Antihypertensive medication changes and blood pressure goal achievement in a managed care population

This study examined achievement of blood pressure (BP) goals, changes in antihypertensive therapy and reasons for these changes among adults with hypertension initiating angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs) or calcium channel blockers (CCBs). Claims data were examined for changes to medication regimens. Patient charts for 501 patients provided BP levels and reasons for changing medications. BP goal achievement was highest for initiators of ARBs (81.4%), compared with ACEIs (75.5%; P=NS) and CCBs (68.9%; P<0.01). Changes in antihypertensive therapy were least likely among ARB recipients (59.9%) compared with ACEIs (71.86%; P=0.02) and CCBs (74.85%; P<0.01). Failure to achieve BP goals was the most common reason for change in therapy (ARB, 32.9%; ACEI, 42.5%, P=NS; CCB, 47.9%, P<0.01). Although most patients achieved target BP goals, many required changes in treatment regimens. Initial choice of antihypertensive therapy may mitigate changes in therapies and better achieve BP goals.

Recurrence following endoscopic extraperitoneal inguinal hernioplasty

Recurrence rate is the utmost outcome parameter in determining the clinical effectiveness of any hernia surgery. Between June 1999 and September 2004, six patients presented with recurrent hernia after endoscopic totally extraperitoneal inguinal hernioplasty (TEP). Four of the six recurrences (67%) occurred within a few months after TEP, indicating a technical failure. Of the 1,093 TEPs performed by the author, a total of three patients developed recurrence, giving an overall recurrence rate of 0.27%. All six patients underwent open Lichtenstein hernioplasty. Intraoperative findings showed recurrent indirect inguinal hernia in all patients. Half of the recurrence (n=3) was due to a sliding lipoma without a peritoneal hernial sac. Untreated herniated retroperitoneal adipose tissue into the internal inguinal ring during initial TEP constitutes the leading cause of recurrence after TEP. Routine exploration of internal ring for any herniated retroperitoneal adipose tissue during TEP is recommended. Herniated retroperitoneal adipose tissue should be resected whenever feasible.

Pharmacokinetics of lenalidomide in subjects with various degrees of renal function

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Background: Lenalidomide is a novel oral immunomodulatory drug approved for treating myelodysplastic syndrome (MDS) and multiple myeloma (MM). As unchanged lenalidomide is eliminated predominantly by urinary excretion, the present study investigated the effect of renal impairment (RI) on pharmacokinetics (PK) of lenalidomide. Results were used to refine initial dosing recommendations based on a subject’s estimated creatinine clearance. Methods: The study was conducted at 3 clinical centers. Thirty male and female subjects aged 39–76 years were stratified into 5 groups based on their creatinine clearance (CLCr) values: normal renal function (NRF) (CLCr > 80 mL/min; N = 7), mild RI (50 = CLCr = 80 mL/min; N = 5), moderate RI (30 = CLCr < 50 mL/min; N = 6), severe RI (CLCr < 30 mL/min, but not on dialysis; N = 6), and end stage renal disease (ESRD, requiring dialysis; N = 6). Subjects with NRF, mild, moderate or severe RI received a single 25-mg oral dose of lenalidomide. Subjects with ESRD received 2 single 25 mg doses which were separated by 7–10 days: one dose on a non-dialysis day and the other dose 3 hours before a 4-hour haemodialysis. Assessments included PK and safety parameters. Results: All subjects completed the study. Total and renal clearance of lenalidomide were strongly correlated with CLCr (R > 0.9, p < 0.01). As a result, AUC8 increased with decreasing CLCr. The mean difference in AUC8 between NRF and mild RI was < 20%. Compared with the pooled data from NRF and mild RI groups, mean AUC8 increased approximately 140% in moderate RI, 240% in severe RI, and 360% in ESRD (off dialysis). There was no correlation between Cmax or Tmax and CLCr. Approximately 10% of the dose was recovered in the dialysate of subjects with ESRD. Protein binding of lenalidomide was not markedly affected by RI (∼35 - 44%). The drug was well tolerated. On the basis of these data, recommendations for initial starting doses were made ( Table below). Conclusions: Lenalidomide dosage adjustment should be considered for patients with CLCr < 50 mL/min.

[Table: see text]

No significant financial relationships to disclose.

Management of herniated retroperitoneal adipose tissue during endoscopic extraperitoneal inguinal hernioplasty

BACKGROUND

Herniation of retroperitoneal adipose tissue into the inguinal canal, traditionally called cord lipoma, is frequently encountered during endoscopic totally extraperitoneal inguinal hernioplasty (TEP). Failure to recognize and manage the cord lipoma accounted for 30%-50% of recurrent hernia after TEP. The present study was undertaken to evaluate the incidence, risk factors, and management of herniated retroperitoneal adipose tissue during TEP.

METHODS

Between December 2002 and November 2005 all patients who underwent TEP were prospectively evaluated for the presence of cord lipoma. Clinical outcomes of patients who were treated for their cord lipoma were compared with those without cord lipoma. Risk factors for the occurrence of cord lipoma were also examined.

RESULTS

A total of 498 patients underwent unilateral (n = 386) or bilateral (n = 112) TEP. The overall incidence of cord lipoma was 26.5% (n = 132). A higher body weight, a higher body mass index, and a larger hernial defect were significantly associated with the presence of cord lipoma. Most of the cord lipoma cases (n = 119) were reduced to pelvic peritoneal reflection line after division of the feeding vessels from surrounding structures, while the rest (n = 13) were resected. Early postoperative outcomes, including pain score, morbidities, and other recovery variables, showed no significant difference between the two groups. No recurrence occurred in the present series.

CONCLUSIONS

Herniation of retroperitoneal adipose tissue into the inguinal canal occurred in more than one-fifth of the patients with inguinal hernia. Awareness and appropriate treatment of the cord lipoma helped to reduce the risk of recurrence. During TEP, the internal inguinal ring and inguinal canal should always be cleared of any herniated adipose tissue by either reduction or resection. This clearing posed no adverse effects on postoperative outcome.

Gastroschisis in the United States 1988-2003: analysis and risk categorization of 4344 patients

OBJECTIVE

Gastroschisis is a rare congenital abdominal wall defect through which intraabdominal organs herniate and it requires surgical management soon after birth. The objectives of this study were to profile patient characteristics of this anomaly utilizing data from two large national databases and to validate previous risk stratification categories of infants born with this condition.

METHODS

An analysis was performed using 13 years of the National Inpatient Sample database (1988-1996, 1998, 1999, 2001, 2002) and 3 years of the Kids' Inpatient Database (1997, 2000, 2003). These combined databases contain information from nearly 93 million discharges in the United States. Infants with gastroschisis were identified by International Classification of Disease-9 procedure code 54.71 (repair of gastroschisis) and an age at admission of <8 days. Variables of gender, race, geographic region, co-existing diagnoses, length of stay, hospital charges adjusted to 2005 dollars, complications and inpatient mortality were collected from the databases. Infants were divided into simple and complex categories based on the absence or presence of intestinal atresia, stenosis, perforation, necrosis or volvulus. Comparisons between groups were performed using Pearson's chi (2) for categorical outcomes and the Kruskal-Wallis test for non-normally distributed continuous variables.

RESULTS

A total of 4344 infants with gastroschisis were identified. These were comprised of 44.0% female infants (n=1910), 46.4% male infants (n=2017) whereas 9.6% were not reported (n=415). Racial analysis showed the largest subset being white in 40.9% of infants (n=1775) with Hispanic infants being the next highest group reported at 17.2% (n=745). Co-existing intestinal anomalies were the most common, affecting 9.9% (n=429) infants, whereas certain cardiac (6.8%, n=294) and pulmonary (1.7%, n=72) conditions were also identified. Simple gastroschisis represented 89.1% (n=3870) of the group whereas 10.9% (n=474) were complex in nature. Simple and complex patients differed in median length of stay (28 vs 67 days, P<0.01), inpatient mortality (2.9 vs 8.7%, P<0.01) and median inflation-adjusted hospital charges (90,788 dollars vs 197,871 dollars, P<0.01).

CONCLUSIONS

These data represent a national analysis of the largest group of infants with gastroschisis to date which further aids the characterization and understanding of this serious congenital condition.

Intensity modulated and three-dimensional conformal radiation therapy plans for oropharyngeal cancer: a comparison of their sensitivity to set-up errors and uncertainties

We compared the effect of set-up error and uncertainty on two radiation therapy treatment plans for head and neck cancer: one using intensity modulated radiation therapy (IMRT) and one using conventional three-dimensional conformal radiation therapy (3D-CRT). We used a Pinnacle3 (Philips Medical Systems, Markham, Ontario) system to create the two treatment plans (7-beam IMRT and 5-beam 3D-CRT) for the same volumetric data set, based on the objectives and constraints defined in the Radiation Therapy Oncology Group H-0022 protocol. In both plans, the dose-volume constraints for the targets and the organs at risk (oars) were met as closely as the beam geometries would allow. Monte Carlo-based simulations of set-up error and uncertainty were performed in three orthogonal directions for 840 simulated "courses of treatment" for each plan. A systematic error (chosen from distributions characterized by standard deviations ranging from 0 mm to 6 mm) and random uncertainties (2 mm standard deviation) were incorporated. We used a probability approach to compare the sensitivities of the IMRT and the 3D-CRT plans to set-up error and uncertainty in terms of equivalent uniform dose (EUD) to targets and oars.Based on the EUD analysis, the targets and oars showed considerably greater sensitivity to set-up error with the IMRT plan than with the 3D-CRT plan. For the IMRT plan, target EUDS were reduced by 4%, 7.5%, and 10% for 2-mm, 4-mm, and 6-mm set-up errors respectively. However, even with set-up error, the mandible, spinal cord, and parotid EUDS always remained lower with the IMRT plan than with the 3D-CRT plan.We conclude that, when quantified by EUD, IMRT-plan doses to oars and targets are more sensitive to set-up error than are 3D-CRT-plan doses. However, as judged by the differences between target and OAR doses, IMRT retains its superiority over 3D-CRT, even in the presence of set-up error.

Multidetector spiral CT renal angiography in the diagnosis of giant renal artery aneurysms

A case of giant renal artery aneurysm in a 63-year-old man is presented. Renal artery aneurysms are rare (incidence < 1%) and this case is one of the largest giant renal artery aneurysms recorded in the literature. This case also demonstrates the value of multidetector spiral computed tomographic renal angiography in the diagnosis, planning, and treatment of renal aneurysms.

Is endoscopic totally extraperitoneal hernioplasty justified for the repair of groin hernia in female patients?

BACKGROUND

Groin hernia is an uncommon surgical pathology in females. The efficacy of the endoscopic approach for the repair of female groin hernia has yet to be examined. The current study was undertaken to compare the clinical outcomes of female patients who underwent open and endoscopic totally extraperitoneal inguinal or femoral hernioplasty (TEP).

METHODS

From July 1998 to June 2004, 108 female patients who underwent elective repair of groin hernia were recruited. The patients were divided into TEP (n = 30) and open groups (n = 78) based on the type of operation. Clinical data and outcome parameters were compared between the two groups.

RESULTS

The mean ages and hernia types were comparable between the two groups. All TEPs were successfully performed. The mean operative times were 52 min for unilateral TEP and 51 min for open repair. The difference was not statistically significant. Comparisons of the length of hospital stay, postoperative morbidity, pain score, and time taken to resume normal activities showed no significant differences between the two groups. A single patient in the TEP group experienced recurrence of hernia.

CONCLUSIONS

The findings show equivalent postoperative outcomes after TEP and open repair of groin hernia in female patients. Because the wound scar after open repair is well concealed beneath the pubic hair and no superior clinical benefits are observed after TEP, open repair appears to be the technique of choice for the management of primary groin hernia in females. The TEP approach should be reserved for female patients with recurrent or multiple groin hernia.

Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males

BACKGROUND

Endoscopic totally extraperitoneal inguinal hernioplasty (TEP) is an accepted technique for the repair of recurrent and bilateral inguinal hernia, but its role in the management of unilateral primary inguinal hernia remains controversial. The current randomized trial was undertaken to compare the postoperative and 1-year outcomes of day-case TEP and open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males.

METHODS

From January 2002 to January 2004, a total of 200 male patients were randomized to undergo either day-case unilateral TEP or open Lichtenstein hernioplasty under general anesthesia. The primary outcome measures included postoperative pain score, time until return to work, incidence of chronic groin pain, and recurrence rate 1 year after the operation.

RESULTS

All TEP procedures were successfully performed without conversion. The mean operation time for TEP (50 +/- 13.2 min) was significantly shorter than for open Lichtenstein hernioplasty (58 +/- 17.6 min) (p < 0.001). The pain score at rest was significantly lower in the TEP group than in the open group on postoperative days 0, 1, 4, 5, and 6. On the average, the patients returned to work 8.6 days after TEP and 14 days after Lichtenstein hernioplasty (p = 0.006). Postoperative recovery and morbidity rates were otherwise comparable between the two groups. The incidence of chronic groin pain 1 year after TEP (9.9%) was significantly lower than after open surgery (21.7%) (p = 0.032). None of the patients in either group showed recurrence at the last follow-up assessment.

CONCLUSIONS

Day-case TEP was superior to open Lichtenstein hernioplasty for the repair of unilateral primary inguinal hernia in males. The benefits of day-case TEP included less postoperative pain, a faster return to work, and a lower incidence of chronic groin pain.

Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis

BACKGROUND

Early laparoscopic cholecystectomy has been advocated for the management of acute cholecystitis, but little evidence exists to support the superiority of this approach over delayed-interval operation. The current systematic review was undertaken to compare the outcomes and efficacy between early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis in an evidence-based approach using metaanalytical techniques.

METHODS

A search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1988 and June 2004. Only randomized or quasi-randomized prospective clinical trials in the English language comparing the outcomes of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were recruited. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio or weighted mean difference where feasible and appropriate.

RESULTS

A total of four clinical trials comprising 504 patients met the inclusion criteria. Failure of conservative treatment requiring emergency cholecystectomy occurred for 43 patients (23%) in the delayed group. Metaanalyses demonstrated a significantly shortened total length of hospital stay in the early group (weighted mean difference, -1.12; 95% confidence interval [CI], -1.42 to -0.99; p < 0.001). Pooled estimates did not show any significant differences between the two approaches in terms of operation time, conversion rate, overall complication rate, incidence of bile leakage, and intraabdominal collection.

CONCLUSIONS

The safety and efficacy of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were comparable. Because evidence suggested that early laparoscopic cholecystectomy reduced the total length of hospital stay and the risk of readmissions attributable to recurrent acute cholecystitis, it is therefore a more cost-effective approach for the management of acute cholecystitis.