit T cell proliferation, and the demonstration that individual GA specific human T cell clones were HLA class II DR-restricted by either restriction element but not both. Furthermore, GA-reactive T cells secreted Th0 cytokines and expressed a diverse repertoire of TCR. Limiting dilution analysis indicated that the T cell precursor frequency among the healthy human adults tested ranged from 1:5,000 to 1:125,000. Given that all of the T cell populations tested were isolated from non-GA-primed donors, it appears that virtually all humans and murine strains contain significant numbers of T cell populations cross-reactive with GA. These findings may explain the recent clinical finding that daily s.c. administration of GA ameliorates the progression of multiple sclerosis.