Operative management of non-elective incisional hernia reduces readmission in a national database.

PURPOSE: The aim of this project was to compare patient characteristics, overall efficacy, and readmission events following operative vs non-operative management modalities of non-elective patients presenting with symptomatic incisional hernias. METHODS: This study is a retrospective study of patients and patient demographics that presented as non-elective hospitalizations with symptomatic incisional hernia. Analysis of patients and characteristics utilized the National Readmission Database from 2010 to Q3 of 2015, delineating patient factors and outcomes following operative or non-operative management of hernias. RESULTS: A total of 14,137 patients met inclusion criteria for our study. The majority of patients were treated operatively rather than non-operatively (79 vs. 21%) on their non-elective admission for incisional hernia. Those undergoing surgical management were younger (56 vs 61 years, p < 0.01), we more often of male gender (69 vs 64%, p < 0.01), and had fewer comorbidities (1.92 vs 2.97, p < 0.01) and chronic conditions (0.45 vs 2.68, p < 0.01). Patients managed operatively had a significantly lower readmission rate when compared to patients managed non-operatively (6.6 vs 14.3%, p < 0.01). However, non-operative management was associated with a shorter length of stay (3 vs 4 days, p < 0.01). Of patients who were initially medically managed and had to be readmitted, a further 61% underwent surgical treatment on their readmission. CONCLUSION: In this nationwide study, patients with non-elective admissions for incisional hernia were mostly managed surgically. Those managed operatively had lower rates of readmission when compared to non-operative management. Initial non-operative management was associated with a shorter length of stay and a lower cost to the patient. The results of this study support operative management of symptomatic incisional hernia.

CDC field triage criteria accurately predicts outcomes in high impact trauma.

BACKGROUND: The precision of emergency medical services (EMS) triage criteria dictates whether an injured patient receives appropriate care. The trauma triage protocol is a decision scheme that groups patients into triage categories of major, moderate and minor. We hypothesized that there is a difference between trauma triage category and injury severity score (ISS). METHODS: This retrospective, observational study was conducted to investigate a difference between trauma triage category and ISS. Bivariate analysis was used to test for differences between the subgroup means. The differences between the group means on each measure were analyzed for direction and statistical significance using ANOVA for continuous variables and chi square tests for categorical variables. Logistic and linear regressions were performed to evaluate factors predicting mortality, ICU length of stay. RESULTS: With respect to trauma triage category, our findings indicate that minor and moderate triage categories are similar with respect to ISS, GCS, ICU LOS, hospital LOS, and mortality. However, after excluding for low impact injuries (falls), differences between the minor and moderate categories were evident when comparing to ISS, GCS, ICU LOS, and hospital LOS. Additionally, after excluding for low impact injures, ISS, ICU LOS, and hospital stay were found to correlate well with trauma triage category. CONCLUSIONS: In this retrospective, observational study significant differences were not seen when comparing ISS with the trauma triage categories of moderate and minor during our initial analysis. However, a difference was found after excluding for low impact injuries. These findings suggest that CDC criteria accurately predicts outcomes in high impact trauma.

Surgical and non-surgical treatment of inguinal hernia during non-elective admissions in the Nationwide Readmissions Database.

INTRODUCTION: Inguinal hernia repair is one of the most common surgical operations, yet the optimal treatment strategy remains undefined. Treatment of symptomatic inguinal hernias include both surgical and non-surgical approaches. The objective of this study was to determine differences in population, readmission rates, and costs between operative and non-operative approaches for patients admitted non-electively for an inguinal hernia in a national dataset. In addition, we sought to define the baseline characteristics of the two groups and identify potential predictive factors in the non-surgically managed subgroup who were readmitted and treated operatively within 90 days of their first visit. METHODS: This study was a retrospective review of data from the Nationwide Readmissions Database (NRD) from 2010 to 2014. Patients above age 18 who were admitted non-electively for a primary diagnosis of inguinal hernia were included. Patients whose length of stay was < 1% or > 95% percentile or died during the initial visit were excluded. Readmissions within 90 days of the initial visit were flagged. Patients were classified according to initial management strategy: operative versus non-operative. Demographic, clinical, and organizational characteristics were compared between the two cohorts. RESULTS: 14,249 patients met inclusion criteria and were operative (n = 8996, 63.13%) and non-operative (n = 5255, 36.88%) cohorts. When comparing the two groups, readmission rate was lower (0.49% for surgical, 1.78% for non-surgical, p < 0.01), mean length of stay (LOS) longer (3.27 [SE = 0.05] days for surgical, 2.76 days [SE = 0.06] for non-surgical, p < 0.01), and mean total cost higher ($9597 for surgical, $7167 for non-surgical, p < 0.01) in surgically treated patients. The non-surgical population was on average older (63.05 years for surgical, 64.52 years for non-surgical, p < 0.01) with more chronic conditions (3.57 for surgical, 4.05 for non-surgical, p < 0.01). Of the patients initially managed non-surgically, 1.78% (n = 91) were readmitted, and of them, 62.63% (n = 57) were readmitted and managed surgically within 90 days of initial admission (i.e., crossed over from watchful waiting to surgical treatment). Average number of chronic conditions (3.79 versus 4.03, p = 0.74), average number of comorbidities (2.26 versus 2.18, p = 0.87), and average total number of ICD-9 discharge codes (7.44 versus 8.23 p = 0.54 did not differ significantly between the operative versus non-operative sample of the readmitted population. The total cost ($5562.38 versus $8737.28, p = 0.01) was greater in the operative versus non-operative sample. CONCLUSION: Watchful-waiting strategy is the most common treatment approach in patients admitted non-electively for symptomatic inguinal hernia. Readmission after non-elective hospitalization for inguinal hernia is rare, but surgical intervention decreased the likelihood of readmission compared to non-operative management, while also increasing LOS and cost of care. Our data supports a patient centric approach to the management; non-surgical treatment is a viable temporary option even in symptomatic inguinal hernias, while surgical treatment may reduce the likelihood of future readmission.

Economic valuation of environmental benefits of removing pharmaceutical and personal care products from WWTP effluents by ozonation.

Continuous release of pharmaceutical and personal care products (PPCPs) present in effluents from wastewater treatment plants (WWTPs) is nowadays leading to the adoption of specific measures within the framework of the Directive 2000/60/EC (Water Framework Directive). The ozonation process, normally employed for drinking water production, has also proven its potential to eliminate PPCPs from secondary effluents in spite of their low concentrations. However, there is a significant drawback related with the costs associated with its implementation. This lack of studies is especially pronounced regarding the economic valuation of the environmental benefits associated to avoid the discharge of these pollutants into water bodies. For the first time the shadow prices of 5 PPCPs which are ethynilestradiol, sulfamethoxazole, diclofenac, tonalide and galaxolide from treated effluent using a pilot-scale ozonation reactor have been estimated. From non-sensitive areas their values are -73.73; -34.95; -42.20; -10.98; and -8.67 respectively and expressed in €/kg. They represent a proxy to the economic value of the environmental benefits arisen from undischarged pollutants. This paper contributes to value the environmental benefits of implementing post-treatment processes aimed to achieve the quality standards required by the Priority Substances Directive.

A knowledge management methodology for the integrated assessment of WWTP configurations during conceptual design.

The current complexity involved in wastewater management projects is arising as the XXI century sets new challenges leading towards a more integrated plant design. In this context, the growing number of innovative technologies, stricter legislation and the development of new methodological approaches make it difficult to design appropriate flow schemes for new wastewater projects. Thus, new tools are needed for the wastewater treatment plant (WWTP) conceptual design using integrated assessment methods in order to include different types of objectives at the same time i.e. environmental, economical, technical, and legal. Previous experiences used the decision support system (DSS) methodology to handle the specific issues related to wastewater management, for example, the design of treatment facilities for small communities. However, tools developed for addressing the whole treatment process independently of the plant size, capable of integrating knowledge from many different areas, including both conventional and innovative technologies are not available. Therefore, the aim of this paper is to present and describe an innovative knowledge-based methodology that handles the conceptual design of WWTP process flow-diagrams (PFDs), satisfying a vast number of different criteria. This global approach is based on a hierarchy of decisions that uses the information contained in knowledge bases (KBs) with the aim of automating the generation of suitable WWTP configurations for a specific scenario. Expert interviews, legislation, specialized literature and engineering experience have been integrated within the different KBs, which indeed constitute one of the main highlights of this work. Therefore, the methodology is presented as a valuable tool which provides customized PFD for each specific case, taking into account process unit interactions and the user specified requirements and objectives.

Assessment of wastewater treatment plant design for small communities: environmental and economic aspects.

The preliminary design and economic assessment of small wastewater treatment plants (less than 2000 population equivalent) are issues of particular interest since wastewaters from most of these agglomerations are not covered yet. This work aims to assess nine different technologies set-up for the secondary treatment in such type of facilities embracing both economic and environmental parameters. The main novelty of this work is the combination of an innovative environmental decision support system (EDSS) with a pioneer approach based on the inclusion of the environmental benefits derived from wastewater treatment. The integration of methodologies based on cost-benefit analysis tools with the vast amount of knowledge from treatment technologies contained in the EDSS was applied in nine scenarios comprising different wastewater characteristics and reuse options. Hence, a useful economic feasibility indicator is obtained for each technology including internal and external costs and, for the first time, benefits associated with the environmental damage avoided. This new methodology proved to be crucial for supporting the decision process, contributing to improve the sustainability of new treatment facilities and allows the selection of the most feasible technologies of a wide set of possibilities.

In vitro - in vivo correlation of gene expression alterations induced by liver carcinogens.

Although cultivated hepatocytes are widely used in the studies of drug metabolism, their application in toxicogenomics is considered as problematic, because previous studies have reported only little overlap between chemically induced gene expression alterations in liver in vivo and in cultivated hepatocytes. Here, we identified 22 genes that were altered in livers of rats after oral administration of the liver carcinogens aflatoxin B1 (AB1), 2-nitrofluorene (2-NF), methapyrilene (MP) or piperonyl-butoxide (PBO). The functions of the 22 genes have been classified into two groups. Genes related to stress response, DNA repair or metabolism and genes associated with cell proliferation, respectively. Next, rat hepatocyte sandwich cultures were exposed to AB1, 2-NF, MP or PBO for 24h and expression of the above mentioned genes was determined by RT-qPCR. Significant correlations between the degree of gene expression alterations in vivo and in vitro were obtained for the stress, DNA repair and metabolism associated genes at concentrations covering a range from cytotoxic concentrations to non-toxic/in vivo relevant concentrations. In contrast to the stress associated genes, no significant in vivo/in vitro correlation was obtained for the genes associated with cell proliferation. To understand the reason of this discrepancy, we compared replacement proliferation in vivo and in vitro. While hepatocytes in vivo, killed after administration of hepatotoxic compounds, are rapidly replaced by proliferating surviving cells, in vitro no replacement proliferation as evidenced by BrdU incorporation was observed after washing out hepatotoxic concentrations of MP. In conclusion, there is a good correlation between gene expression alterations induced by liver carcinogens in vivo and in cultivated hepatocytes. However, it should be considered that cultivated primary hepatocytes do not show replacement proliferation explaining the in vivo/in vitro discrepancy concerning proliferation associated genes.

Fate and removal of permethrin by conventional activated sludge treatment.

The fate and removal of permethrin during conventional wastewater treatment were evaluated at pilot-plant scale at different concentrations of mixed liquor suspended solids (MLSS) and, hence, different solids retention times (SRT). At feed concentrations of 0.26-0.86 microg L(-1), the permethrin was removed by primary treatment at an efficiency rate of 37%, similar to previously reported data, and from 40% to 83% for secondary treatment, decreasing with decreasing SRT. Comparable ranges, from 37% up to 98%, have been reported for micropollutants with similar physicochemical properties to permethrin, such as galaxolide and tonalide. Little difference in removal was noted between the medium and low MLSS concentrations trials, the main difference in treated effluent permethrin concentration arising on changing from high to medium MLSS levels. This was attributed to the limited acclimatization period employed in these two trials, leading to higher levels of soluble organic matter in the treated water, with which the permethrin appeared to be associated.

Comparison of PPCPs removal on a parallel-operated MBR and AS system and evaluation of effluent post-treatment on vertical flow reed beds.

The presence in the aquatic environment of xenobiotics such as Pharmaceutical and Personal Care Products (PPCPs) has emerged as an issue of concern. Upgrading sewage treatment quality with modern technologies such as Membrane Bioreactors (MBRs) and/or implementing a further posttreatment might mitigate the release of xenobiotics into surface waters. The performance of two processes treating municipal sewage, a MBR and an Activated Sludge (AS) unit, have been compared in terms of PPCPs removal. Moreover, their effluents were treated using vertical flow reed beds. Both systems were operated under similar conditions, more specifically Hydraulic Retention Time (HRT), maintained at 8 hours, and Sludge Retention Time (SRT) set at 6 and 20 days. Pharmaceuticals belong to therapeutic groups such as antiepileptics (carbamazepine) and analgesics (ibuprofen, naproxen, diclofenac), whereas the personal care products are musk fragrances (galaxolide and tonalide). Xenobiotics removals achieved in the MBR showed better results, particularly for the acidic drugs ibuprofen (87% vs. 50%) and naproxen (56% vs. 6%) operating at low SRT. After filtration through vertical flow reed-beds, PPCPs content in effluents was decreased, below 1 ppb in most cases, improving the effluent quality and confirming reed-beds as an interesting low cost alternative in order to attenuate xenobiotics contamination.

Poor design of local exhaust hood leads to radioactive release in the work area.

At a U.S. Department of Energy (DOE) waste handling facility, transuranic waste contained in standard 208-L (55-gallon) drums was being prepared to meet the DOE's Waste Isolation Pilot Project Waste Acceptance Criteria. During a particular waste handling operation, it was necessary for the workers to open several 208-L drums with TRU waste and prepare the waste to meet the WIPP Waste Acceptance Criteria. This operation was performed while the waste drums where positioned adjacent to a drum ventilator, which was designed to capture emissions generated from the drums during waste handling activities. During this activity, the continuous air monitor alarmed and reached an instantaneous air concentration of 0.1 Bq m(-3), or a factor of 300 times higher than the derived air concentration for inhalation class W 239Pu. The DOE conducted an investigation to determine why the drum ventilator did not control the transuranic emissions and to evaluate possible improvements to the drum ventilator and exposure controls. By adding upper and lower flanges to the drum ventilator, the capture velocity was increased by 88% without increasing the fan's speed. Adding flanges is a simple and inexpensive modification that enhances the performance of the drum ventilator. In addition to a poor design, the drum ventilator's capture velocity was compromised by competing air velocities that were generated by waste handling activities.

Measurements of the bulk, C-axis electromechanical coupling constant as a function of AlN film quality.

Piezoelectric thin film AlN has great potential for on-chip devices such as thin-film resonator (TFR)-based bandpass filters. The AlN electromechanical coupling constant, K(2), is an important material parameter that determines the maximum possible bandwidth for bandpass filters. Using a previously published extraction technique, the bulk c-axis electromechanical coupling constant was measured as a function of the AlN X-ray diffraction rocking curve [full width at half maximum (FWHM)]. For FWHM values of less than approximately 4 degrees , K (2) saturates at approximately 6.5%, equivalent to the value for epitaxial AlN. For FWHM values >4 degrees , K(2) gradually decreases to approximately 2.5% at a FWHM of 7.5 degrees . These results indicate that the maximum possible bandwidth for TFR-based bandpass filters using polycrystalline AlN is approximately 80 MHz and that, for 60-MHz bandwidth PCS applications, an AlN film quality of >5.5 degrees FWHM is required.

[Immunomodulation of recurrent urinary tract infections with Urvakol vaccine]. / Imunomodulace recidivujících uroinfekcí vakcínou URVAKOL.

The authors present the results of the URVAKOL vaccine use in clinical practice. The vaccine was administered in the treatment of recurrent cystitis, persistent lower urinary tract infection, chronic pyelonephritis and prostatovesiculitis. The clinical efficacy of the vaccine was assessed by detection of bacteria and leukocytes in the urine, subjective complaints, skin tests and the assessment of selected specific and nonspecific immunity parameters in the urine and saliva. Significantly positive clinical and laboratory responses were observed in patients with uncomplicated cystitis. In the group of persistent urinary tract infections excellent responses were detected in one half of the patients. The remainder half stated disappearance of subjective complaints, but with persistence of pyuria or bacteriuria. Similar results of "improvement" were observed in 10 patients with chronic pyelonephritis. There were no changes of the clinical state observed in patients with chronic prostatitis. (Tab. 5, Fig. 2, Ref. 7.)

Electromechanical coupling constant extraction of thin-film piezoelectric materials using a bulk acoustic wave resonator.

Thin-film piezoelectric materials such as ZnO and AlN have great potential for on-chip devices such as filters, actuators and sensors. The electromechanical coupling constant is an important material parameter which determines the piezoelectric response of these films. This paper presents a technique based on the Butterworth Van-Dyke (BVD) model which, together with a simple one-mask over-moded resonator, can be used to extract the bulk, one-dimensional electromechanical coupling constant K(2) of any piezoelectrically active thin-film. The BVD model is used to explicitly define the series resonance, parallel resonance, and quality factor Q of any given resonating mode. Common methods of defining the series resonance, parallel resonance, and Q are shown to be inaccurate for low coupling, lossy resonators such as the over-moded resonator. Specifically, an electromechanical coupling constant K(2) of (2.6+/-0.1)% was measured for an (002) c-axis textured AlN film with an X-ray diffraction rocking curve of 7.5 degrees using the BVD based extraction technique.

[Surgical treatment of hydronephrosis]. / K moznostem operacního resení hydronefróz.

The objective of the study was to find the most suitable method of surgery of primary hydronephrosis and congestive horseshoe kidney, based on the authors own experience. The result was the finding that plastic resection operations according to Anderson-Hynes and flap operations in long stenoses and horseshoe kidneys meet the demands which are the prerequisite of favourable therapeutic results.