Descriptive Analysis of Outcomes After Onlay Ventral Hernia Repair in Obese Patients.

OBJECTIVE: To determine outcomes after on lay large ventral hernia repair in obese patients. INTRODUCTION: Large ventral hernia repairs (VHR) in obese patients remain a challenge. Obesity is a risk factor for intraoperative difficulties and postoperative complications. Recurrence rates after VHR in obese patients range between 12-50% versus 10% in nonobese patients. While results of laparoscopic techniques in VHR compare favorably to open, outcomes in correlation with obesity, technique, and defect size are less understood. METHODS: A single surgeon's experience of 329 consecutive VHR between 2013-2022 was retrospectively reviewed. Inclusion criteria were obesity (BMI >30) and large hernia defects (>5 cm). A modified onlay technique was used which included component release and a lightweight monofilament polypropylene mesh. Primary outcome measures were hernia recurrence and wound complications. RESULTS: A total of 56 patients met inclusion criteria. Patients were majority male (n=30, 54%), with a median age of 58.5 years (inter quartile range (IQR) 33-83), and median BMI of 36 kg/m2 (IQR: 30-72). Median hernia defect size was 8 cm (IQR: 5-15). Twenty patients had undergone prior mesh repairs. Median follow-up was 52 months (IQR: 6 months-9 years). Two patients experienced recurrence (3.6%) and four experienced wound complications (four seromas, one panniculitis, 8.9%). No patients suffered flap ischemia or necrosis. CONCLUSION: Obesity is a risk factor for poor outcomes after VHR. We developed a protocol for obese patients with large defects involving a modified onlay technique which demonstrates comparable results to other VHR techniques in obese patients.

Behavioral and endocrine correlates of dominance in captive female Jackson's hartebeest (Alcelaphus buselaphus).

For species that form dominance hierarchies, such as group-living ungulates, aggressive interactions can pose a challenge to successful captive management. For example, Jackson's hartebeest (Alcelaphus buselaphus), a rare antelope of east Africa, can be difficult to maintain in captivity because aggression within female dominance hierarchies can lead to injury and death. We quantified behavioral and endocrine correlates of dominance in a captive herd of ten female hartebeest with the goal of understanding how to minimize dangerous interactions. We observed hartebeest for 18 months in a 4-ha enclosure on St. Catherines Island, Georgia. We quantified type of agonistic behavior, initiator and recipient of the behavior, who displaced whom, and age and relative size of participants. We also used fecal steroid analysis to take weekly measurements of corticoids, a hormonal correlate of stress. Hartebeest maintained a stable, linear dominance hierarchy. Only 5.9% of interactions were reversals of established rank. Most dominance interactions were low intensity, but 17.3% of interactions carried a high risk of injury (chase, horn butt, horn clash, horn clash on knees, and head push). High-ranking individuals usually initiated interactions. Most interactions were between animals of similar rank, and animals of intermediate rank participated in the highest number of interactions. The frequency of high-intensity interactions was unrelated to rank. Rank was correlated with age, but not size. There was no relationship between rank and fecal corticoid levels. Dominance interactions in hartebeest are not a function of social instability, and the frequency of dangerous interactions is not a function of rank.

Perineural bupivacaine injection reduces inguinodynia after inguinal hernia repair.

BACKGROUND: Inguinodynia, defined as pain lasting >3 months after inguinal hernia repair, remains the major complication of hernia operation. We sought to determine the effect of direct perineural infiltration on acute pain and inguinodynia after open inguinal hernia repair. METHODS: Patients who presented with an inguinal hernia at a university teaching hospital were evaluated prospectively and randomized to either (1) percutaneous ilioinguinal nerve block or (2) percutaneous ilioinguinal nerve block with additional perineural infiltration of the ilioinguinal, iliohypogastric, genitofemoral nerves. All patients in each group received a total of 12 mL of 0.5% bupivacaine. Self-reported faces of pain level (1-10), minutes to discharge from the recovery room, narcotic quantity consumed (oxycodone 5 mg/paracetamol 325 mg), days on narcotics, and incidence of inguinodynia at 3 months were all recorded. RESULTS: Ninety-two patients were randomized in the study. Patients who received perineural bupivacaine infiltration of nerves had less recovery room pain (1.3 vs 3.9, P < .001) and shorter recovery discharge times (89 vs 105 min, P = .047) and consumed fewer narcotics (9.7 vs 15.1 doses, P = .010). The incidence of inguinodynia at 3 months was less in the treatment group (8.2% vs 27.9%, P = .013). CONCLUSION: We have implemented a novel and inexpensive method of local nerve blockade that decreases pain immediately after operation and at 3 months postoperatively. Furthermore, our method leads to shorter recovery room stay and fewer narcotics after operation.

Variability in Spectral-Domain Optical Coherence Tomography over 4 Weeks by Age.

PURPOSE: To quantify variation in spectral-domain optical coherence tomography (SD-OCT) measures of total retinal thickness (top of inner limiting membrane to top of retinal pigment epithelium, RPE) and RPE thickness measures over a 4-week period and by age. METHODS: A total of 76 volunteers aged 40-85 years were seen at three visits over 4 weeks. Two Topcon SD-OCT scans were taken at each visit. Following grid re-centration, total retinal and RPE thickness were determined in nine subfields. Multilevel modeling was used to quantify variance between scans and by age. RESULTS: In the central circle, mean total retinal thickness was 237.9 µm (standard deviation, SD, 23.5 µm) and RPE thickness was 46.0 µm (SD 5.3 µm). Intraclass correlation coefficient in the central circle was 0.988 for total retinal thickness and 0.714 for RPE thickness. Pairwise measures taken within 4 weeks were strongly correlated (p > 0.95). Within-subject variation of total retinal thickness increased significantly with age. Subjects in the oldest age group had significantly increased among- and within-subject variability in measures of RPE thickness. CONCLUSIONS: Correlation between retinal thickness measures was very high (>0.95) over a period of 4 weeks with small changes likely due to variation in measurement. Increasing variability in total retinal and RPE thickness measures with age suggest that the use of more and/or higher quality images to calculate mean thickness to reduce variability may benefit the study of these measures in older persons. This may also impact sample size calculations for future studies of SD-OCT measures in older adults.

Retinal thickness measured by spectral-domain optical coherence tomography in eyes without retinal abnormalities: the Beaver Dam Eye Study.

PURPOSE: To examine relationships of age, sex, and systemic and ocular conditions with retinal thickness measured by spectral-domain ocular coherence tomography (SD OCT) in participants without retinal disease. DESIGN: Longitudinal study. METHODS: setting: Population-based cohort. study population: Persons aged 43-86 years living in Beaver Dam, Wisconsin in 1988-1990. observation procedures: Retinal thickness was measured via SD OCT at the Beaver Dam Eye Study examination in 2008-2010. Retinal disease was determined by ophthalmoscopy, fundus photography, or SD OCT. main outcome measures: Retinal thickness from the inner limiting membrane to the Bruch membrane. RESULTS: The retina was thickest in the inner circle (mean 334.5 µm) and thinnest in the center subfield (285.4 µm). Mean retinal thickness decreased with age in the inner circle (P < .0001) and outer circle (P < .0001). Adjusting for age, eyes in men had thicker retinas than eyes in women in the center subfield (P < .001) and inner circle (P < .001). Sex, axial length/corneal curvature ratio, and peak expiratory flow rate were associated with center subfield thickness. Sex and peak expiratory flow rate were associated with retinal thickness in the inner circle. Alcohol consumption, age, axial length/corneal curvature ratio, cataract surgery, ocular perfusion pressure, and peak expiratory flow rate were associated with retinal thickness in the outer circle. CONCLUSIONS: This study provides data for retinal thickness measures in eyes of individuals aged 63 years and older without retinal disease. This information may be useful for clinical trials involving the effects of interventions on retinal thickness and for comparisons with specific retinal diseases affecting the macula.

Effect of image compression and resolution on retinal vascular caliber.

PURPOSE: Changes in retinal vascular caliber measured from digital color fundus photographs have been independently associated with systemic outcomes in epidemiologic studies, but the effect of image resolution and compression on vascular measurements has not been previously evaluated. METHODS: To explore image compression, 40 natively digital fundus images were selected with good photo quality, high spatial resolution, and no previous image compression. Using Adobe Photoshop, these images were compressed at progressively higher levels up to 147:1, and then retinal vascular caliber was measured at each level using semiautomated software. To examine resolution, 40 fundus photographs acquired on high-resolution film were scanned with settings corresponding to 10, 7, 5, 3, and 1 megapixel fundus cameras. After adjusting for scale factor, vascular caliber was measured at each level of resolution. Data were analyzed by comparing the calculated central retinal arteriole equivalent (CRAE) and the central retinal venular equivalent (CRVE) of the original and altered images, using repeated measures ANOVA. RESULTS: CRAE became significantly wider with increasing levels of compression at the 25:1 threshold (~1 µm wider, P < 0.001) and was ~5 µm wider with 147:1 compression. CRVE also increased, but less than CRAE. Using 7 (megapixel)-MP resolution as the standard, CRVE was significantly narrower at the 5-MP simulation (~2 µm, P < 0.001) and was ~12 µm narrower at the 1-MP simulation. CRAE also decreased, but less than CRVE. CONCLUSIONS: Increasing digital image file compression and decreasing fundus image spatial resolution led to skewed measurements of the retinal vascular caliber.

Quality improvement pilot program for vulnerable elderly surgical patients.

The elderly are a growing surgical population with more comorbidities and less physiological reserve compared with nonelderly patients. The objective of our study was to implement a quality improvement pilot program targeting the specific needs of the elderly. We prospectively enrolled consecutive patients aged 65 years or older undergoing inpatient general or vascular surgery operations. Patients completed a preoperative assessment including the Vulnerable Elder Survey (VES) to determine baseline functional status and incidence of polypharmacy (five or more medications). They were interviewed postdischarge Day 2 and Day 30 for changes in functional status. An intervention was implemented consisting of an elderly-specific postoperative order set and preoperative risk reports sent to the surgical team with instructions to order physical therapy consults and home health nursing on discharge for VES 3 or greater and geriatrics consults for patients with polypharmacy. The elderly-specific order set was used for 71 per cent of the postintervention group. There were no differences in the percentage of participants receiving physical therapy, geriatric, or home health nursing consults between the two groups. The postintervention group had significantly better functional status on postdischarge Day 30 (P < 0.01). Our preliminary data suggest that individualizing care for elderly patients is feasible and may improve postoperative outcomes.

Suboptimal image focus broadens retinal vessel caliber measurement.

PURPOSE: Studies have used central retinal arteriolar (CRAE) and central retinal venular (CRVE) calibers, measured from images produced with computerized image analysis, to detect risk factors for systemic diseases. The authors explored suboptimal image focus as a possible contributing factor to artificially larger vascular caliber measurements. METHODS: From the reading center image collections, 30 digital retinal images were selected for optimum quality. Image analysis software was used to derive nine progressively blurred versions of the originals. IVAN measurement software was used to measure CRAE and CRVE in the original and the blurred series derived from them. To check the adequacy of the simulation, progressively defocused series of images were taken of several volunteers. RESULTS: For CRAE, each level of simulated blurring produced a statically significant increase in apparent vessel caliber from the original (P<0.01, Wilcoxon signed rank test). For an average CRAE of 160 µm, mean broadening with minimal/moderate/severe blurring was 3 µm/12 µm/33 µm. For CRVE, every blurring level beyond the first was found to be significant (P<0.01). From an average CRVE of 200 µm, mean broadening ranged from 0 to 11 µm with minimal to severe blurring. Analysis of the progressively defocused series taken of volunteers yielded similar results overall. CONCLUSIONS: Suboptimal focus can result in erroneously larger vessel caliber measurements. Slight blurring has a minimal effect, but more severe blurring has a progressively greater effect.

Acute small bowel perforation after wireless capsule endoscopy in a patient with Crohn's disease: a case report.

INTRODUCTION: Wireless capsule endoscopy is an important tool for minimally invasive evaluation of the small bowel, allowing improved diagnostic yield with low complication rates relative to traditional modalities. Recently however, reports on small bowel perforation after wireless capsule endoscopy have surfaced. Here we present the first case of acute small bowel perforation in a middle-aged male in the United States. CASE PRESENTATION: A 58-year-old male with a presumed quiescent history of Crohn's Disease presented to the Emergency Department in a septic state 48 hours after a wireless capsule endoscopy procedure complaining of abdominal pain, distension, and frequent emesis. A computed tomography scan of the abdomen was suggestive of small bowel perforation and ischemic enteritis. The patient was adequately resuscitated and taken to the operating room for an ileocecectomy and extensive resection of the small bowel. Pathology of the resected specimen revealed an ileal stricture and associated necrotizing ileitis, and a perforation just proximal to the stricture. CONCLUSION: Wireless capsule endoscopy remains the preferred endoscopic imaging method of the small bowel. This case illustrates the importance of appropriate patient selection and evaluation of functional patency of the small bowel prior to wireless capsule endoscopy, especially with the growing role of this procedure in the evaluation of inflammatory bowel disease.

Diagnosis and management of ST elevation myocardial infarction: a review of the recent literature and practice guidelines.

There is a large volume of literature available to guide the peri-infarct management of ST elevation myocardial infarction (STEMI). Most of this literature focuses on improving the availability and efficacy of reperfusion therapy. The purpose of this article is to review contemporary scientific evidence and guideline recommendations regarding the diagnosis and therapy of STEMI. Studies and epidemiological data were identified using Medline, the Cochrane Database, and an Internet search engine. Medline was searched for landmark and recent publications using the following key words: STEMI, guidelines, epidemiology, reperfusion, fibrinolytics, percutaneous coronary intervention (PCI), facilitated PCI, transfer, delay, clopidogrel, glycoprotein IIb/IIIa, low-molecular-weight heparin (LMWH), beta-blockers, nitrates, and angiotensin-converting enzyme (ACE) inhibitors. The data accessed indicate that urgent reperfusion with either fibrinolytics or percutaneous intervention should be considered for every patient having symptoms of myocardial infarction with ST segment elevation or a bundle branch block. The utility of combined mechanical and pharmacological reperfusion is currently under investigation. Ancillary treatments may utilize clopidogrel, glycoprotein IIb/IIIa inhibitors, or low molecular weight heparin, depending on the primary reperfusion strategy used. Comprehensive clinical practice guidelines incorporate much of the available contemporary evidence, and are important resources for the evidence-based management of STEMI.

The Santa Monica crash: an urban multicasualty event.

Mass casualty events provide dramatic challenges for trauma centers and trauma systems. We analyzed the management of victims and assessed the response of the UCLA Healthcare System to the Santa Monica multicasualty event of July 16, 2003, when an elderly man drove his car through a crowded outdoor market and injured 73 people, 10 of whom died (eight at the scene). Of the victims, 26 were treated at UCLA (n = 15) and Santa Monica (n = 11) Medical Centers. Fourteen patients (54%) were female; average age was 41.9 years (range 7 months to 88 years). Fifteen patients were treated in the ER only, and 11 patients required admission. Of the latter, 10 (91%) had multisystem injuries, most commonly musculoskeletal, which occurred in nine patients (82%). Seven patients required immediate operations (orthopedic in six and a pericardial window in one). Three patients required delayed operations (orthopedic and plastic surgery). Most surgical and medical specialties were needed in consultation. Average LOH was 11.8 (range 2-23) days. Mean ISS was 21.2 (range 1-75). There were six complications (three early and three late) and one death from head injury. Seven patients (64%) required rehabilitation. We conclude that mass casualty victims have multisystem injuries of variable severity, which underscores the importance of trauma centers and trauma systems. The large trauma scene and particular need for orthopedic services were notable features of this event.

CP-346086: an MTP inhibitor that lowers plasma cholesterol and triglycerides in experimental animals and in humans.

A microsomal triglyceride transfer protein (MTP) inhibitor, CP-346086, was identified that inhibited both human and rodent MTP activity [concentration giving half-maximal inhibition (IC50) 2.0 nM]. In Hep-G2 cells, CP-346086 inhibited apolipoprotein B (apoB) and triglyceride secretion (IC50 2.6 nM) without affecting apoA-I secretion or lipid synthesis. When administered orally to rats or mice, CP-346086 lowered plasma triglycerides [dose giving 30% triglyceride lowering (ED30) 1.3 mg/kg] 2 h after a single dose. Coadministration with Tyloxapol demonstrated that triglyceride lowering was due to inhibition of hepatic and intestinal triglyceride secretion. A 2 week treatment with CP-346086 lowered total, VLDL, and LDL cholesterol and triglycerides dose dependently with 23%, 33%, 75%, and 62% reductions at 10 mg/kg/day. In these animals, MTP inhibition resulted in increased liver and intestinal triglycerides when CP-346086 was administered with food. When dosed away from meals, however, only hepatic triglycerides were increased. When administered as a single oral dose to healthy human volunteers, CP-346086 reduced plasma triglycerides and VLDL cholesterol dose dependently with ED50s of 10 mg and 3 mg, and maximal inhibition (100 mg) of 66% and 87% when measured 4 h after treatment. After a 2 week treatment (30 mg/day), CP-346086 reduced total and LDL cholesterol and triglycerides by 47%, 72%, and 75%, relative to either individual baselines or placebo, with little change in HDL cholesterol. Together, these data support further evaluation of CP-346086 in hyperlipidemia.

Outcomes from peptic ulcer surgery have not benefited from advances in medical therapy.

Given the advancements in medical treatment of peptic ulcer disease such as Helicobacter pylori eradication and proton-pump inhibitors, we sought to assess their impact on the need for surgical intervention. Patients who underwent peptic ulcer surgery between 1981 and 1998 were evaluated in a retrospective chart review from a tertiary-care hospital (n = 222). The number of operations performed for peptic ulcers decreased annually (24 vs 11.3). Seventy-seven per cent of all cases were done urgently; most were performed for acute perforated ulcers. The overall 30-day mortality rate was 13 per cent, which remained unchanged over the past two decades. The highest mortality rate (82%) was in the transplanted population (n = 11). Our institutional experience demonstrates that despite the lower volume of patients requiring operative management a greater percentage of these patients are presenting with urgent need for surgery. Also despite the aggressive endoscopic management of acutely bleeding ulcers there was no change in the percentage of patients taken to the operating room for uncontrollable hemorrhage. Improvements in medical management of peptic ulcer disease have decreased the surgical volume; nevertheless we show a rising proportion of urgent operations performed annually, and mortality remains high.

Human cytokine levels in nonperforated versus perforated appendicitis: molecular serum markers for extent of disease?

Appendicitis is a common surgical problem that is associated with a systemic inflammatory response. Previous studies have shown that cytokines are activated early in acute inflammation and sepsis and may serve as indicators of clinical severity. In this study we examined the role of cytokines as serum markers to distinguish nonperforated versus perforated appendicitis. Patients with the presumptive diagnosis of appendicitis had serum drawn preoperatively. Only patients (n = 59) with an intraoperative diagnosis of nonperforated (n = 34) and perforated (n = 25) appendicitis had serum drawn 12 hours postoperatively. Diagnosis was later confirmed by pathologic examination. The serum specimens were batch analyzed using enzyme-linked immunosorbent assays specific for interleukin (IL)-1beta, IL-2, IL-6, IL-8, and IL-10. Serum from normal healthy subjects served as control specimens (n = 9). Patients in the nonperforated and perforated groups were similar with regard to age, gender, race, white blood cell count, and fever. All cytokine levels including preoperative, postoperative, nonperforated, and perforated were higher in patients with appendicitis as compared with controls. IL-1beta, IL-2, and IL-10 levels were not different between groups with appendicitis. Preoperative serum levels of IL-6 (P = 0.036) and IL-8 (P = 0.047) were higher in patients with perforated versus nonperforated appendicitis. In addition postoperative serum levels of IL-6 (P = 0.0001) remained higher in the perforated group versus the nonperforated group. Serum levels of IL-6 and IL-8 may have a role in discerning the extent of disease in this condition. This initial step in systemically studying the role of cytokines in this disease may ultimately lead to the development of molecular indicators to aid in diagnosis and differentiate appendicitis from other conditions.