Endoscopic repair of primary versus recurrent male unilateral inguinal hernias: Are there differences in the outcome?

Introduction

To date, there are no prospective randomized studies that compare the outcome of endoscopic repair of primary versus recurrent inguinal hernias. It is therefore now attempted to answer that key question on the basis of registry data.

Patients and methods

In total, 20,624 patients were enrolled between September 1, 2009, and April 31, 2013. Of these patients, 18,142 (88.0 %) had a primary and 2482 (12.0 %) had a recurrent endoscopic repair. Only patients with male unilateral inguinal hernia and with a 1-year follow-up were included. The dependent variables were intra- and postoperative complications, reoperations, recurrence, and chronic pain rates. The results of unadjusted analyses were verified via multivariable analyses.

Results

Unadjusted analysis did not reveal any significant differences in the intraoperative complications (1.28 vs 1.33 %; p = 0.849); however, there were significant differences in the postoperative complications (3.20 vs 4.03 %; p = 0.036), the reoperation rate due to complications (0.84 vs 1.33 %; p = 0.023), pain at rest (4.08 vs 6.16 %; p < 0.001), pain on exertion (8.03 vs 11.44 %; p < 0.001), chronic pain requiring treatment (2.31 vs 3.83 %; p < 0.001), and the recurrence rates (0.94 vs 1.45 %; p = 0.0023). Multivariable analysis confirmed the significant impact of endoscopic repair of recurrent hernia on the outcome.

Conclusion

Comparison of perioperative and 1-year outcome for endoscopic repair of primary versus recurrent male unilateral inguinal hernia showed significant differences to the disadvantage of the recurrent operation. Therefore, endoscopic repair of recurrent inguinal hernias calls for particular competence on the part of the hernia surgeon.

Do we need antibiotic prophylaxis in endoscopic inguinal hernia repair? Results of the Herniamed Registry

Introduction

The use of antibiotic prophylaxis in inguinal hernia repair is a controversial issue. Accepted randomized controlled trials or registry data with specific analysis of endoscopic repaired patients do not exist.

Patient and methods

The data presented in this study compared the prospectively collected data from the Herniamed Registry on all patients who had undergone unilateral, bilateral or recurrent repair of inguinal hernias using either endoscopic or open techniques between September 1, 2009, and March 5, 2014. In total, 85,033 patients were enrolled. Of these patients, 48,201 (56.7 %) had an endoscopic and 36,832 (43.3 %) an open repair. The target variables analyzed were impaired wound healing and deep infections with mesh involvement within 30 days after the operation.

Results

Analysis of the patient group with endoscopic/laparoscopic inguinal hernia repair (n = 48,201) did not identify any significant influence of antibiotic prophylaxis on postoperative impaired wound healing, which occurred in 53 cases (p = 0.6431). Nor was it possible to identify any significant impact of antibiotic prophylaxis on the deep infections seen in 27 cases (p = 0.8409). Analysis of the open inguinal hernia repair group revealed that, unlike the laparoscopic/endoscopic group, antibiotic prophylaxis had a significant impact on the postoperative impaired wound healing and deep infection rates. The risk of postoperative impaired wound healing with antibiotic prophylaxis was significantly lower [OR 0.677 (0.479; 0.958), p = 0.027].

Conclusion

The positive impact of the endoscopic/laparoscopic technique on avoidance of impaired wound healing and deep infections with mesh involvement is already so great that antibiotic prophylaxis has no additional benefit. In contrast, antibiotic prophylaxis should be administered for open inguinal hernia repair.

Comparison of eleven commercially available rapid tests for detection of Bacillus anthracis, Francisella tularensis and Yersinia pestis

Yersinia pestis, Bacillus anthracis and Francisella tularensis cause serious zoonotic diseases and have the potential to cause high morbidity and mortality in humans. In case of natural outbreaks and deliberate or accidental release of these pathogens rapid detection of the bacteria is crucial for limitation of negative effects of the release. In the present study, we evaluated 11 commercially available rapid test kits for the detection of Y. pestis, B. anthracis and F. tularensis in terms of sensitivity, specificity and simplicity of the procedure. The results revealed that rapid and easy-to-perform lateral flow assays for detection of highly pathogenic bacteria have very limited sensitivity. In contrast, the immunofiltration assays showed high sensitivity but limited specificity and required a too complicated procedure to be applied in the field by nonlaboratory workers (e.g. First Responders like fire, police and emergency medical personnel). Each sample - whether tested negative or positive by the rapid tests - should be retested in a reference laboratory using validated methods.

SIGNIFICANCE AND IMPACT OF THE STUDY

Rapid detection of highly pathogenic bacteria causing anthrax, plague and tularemia is crucial for the limitation of negative effects of a potential release (natural, accidental or deliberate). In the study, commercially available rapid tests for detection of Bacillus anthracis, Yersinia pestis and Francisella tularensis were investigated in terms of sensitivity, specificity and ease-to-perform. The study showed problems which could be faced during testing and results interpretation. Conclusions from this study should be helpful not only in selection of the most appropriate test for particular group of First Responders but also in undertaking decisions in situation of a contamination suspicion which have high social and economical impacts.

Nonideal effects in electroacoustics of solutions of charged particles: combined experimental and theoretical analysis from simple electrolytes to small nanoparticles

The electric signal induced by an ultrasonic wave in aqueous solutions of charged species is measured and modeled without any adjustable parameter.

Benefits of a European project on diagnostics of highly pathogenic agents and assessment of potential "dual use" issues

Quality assurance exercises and networking on the detection of highly infectious pathogens (QUANDHIP) is a joint action initiative set up in 2011 that has successfully unified the primary objectives of the European Network on Highly Pathogenic Bacteria (ENHPB) and of P4-laboratories (ENP4-Lab) both of which aimed to improve the efficiency, effectiveness, and response capabilities of laboratories directed at protecting the health of European citizens against high consequence bacteria and viruses of significant public health concern. Both networks have established a common collaborative consortium of 37 nationally and internationally recognized institutions with laboratory facilities from 22 European countries. The specific objectives and achievements include the initiation and establishment of a recognized and acceptable quality assurance scheme, including practical external quality assurance exercises, comprising living agents, that aims to improve laboratory performance, accuracy, and detection capabilities in support of patient management and public health responses; recognized training schemes for diagnostics and handling of highly pathogenic agents; international repositories comprising highly pathogenic bacteria and viruses for the development of standardized reference material; a standardized and transparent Biosafety and Biosecurity strategy protecting healthcare personnel and the community in dealing with high consequence pathogens; the design and organization of response capabilities dealing with cross-border events with highly infectious pathogens including the consideration of diagnostic capabilities of individual European laboratories. The project tackled several sensitive issues regarding Biosafety, Biosecurity and "dual use" concerns. The article will give an overview of the project outcomes and discuss the assessment of potential "dual use" issues.

Lack of p38 MAP Kinase Activation in TRAIL-Resistant Cells is Not Related to the Resistance to TRAIL-Mediated Cell Death

Activation of MAP kinases is involved in various cellular processes, including immunoregulation, inflammation, cell growth, cell differentiation, and cell death. To investigate the role of p38 MAP kinase activation in the signaling pathway of TRAIL-mediated apoptosis, we compared TRAIL-mediated MAP kinase activation in TRAIL-susceptible human colon cancer cell line DLD1 and TRAIL-resistant DLD1/TRAIL-R cells. TRAIL-mediated activation of ERK occurred in both cell lines. In contrast, both DLD1 and DLD1/TRAIL-R cells showed no obvious JNK activation after treatment with TRAIL. Interestingly, TRAIL-mediated activation of p38 MAP kinases was observed in DLD1 cells but not in DLD1/TRAIL-R cells. However, activation of p38 MAP kinases was observed in both DLD1 and DLD1/TRAIL-R cells after treatment with anisomycin. Furthermore, inhibiting activated p38 MAP kinases with known inhibitors or with an adenovector expressing dominant negative p38alpha did not block TRAIL-mediated cell death in DLD1 cells. Moreover, activation of p38 MAP kinases by adenovectors expressing constitutive MKK3 or MKK6 (Ad/MKK3bE or Ad/MKK6bE) did not induce cell death in either DLD1 or DLD1/TRAIL-R cell lines. Our results suggest that activation of p38 MAP kinases does not play a major role in TRAIL-mediated apoptosis in DLD1 cells and that lack of TRAIL-mediated p38 MAP kinase activation may not be the mechanism of TRAIL-resistance in DLD1/TRAIL-R cells.

Modified plug repair with limited sphincter sparing fistulectomy in the treatment of complex anal fistulas

PURPOSE

New technical approaches involving biologically derived products have been used to treat complex anal fistulas in order to avoid the risk of fecal incontinence. The least invasive methods involve filling out the fistula tract with fibrin glue or introduction of an anal fistula plug into the fistula canal following thorough curettage. A review shows that the new techniques involving biologically derived products do not confer any significant advantages. Therefore, the question inevitably arises as to whether the combination of a partial or limited fistulectomy, i.e., of the extrasphincteric portion of the fistula, and preservation of the sphincter muscle by repairing the section of the complex anal fistula running through the sphincter muscle and filling it with a fistula plug produces better results.

METHODS

A modified plug technique was used, in which the extrasphincteric portion of the complex anal fistula was removed by means of a limited fistulectomy and the remaining section of the fistula in the sphincter muscle was repaired using the fistula plug with fixing button.

RESULTS

Of the 52 patients with a complex anal fistula, who had undergone surgery using a modified plug repair with limited fistulectomy of the extrasphincteric part of the fistula and use of the fistula plug with fixing button, there are from 40 patients (follow-up rate: 77%) some kind of follow-up informations, after a mean of 19.32 ± 6.9 months. Thirty-two were men and eight were women, with a mean age of 52.97 ± 12.22 years. Surgery was conducted to treat 36 transsphincteric, 1 intersphincteric, and 3 rectovaginal fistulas. In 36 of 40 patients (90%), the complex anal fistulas or rectovaginal fistulas were completely healed without any sign of recurrence. None of these patients complained about continence problems.

CONCLUSION

A modification of the plug repair of complex anal fistulas with limited fistulectomy of the extrasphincteric part of the fistula and use of the plug with fixing button seems to increase the healing rate in comparison to the standard plug technique.

Application of regional climate models to the Indian winter monsoon over the western Himalayas

The Himalayan region is characterized by pronounced topographic heterogeneity and land use variability from west to east, with a large variation in regional climate patterns. Over the western part of the region, almost one-third of the annual precipitation is received in winter during cyclonic storms embedded in westerlies, known locally as the western disturbance. In the present paper, the regional winter climate over the western Himalayas is analyzed from simulations produced by two regional climate models (RCMs) forced with large-scale fields from ERA-Interim. The analysis was conducted by the composition of contrasting (wet and dry) winter precipitation years. The findings showed that RCMs could simulate the regional climate of the western Himalayas and represent the atmospheric circulation during extreme precipitation years in accordance with observations. The results suggest the important role of topography in moisture fluxes, transport and vertical flows. Dynamical downscaling with RCMs represented regional climates at the mountain or even event scale. However, uncertainties of precipitation scale and liquid-solid precipitation ratios within RCMs are still large for the purposes of hydrological and glaciological studies.

Anthrax among heroin users in Europe possibly caused by same Bacillus anthracis strain since 2000

Injection anthrax was described first in 2000 in a heroin-injecting drug user in Norway. New anthrax cases among heroin consumers were detected in the United Kingdom (52 cases) and Germany (3 cases) in 2009-10. In June 2012, a fatal case occurred in Regensburg, Bavaria. As of December 2012, 13 cases had been reported in this new outbreak from Germany, Denmark, France and the United Kingdom. We analysed isolates from 2009-10 and 2012 as well as from the first injection anthrax case in Norway in 2000 by comparative molecular typing using a high resolution 31 marker multilocus variable-number tandem repeat analysis (MLVA) and a broad single nucleotide polymorphism (SNP) analysis. Our results show that all cases may be traced back to the same outbreak strain. They also indicate the probability of a single source contaminating heroin and that the outbreak could have lasted for at least a decade. However, an additional serological pilot study in two German regions conducted in 2011 failed to discover additional anthrax cases among 288 heroin users.

Anthrax among heroin users in Europe possibly caused by same Bacillus anthracis strain since 2000

Injection anthrax was described first in 2000 in a heroin-injecting drug user in Norway. New anthrax cases among heroin consumers were detected in the United Kingdom (52 cases) and Germany (3 cases) in 2009-10. In June 2012, a fatal case occurred in Regensburg, Bavaria. As of December 2012, 13 cases had been reported in this new outbreak from Germany, Denmark, France and the United Kingdom. We analysed isolates from 2009-10 and 2012 as well as from the first injection anthrax case in Norway in 2000 by comparative molecular typing using a high resolution 31 marker multilocus variable-number tandem repeat analysis (MLVA) and a broad single nucleotide polymorphism (SNP) analysis. Our results show that all cases may be traced back to the same outbreak strain. They also indicate the probability of a single source contaminating heroin and that the outbreak could have lasted for at least a decade. However, an additional serological pilot study in two German regions conducted in 2011 failed to discover additional anthrax cases among 288 heroin users.

Interdependence of Genotype and Growing Site on Seed Mineral Compositions in Common Bean

Essential minerals are considered as key determinants of optimum health and nutritive quality of common bean seed. This study aimed to identify genetically stable essential minerals in common bean. Eleven diverse common bean genotypes were grown in three distinct growing environments and 17 essential minerals were analyzed by Inductively Coupled Plasma-Optical Emission Spectroscopy. Genetic control of mineral composition in common bean seed was demonstrated by large (p<0.01) genotypic differences in Ca and Sr contents and moderate genotypic difference was observed in Fe content. Significant influence of genotype and environments (G×E) interaction was observed in the content of all minerals. The ratios between genetic and environmental variances and between genetic and G×E variances indicated the greater influence and stability of genetic factor on the concentration of Ca and Sr in common bean seed. Significant positive correlations among important minerals such as Zn with S, P, Fe and Na and Cu with K, Mg, Ni, P were identified. The stability of genetic effects on Ca and Sr concentration in common bean has been identified in this study. Calcium is one of the most important minerals which regulates many cellular processes and has important structural roles in living organisms. Further studies to characterize Ca physiology in common bean may identify genetic or biochemical markers to expedite breeding common bean with enhanced Ca concentration.

Agronomic biofortification of cereal crop plants with Fe, Zn, and Se, by the utilization of coal fly ash as plant growth media

The implementation of agronomic biofortification of cereal crops with Fe, Zn, and Se appears to be a rapid and simple solution to the deficiency of these elements in soils and plants. These deficiencies are a reason for serious public health concerns. Low levels of Fe, Zn, and Se are important soil constraints to crop production, especially in the developing world. In our study we planted six cereal crops on soil control and different coal combustion residues, naturally rich in these micronutrients. Plants were harvested and chemically analyzed for Fe, Zn, and Se concentration using ICP. Six plant species have been tested including barley (Hordeum vulgare), Jerry oats (Avena sativa), rye (Secale cereale), wheat (Triticum aestivum), perennial ryegrass (Lolium multiflorum), and ReGreen (wheat x wheatgrass hybrid (Triticum aestivum x Thinopyrum intermedium). All tested plants were able to establish growth on coal ash based growth media, and accumulated significant amounts of Fe, Zn, and Se. It supported our hypothesis, that phytoremediation of coal ash piles may serve also as agronomic biofortification of plants, especially cereal crops cultivated on coal fly ash (FA).

A systematic method to identify the space group from PED and CBED patterns part I--theory

This systematic method allows the unambiguous identification of the extinction and diffraction symbols of a crystal by comparison of a few experimental Precession Electron Diffraction (PED) patterns with theoretical patterns drawn for all the extinction and diffraction symbols. The method requires the detection of the Laue class, of the kinematically forbidden reflections and of the shift and periodicity differences between the reflections located in the First-Order Laue Zone (FOLZ) with respect to the ones located in the Zero-Order Laue Zone (ZOLZ). The actual space group can be selected, among the possible space groups connected with each extinction symbol or diffraction symbol, from the identification of the point group. This point group is available from observation of the 2D symmetry of the ZOLZ on Convergent-Beam Electron Diffraction (CBED) patterns.

A systematic method to identify the space group from PED and CBED patterns part II--practical examples

Precession Electron Diffraction and Convergent-Beam Electron Diffraction are used in a complementary way to determine the space group of three known structures following the general method described in the first part of this paper. The selected structures concern a monoclinic example (coesite SiO(2) with space group C2/c) and two cubic examples (γ-Al(4)Cu(9) with space group P43[combining overline]m and pyrite FeS(2) with space group Pa3[combining overline]). For each case, a minimum number of zone axis patterns are used to determine the space group without ambiguity, which illustrates the simplicity and reliability of the method.

SU-E-T-236: Brachytherapy for Breast Cancer Patients with Implanted Pacemeker, Using Multi Lumen Partial Breast Applicator

PURPOSE

Discuss optimised Accelerated Partial Breast Irradiation (APBI) using a Strut-Adjused Volume Implant (SAVI) applicator for patients with implanted pacemeker, without overdosing or relocating the pacemaker.

METHODS

A right breast cancer patient with an in situ pacemaker (Medtronic model ADDR01) on the right side underwent breast conservative surgery and was referred for Partial Breast Irradiation (PBI) using Ir-192 High Dose Rate Brachytherapy. Preliminary estimation of the pacemaker dose from a pre-insertion CT study was about 8 % of the prescribed dose which exceeded the generally accepted dose of 2Gy. The challenge was to use a suitable applicator to treat the tumor bed and 1cm margin without exceeding the 2Gy limit to the pacemaker and the leads. A seven catheter SAVI device was selected and implanted in the right breast in an optimal direction and a 3D treatment plan was generated following a post insertion CT scan, using the Oncentra Brachy treatment planning system. Optimization tools namely anatomy based Inverse Planning Simulated Annealing (IPSA), and graphical optimization were utilized to load and optimize the dwell time in the catheters and reduce the dose received by the pacemaker. Device interrogation was conducted before and after the treatment. All operational parameters of the pacemaker were found to be normal.No change in the baseline reference values were observed.

RESULTS

Using the SAVI device it was possible to limit the pacemaker/ leads dose to less than 2 Gy. Target V100, V95 and V90 were 90.1%, 95.5% and 98.5% respectively. V150 and V200 being 18.6cc and 10.6cc respectively.Calculated average point doses on pacemaker assembly for ten fractions was 140cGy.

CONCLUSIONS

By combining the optimization tools of today's Brachytherapy planning system and a multilumen SAVI applicator, HDR partial breast irradiation can be safely delivered for breast cancer patients with in situ pacemaker, with out the fear of interrupting pacemaker functionality.

Matched-pair analysis of postoperative morbidity and mortality for pancreaticogastrostomy and pancreaticojejunostomy using mattress sutures in soft pancreatic tissue remnants

BACKGROUND

After pancreaticoduodenectomy, the incidence of postoperative pancreatic fistula remains high, especially in patients with "soft" pancreatic tissue remnants. No "gold standard" surgical technique for pancreaticoenteric anastomosis has been established. This study aimed to compare the postoperative morbidity and mortality of pancreaticogastrostomy and pancreaticojejunostomy for "soft" pancreatic tissue remnants using modified mattress sutures.

METHODS

Seventy-five patients who had undergone pancreaticogastrostomy and 75 who had undergone pancreaticojejunostomy after pancreaticoduodenectomy between 2002 and 2008 were retrospectively compared using matched-pair analysis. A modified mattress suture technique was used for the pancreaticoenteric anastomosis. Patients with an underlying "hard" pancreatic tissue remnant, as in chronic pancreatitis, were excluded. Both groups were homogeneous for age, gender, and underlying disease. Postoperative morbidity, mortality, and preoperative and operative data were analyzed.

RESULTS

There were no significant differences between the groups for the incidence of postoperative pancreatic fistula (10.7% in both). Postoperative morbidity and mortality, median operation time, median length of hospital stay, intraoperative blood loss, and the amount of intraoperatively transfused erythrocyte concentrates also did not significantly differ between the groups. Patient age >65 years (P=0.017), operation time >350 minutes (P=0.001), and intraoperative transfusion of erythrocyte concentrates (P=0.038) were identified as risk factors for postoperative morbidity.

CONCLUSIONS

Our results showed no significant differences between the groups in the pancreaticogastrostomy and pancreaticojejunostomy anastomosis techniques using mattress sutures for "soft" pancreatic tissue remnants. In our experience, the mattress sutures are safe and simple to use, and pancreaticogastrostomy in particular is feasible and easy to learn, with good endoscopic accessibility to the anastomosis region. However, the location of the anastomosis and the surgical technique need to be individually evaluated to further reduce the incidence of postoperative pancreatic fistula.