Female sex and ipsilateral reoperation risk following mesh-based inguinal hernia repair: a cohort study including 131,626 repairs in adults from an integrated healthcare system over a 10-year period.

PURPOSE: We sought to compare females and males for the risk of reoperation following different inguinal hernia repair approaches (open, laparoscopic, and robotic). METHODS: We conducted a retrospective cohort study including all patients aged ≥ 18 who underwent first inguinal hernia repair with mesh within a US integrated healthcare system (2010-2020). Data were obtained from the system's integrated electronic health record. Multiple Cox proportional-hazards regression was used to evaluate the association between sex and risk for ipsilateral reoperation during follow-up. Analysis was stratified by surgical approach (open, laparoscopic, and robotic). RESULTS: The study cohort was comprised of 110,805 patients who underwent 131,626 inguinal hernia repairs with mesh, 10,079 (7.7%) repairs were in females. After adjustment for confounders, females had a higher risk of reoperation than males following open groin hernia repair (hazard ratio [HR] = 1.98, 95% CI 1.74-2.25), but a lower reoperation risk following laparoscopic repair (HR = 0.70, 95% CI 0.51-0.97). The crude 5-year cumulative reoperation probability following robotic repair was 2.8% in males and no reoperations were observed for females. Of females who had a reoperation, 10.3% (39/378) were for a femoral hernia, while only 0.6% (18/3110) were for femoral hernias in males. CONCLUSION: In a large multi-center cohort of mesh-based inguinal hernia repair patients, we found a higher risk for reoperation in females after an open repair approach compared to males. Lower risk was observed for females through a minimally invasive approach (laparoscopic or robotic) and may be due to the ability to identify an occult femoral hernia through these approaches.

Risk factors for reoperation following inguinal hernia repair: results from a cohort of patients from an integrated healthcare system.

PURPOSE: Inguinal hernia repair is one of the most common operations performed globally. Identification of risk factors that contribute to hernia recurrence following an index inguinal hernia repair, especially those that are modifiable, is of paramount importance. Therefore, we sought to investigate risk factors for reoperation following index inguinal hernia repair. METHODS: 125,133 patients aged ≥ 18 years who underwent their first inguinal hernia repair with mesh within a large US integrated healthcare system were identified for a cohort study (2010-2020). Laparoscopic, robotic, and open procedures were included. The system's integrated electronic health record was used to obtain data on demographics, patient characteristics, surgical characteristics, and reoperations. The association of these characteristics with ipsilateral reoperation during follow-up was modeled using Cox proportional-hazards regression. Risk factors were selected into the final model by stepwise regression with Akaike Information Criteria, which quantifies the amount of information lost if a factor is left out of the model. Factors associated with reoperation with p < 0.05 were considered statistically significant. RESULTS: The cumulative incidence of reoperation at 5-year follow-up was 2.4% (95% CI 2.3-2.5). Increasing age, female gender, increasing body mass index, White race, chronic pulmonary disease, diabetes, drug abuse, peripheral vascular disease, and bilateral procedures all associated with a higher risk for reoperation during follow-up. CONCLUSION: This study identifies several risk factors associated with reoperation following inguinal hernia repair. These risk factors may serve as targets for optimization protocols prior to elective inguinal hernia repair, with the goal of reducing reoperation risk.

Mesh-based inguinal hernia repairs in an integrated healthcare system and surgeon and hospital volume: a cohort study of 110,808 patients from over a decade.

PURPOSE: The aim of this study was to describe a cohort of patients who underwent inguinal hernia repair within a United States-based integrated healthcare system (IHS) and evaluate the risk for postoperative events by surgeon and hospital volume within each surgical approach, open, laparoscopic, and robotic. METHODS: Patients aged ≥ 18 years who underwent their first inguinal hernia repair were identified for a cohort study (2010-2020). Average annual surgeon and hospital volume were broken into quartiles with the lowest volume quartile as the reference group. Multiple Cox regression evaluated risk for ipsilateral reoperation following repair by volume. All analyses were stratified by surgical approach (open, laparoscopic, and robotic). RESULTS: 110,808 patients underwent 131,629 inguinal hernia repairs during the study years; procedures were performed by 897 surgeons at 36 hospitals. Most repairs were open (65.4%), followed by laparoscopic (33.5%) and robotic (1.1%). Reoperation rates at 5 and 10 years of follow-up were 2.4% and 3.4%, respectively; rates were similar across surgical groups. In adjusted analysis, surgeons with higher laparoscopic volumes had a lower reoperation risk (27-46 average annual repairs: hazard ratio [HR] = 0.63, 95% confidence interval [CI] 0.53-0.74; ≥ 47 repairs: HR 0.53, 95% CI 0.44-0.64) compared to those in the lowest volume quartile (< 14 average annual repairs). No differences in reoperation rates were observed in reference to surgeon or hospital volume following open or robotic inguinal hernia repair. CONCLUSION: High-volume surgeons may reduce reoperation risk following laparoscopic inguinal hernia repair. We hope to better identify additional risk factors for inguinal hernia repair complications and improve patient outcomes with future studies.

Detection of in vivo hepatitis B virus surface antigen mutations-A comparison of four routine screening assays.

An important requirement for a state-of-the-art hepatitis B surface antigen (HBsAg) screening assay is reliable detection of mutated HBsAg. Currently, there is a striking shortage of data regarding the detection rates of in vivo HBsAg mutations for these clinically important assays. Therefore, we compared the detection rates of four commercial HBsAg screening assays using a global cohort of 1553 patients from four continents with known HBV genotypes. These samples, which represent the broadest spectrum of known and novel HBsAg major hydrophilic region (MHR) mutations to date, were analyzed for the presence of HBsAg using the Roche Elecsys® HBsAg II Qualitative, Siemens ADVIA Centaur XP HBsAg II, Abbott Architect HBsAg Qualitative II and DiaSorin Liaison® HBsAg Qualitative assays, respectively. Of the 1553 samples, 1391 samples could be sequenced; of these, 1013 (72.8%) carried at least one of the 345 currently known amino acid substitutions (distinct HBsAg mutation) in the HBsAg MHR. All 1553 patient samples were positive for HBsAg using the Elecsys® HBsAg II Qual assay, with a sensitivity (95% confidence interval) of 99.94% (99.64%-100%), followed by the Abbott Architect 99.81% (99.44%-99.96%), Siemens ADVIA 99.81% (99.44%-99.96%) and DiaSorin Liaison® 99.36% (98.82%-99.69%) assays, respectively. Our results indicate that the Elecsys® HBsAg II Qual assay exhibits the highest sensitivity among the commercial HBsAg screening assays, and demonstrate that its capacity to detect HBV infection is not compromised by HBsAg MHR mutants.

Hybrid sterility and evolution in Hawaiian Drosophila: differential gene and allele-specific expression analysis of backcross males.

The Hawaiian Drosophila are an iconic example of sequential colonization, adaptive radiation and speciation on islands. Genetic and phenotypic analysis of closely related species pairs that exhibit incomplete reproductive isolation can provide insights into the mechanisms of speciation. Drosophila silvestris from Hawai'i Island and Drosophila planitibia from Maui are two closely related allopatric Hawaiian picture-winged Drosophila that produce sterile F1 males but fertile F1 females, a pattern consistent with Haldane's rule. Backcrossing F1 hybrid females between these two species to parental species gives rise to recombinant males with three distinct sperm phenotypes despite a similar genomic background: motile sperm, no sperm (sterile), and immotile sperm. We found that these three reproductive morphologies of backcross hybrid males produce divergent gene expression profiles in testes, as measured with RNA sequencing. There were a total of 71 genes significantly differentially expressed between backcross males with no sperm compared with those backcross males with motile sperm and immotile sperm, but no significant differential gene expression between backcross males with motile sperm and backcross males with immotile sperm. All of these genes were underexpressed in males with no sperm, including a number of genes with previously known activities in adult testis. An allele-specific expression analysis showed overwhelmingly more cis-divergent than trans-divergent genes, with no significant difference in the ratio of cis- and trans-divergent genes among the sperm phenotypes. Overall, the results indicate that the regulation of gene expression involved in sperm production likely diverged relatively rapidly between these two closely related species.

Conjunctive use of models to design cost-effective ozone control strategies.

The management of tropospheric ozone (O3) is particularly difficult. The formulation of emission control strategies requires considerable information including: (1) emission inventories, (2) available control technologies, (3) meteorological data for critical design episodes, and (4) computer models that simulate atmospheric transport and chemistry. The simultaneous consideration of this information during control strategy design can be exceedingly difficult for a decision-maker. Traditional management approaches do not explicitly address cost minimization. This study presents a new approach for designing air quality management strategies; a simple air quality model is used conjunctively with a complex air quality model to obtain low-cost management strategies. A simple air quality model is used to identify potentially good solutions, and two heuristic methods are used to identify cost-effective control strategies using only a small number of simple air quality model simulations. Subsequently, the resulting strategies are verified and refined using a complex air quality model. The use of this approach may greatly reduce the number of complex air quality model runs that are required. An important component of this heuristic design framework is the use of the simple air quality model as a screening and exploratory tool. To achieve similar results with the simple and complex air

Application of genetic algorithms for the design of ozone control strategies.

Designing air quality management strategies is complicated by the difficulty in simultaneously considering large amounts of relevant data, sophisticated air quality models, competing design objectives, and unquantifiable issues. For many problems, mathematical optimization can be used to simplify the design process by identifying cost-effective solutions. Optimization applications for controlling nonlinearly reactive pollutants such as tropospheric ozone, however, have been lacking because of the difficulty in representing nonlinear chemistry in mathematical programming models. We discuss the use of genetic algorithms (GAs) as an alternative optimization approach for developing ozone control strategies. A GA formulation is described and demonstrated for an urban-scale ozone control problem in which controls are considered for thousands of pollutant sources simultaneously. A simple air quality model is integrated into the GA to represent ozone transport and chemistry. Variations of the GA formulation for multiobjective and chance-constrained optimization are also presented. The paper concludes with a discussion of the practically of using more sophisticated, regulatory-scale air quality models with the GA. We anticipate that such an approach will be practical in the near term for supporting regulatory decision-making.

Molecular characterisation and expression of a wound-inducible cDNA encoding a novel cinnamyl-alcohol dehydrogenase enzyme in lucerne (Medicago sativa L.)

A lucerne (alfalfa, Medicago sativa) stem cDNA library was screened with a cinnamyl-alcohol dehydrogenase (CAD) cDNA probe from tobacco (Nicotiana tabacum cv. Samsun). Two distinctly different cDNA clones (54% identical) were isolated and identified as putative CAD-encoding cDNAs by comparison of their nucleotide sequences with those of CAD-encoding DNA sequences from other plant species. One of the cDNAs, MsaCad2, was found to be 99.4% identical at the nucleotide level to the previously isolated lucerne cad cDNA which encodes a CAD isoform involved in lignin biosynthesis. The other cDNA, MsaCad1, has not been reported previously in lucerne, and encodes a protein related to the ELI3 class of elicitor-inducible defence-related plant proteins. The MsaCad1- and MsaCad2-encoded proteins were expressed in Escherichia coli and CAD1 was shown to be active with a range of cinnamyl, benzyl and aliphatic aldehyde substrates, while CAD2 was specific for the cinnamyl aldehydes only. Each of the respective genes is present as one or two copies. The MsaCad1 gene is expressed most actively in stem and floral tissue, whereas MsaCad2 is most actively expressed in stem, hypocotyl and root tissue. In stem tissue, expression of both genes occurs predominantly in internodes 4 and 5 (from the apex). MsaCad2, in contrast to MsaCad1, is not significantly expressed in the top three internodes of the stem. Both MsaCad1 and MsaCad2 are wound-inducible, and the wound-responsiveness of each gene is modulated by salicylic acid.

Thrombus precursor protein (TpP): marker of thrombosis early in the pathogenesis of myocardial infarction.

We have developed an enzyme-linked immunosorbent immunoassay for quantifying the immediate precursor proteins to intravascular thrombi. This thrombus precursor protein (TpP) assay identifies active thrombosis in several clinical conditions, including early myocardial infarction (MI). In a study of patients recruited for the GUSTO intervention study, MI patients had concentrations of TpP 4-20-fold that of controls; patients diagnosed without MI had concentrations similar to the control subjects. In a separate study of subjects presenting at the emergency room with chest pain, MI patients who presented early after the onset of chest pain had TpP concentrations significantly (P <0.01) higher than controls. Patients presenting late or diagnosed with other chest pain had concentrations within the reference range. The potential utility of the TpP assay as an aid for the diagnosis of thrombotic MI and other thrombotic conditions is described.

Molecular basis for heterogeneity of the human p53 protein.

The human p53 tumor antigen comprises several physically distinct proteins. Two p53 proteins, separable by polyacrylamide gel electrophoresis, are expressed by the human transformed cell line SV-80. The individual cDNAs which code for these proteins were isolated and constructed into the SP6 transcription vector. The proteins encoded by these clones were identified by in vitro transcription with the SP6 vector and translation in a cell-free system. p53-H-1 and p53-H-19 cDNA clones code for the faster- and slower-migrating p53 protein species, respectively, of SV-80. The in vitro-expressed proteins of p53-H-1 and p53-H-19 had the same antigenic determinants and were structurally indistinguishable from their in vivo counterparts. By expressing defined restricted cDNA fragments in vitro, the region of heterogeneity between the respective cDNAs was located at the 5' end of the cDNAs. Exchanging the 5' fragments of interest and expressing the chimeric clones in vitro confirmed that the DNA heterogeneity was responsible for the difference in the electrophoretic mobility of these proteins. The sequences of the two cDNAs revealed a single base pair difference (G versus C) in the coding region of the clones. This sequence difference resulted in an arginine being coded for in clone p53-H-1 and a proline being coded for at the equivalent position in clone p53-H-19. This variation accounted for the change in the electrophoretic mobility of the individual p53 protein species.

Immunologically distinct p53 molecules generated by alternative splicing.

Transfection of a functional cloned p53 gene into an L12 p53 nonproducer cell line efficiently reconstituted p53 expression. The p53 protein synthesized in these clones was indistinguishable from that occurring naturally in tumor cells. When a p53 cDNA clone was used instead, we observed that the L12-derived clones exhibited a distinct immunological profile. In the present experiments we compared the immunological epitopes of p53 proteins encoded by several full-length cDNA clones. Immunoprecipitation of p53 proteins generated by in vitro transcription and translation of the various cDNA clones indicated variations in the content of immunological epitopes. Basically, two p53 protein species were detected. Both species contained the same antigenic determinants except the PAb421-PAb122 site, which was present in proteins encoded by p53-M11 and pcD-p53, but not in the p53 protein encoded by the p53-M8 cDNA clone. Sequence analysis of the various cDNA clones indicated the existence of a 96-base-pair (bp) insert in clone p53-M8 as compared with clone p53-M11 or pCD-p53. The 96-bp insert contained a termination signal which caused the premature termination of the protein, leading to the generation of a p53 product 9 amino acids shorter than usual. The existence of this insert also accounted for the lack of the PAb421-PAb122 epitope which was mapped to the 3' end of the cDNA clone, following the 96-bp insert. This insert shared complete homology with the p53 intron 10 sequences mapping 96 bp upstream of the 5' acceptor splicing site of p53 exon 11. It was therefore concluded that the different cDNA clones represented p53 mRNA species which were generated by an alternative splicing mechanism. Differential hybridization of the mRNA population of transformed fibroblastic or lymphoid cells with either the 96-bp synthetic oligonucleotide or the p53-M11 cDNA indicated that the various mRNA species are expressed in vivo.

Failure of the N-oxodized metabolites of some carcinogenic amines to induce tumors in normal and wounded rat skin.

The skin of Osborne-Mendel and Sprague-Dawley rats was treated by repeated topical application of 1- and 2-naphthylamine, 4-biphenylamine and their corresponding N-arylhydroxylamine and nitroso derivatives for 52 weeks. In addition, the possibility of enhancing the susceptibility of the skin to the tumor induction by periodic wounding at the site of compound application was investigated in the Sprague-Dawley strain. The animals were observed for an additional year after which all survivors were sacrificed. No skin tumours were elicited in any of the rats although a small number of systemic tumors at sites distant from the area of application were observed in the Osborne-Mendel strain. No discernable increase in the sensitivity of the skin as a consequence of wounding to the carcinogenic effect of the compounds tested were observed.

Hypotensive activity of sodium nitroprusside and structurally related complexes of sodium pentacyanoamine ferrate with amylnitrite, butylnitrite and n-octylamine.

Complexes of sodium pentacyanoamine ferrate (TPF) with amylnitrite and with butylnitrite showed hypotensive activity equal to that of sodium nitroprusside, as tested intravenously, in unanesthetized , instrumented Rhesus, monkeys. The complex with n-octylamine, on the other hand, had significantly lower activity. These complexes produced only marginal hypotensive effects when administered orally in a dose of 10 mg/kg to spontaneously hypertensive rats.

The role of dog bladder mucosa in the N-oxidation of arylamines.

The in vitro metabolic N-oxidation of 1- and 1-napthylamine, 4-biphenylamine, 2-fluorenylamine and 3-dibenzolfuranylamine has been investigated with intact dog bladder, whole intact bladder mucosa and microsomes prepared from this tissue. Very low levels of metabolic N-oxidation of these carcinogenic amines were detected with these tissue preparations using ferrihemoglobin formation in dog erythrocytes. No N-oxidation by these tissue preparations was observed using gas-liquid chromatography. The concentrations of the N-oxidized metabolites observed in the urine of dogs in vivo exposed to thse amines suggests that N-oxidation takes place predominately in the liver and that the bladder plays, at most, a minor role in the formation of these presumed proximate urinary carcinogens.

Failure of ascrobic acid to inhibit the metabolic N-oxidation of the bladder carcingen 4-biphenylamine.

The effect of L-ascorbic acid on the in vivo metabolic N-oxidation of the bladder carcinogen 4-biphenylamine has been investigated in the dog. Gas chromatographic analysis of the urines of dogs receiving concomitant oral doses of L-ascorbic acid and 4-biphyenylamine showed no significant difference in the N-oxidized metabolites when compared to dogs receiving arylamine alone. The results indicate that pretreatment with large doses of L-ascorbic acid has no effect on the metabolic N-oxidation of 4-biphenylamine or on the urinary concentration of these metabolites. The failure of L-ascrobic acid to lower the urinary concentration of these presumed proximate urinary carcinogens casts doubt on its efficacy in bladder tumor prophylaxis.