Open mesh versus non-mesh for repair of femoral and inguinal hernia

BACKGROUND

Inguinal hernia repair is the most frequent operation in general surgery. Until recently the standard procedure has been open musculo-aponeurotic repair using sutures under tension to close the defect but 'tension-free' repair using prosthetic mesh is becoming increasingly common in many countries.

OBJECTIVES

The purpose of this review is to evaluate open mesh techniques in comparison with open non-mesh techniques for the surgical repair of groin hernia.

SEARCH STRATEGY

Electronic databases were searched and further trials were sought from the reference lists of reports of known trials. Through the EU Hernia Trialists Collaboration authors of identified randomised controlled trials were asked for information on any other trials known to them. There was no language restriction.

SELECTION CRITERIA

Studies were eligible for inclusion if they were randomised or quasi-randomised trials comparing either a) open mesh with open non-mesh repair of groin hernia or b) open flat mesh repair with plug and mesh repair of groin hernia.

DATA COLLECTION AND ANALYSIS

For each outcome the results were derived using data from the best available source. The majority of data for this review came from individual patient data (IPD) supplied by the trialists. When these were unavailable data came from additional aggregated information or from published trial reports. All trials were analysed using the 'intention to treat' principle.

MAIN RESULTS

Twenty trials comparing open mesh with open non-mesh repair were identified. Open mesh methods, on average, took 7-10 minutes less to perform than Shouldice procedures, but took 1-4 minutes longer than other non-mesh methods. There were no clear differences between mesh and non-mesh groups for haematomas, seromas or wound/superficial infections. Three serious operative complications were reported after open mesh repair and three following non-mesh repair. Overall, those in the mesh groups had a shorter length of hospital stay and quicker return to usual activities, but this pattern was not observed for all trials. There was a suggestion that persisting pain was less frequent after mesh repair than after non-mesh repair but this result was dependent on one trial and data were not available for 11 trials. There was no evidence of a difference between the groups with respect to persisting numbness. Fewer hernia recurrences were reported after mesh repair (Peto OR: 0.37, 95% CI: 0.26 to 0.51). There were too few data to reliably address differential effects for patients with recurrent, bilateral or femoral hernias. Two trials comparing flat mesh with plug and mesh were identified. There was no clear evidence of differences between the groups.

REVIEWER'S CONCLUSIONS

There is evidence that the use of open mesh repair is associated with a reduction in the risk of recurrence of between 50% and 75%. Although the trials were heterogeneous there is also some evidence of quicker return to work and of lower rates of persisting pain following mesh repair.

Plesiomonas shigelloides sepsis and splenic abscess in an adolescent with sickle-cell disease

Plesiomonas shigelloides is a rare cause of self-limiting gastroenteritis. We report a case of extraintestinal P. shigelloides infection in an adolescent with sickle-cell disease who presented with bacteremia complicated by a splenic abscess. Despite the high mortality rate reported in extraintestinal P. shigelloides infection, the patient survived after drainage of the abscess and treatment with antibiotics.

The effect of oral sucralfate on the acute proctitis associated with prostate radiotherapy: a double-blind, randomized trial

PURPOSE

Acute rectal complications occur in the majority of patients receiving external-beam radiotherapy for carcinoma of the prostate. Sucralfate has been proposed to reduce radiation-induced mucosal injury by forming a protective barrier on ulcer bases, binding local growth factors, and stimulating angiogenesis. However, there is conflicting clinical evidence as to whether sucralfate, taken prophylactically during radiotherapy, can ameliorate the symptoms of acute radiation proctitis.

METHODS AND MATERIALS

A double-blind randomized trial was conducted at four Radiation Oncology Departments in Sydney, Australia, between February 1995 and June 1997. A total of 338 patients with clinically localized prostate cancer receiving small volume radiotherapy, of whom 335 were evaluable, were randomized to receive either 3 g of oral sucralfate suspension or placebo twice a day during radiotherapy. Patients kept a daily record of their bowel symptoms and were graded according to the RTOG/EORTC acute toxicity criteria.

RESULTS

One hundred sixty-four patients received sucralfate and 171 received placebo. Both groups were well balanced with regard to patient, tumor, treatment factors, and baseline symptoms, except that the placebo group had a significantly more liquid baseline stool consistency score (p = 0.004). Patients kept a daily diary of symptoms during radiotherapy. After adjusting for baseline values, there was no significant difference between the two groups with regard to stool frequency (p = 0.41), consistency (p = 0.20), flatus (p = 0.25), mucus (p = 0.54), and pain (p = 0.73). However, there was more bleeding in the sucralfate group, with 64% of patients noticing rectal bleeding, compared with 47% in the placebo group (p = 0.001). There was no significant difference between the two groups with respect to RTOG/EORTC acute toxicity (p = 0.88; sucralfate 13%, 44%, 43% and placebo 15%, 44%, 40% for grade 0, 1, and 2, respectively).

CONCLUSION

This study suggests that oral sucralfate taken prophylactically during radiotherapy does not ameliorate the symptoms of acute radiation proctitis and may increase acute bleeding. The cause of the increased bleeding in the sucralfate group is unclear. As the pathogenesis of acute and late reactions are different, late follow-up, which includes sigmoidoscopic evaluation, is currently being performed on this cohort of patients.

Notification of gastrointestinal illness by Canterbury and West Coast general practitioners

AIM

To identify factors influencing notification of enteric diseases by general practitioners (GPs).

METHODS

The 'laboratory-based notification rate' was calculated for each GP by dividing the number of cases they notified by their number of laboratory detected cases of selected enteric diseases during 1997 and 1998. The 'annual full time equivalent (FTE) notification rate' was defined as the number of notifications received during the study period adjusted for the proportion of that time spent in clinical practice. These measures were compared with responses to a questionnaire posted to 395 Canterbury and West Coast GPs.

RESULTS

82% responded to the questionnaire. Higher 'laboratory-based notification rates' and 'annual FTE notification rates' were associated with the practice nurse being responsible for notifying and with GPs who were more recent graduates or who practised in rural areas. Few respondents identified high risk groups in their criteria for requesting a specimen.

CONCLUSIONS

Communicable disease control could be enhanced by emphasising the importance of specimen collection in high risk groups, encouraging delegation of notification to practice nurses and encouraging the development of public health based guidelines to determine the need for specimen request

A comparison of primary and proxy respondent reports of habitual physical activity, using kappa statistics and log-linear models

BACKGROUND

Many epidemiological studies rely in part on proxy informants. There is little published information on the reliability of proxy-respondent reports of physical activity.

METHODS

Self-reported data on vigorous and moderate physical activity, from a representative sub-sample of participants in a community-based case-control study of coronary heart disease, were compared with information collected from their next-of-kin.

RESULTS

Relative to primary respondents, proxy respondents under-reported activity by approximately 10 percentage points, for both leisure and work-time activity. On a simple three point scale (inactivity/moderate activity/physical activity), 70% of primary-proxy pairs were in exact agreement with regard to leisure time activity and 67% of pairs were in exact agreement on work-time activity. The corresponding values for the weighted kappa statistic were 0.66 [95% confidence interval (CI) 0.59-0.72] and 0.62 (0.54-0.72). Log-linear modelling provided evidence for superior agreement on worktime activity when the proxy was not the primary respondent's spouse.

DISCUSSION

Overall levels of primary-proxy respondent agreement on physical activity seem somewhat lower than has been reported for smoking and alcohol-drinking frequency. There seems little reason to prefer spouse proxies when endeavouring to elicit information on work-time physical activity. Log-linear modelling provides an efficient means of exploring covariate effects in observer-agreement studies.

Medical complications of female genital mutilation

More than 130 million women are subjected to genital mutilation. Despite increasing efforts to reduce the practice, there are many obstacles to eliminating this 2,000-year-old practice, which is based on strong cultural traditions. As college health clinicians provide care to more international students from countries where female genital mutilation is performed, increased awareness and knowledge of the procedure will enable clinicians to understand and manage its complications. We report a case of obstructive uropathy resulting in hydronephrosis secondary to female genital mutilation and review the medical literature regarding this and other complications of genital mutilation "surgery."

Patterns of alcohol use and misuse among elderly rest home residents in Christchurch

AIMS

To determine the prevalence of alcohol use and misuse among elderly rest home residents in Christchurch.

METHODS

A cross-sectional prevalence survey was conducted among 175 residents aged 65 years and over, randomly selected from 30 rest homes in Christchurch, in 1998. Hazardous patterns of alcohol consumption in the past twelve months were determined by the Alcohol Use Disorders Identification Test (AUDIT) questionnaire, and alcohol dependence in the past 12-months and lifetime was determined by a strctured clinical interview using DSM-IV criteria.

RESULTS

Of 246 eligible participants, 175 (71.1%) residents were interviewed, 115 women and 60 men, mean age, 82.6 years (SD=7.8) compared with 83.2 years (SD=6.3) for non-participants. The prevalence of hazardous patterns of alcohol consumption in the past twelve months by the AUDIT (cut-off score 8) was 5.1% (95% CI = 1.8-8.4). According to DSM-IV criteria, the prevalence of lifetime alcohol dependence was 20.5% (95% CI = 13.5-27.6) and for the past twelve months was 0.5% (95% CI = 0-1.7). The prevalence of lifetime alcohol dependence was significantly higher in men 36.7% (95% CI = 23.2-50.1) than women 12.2% (95% CI = 5.6-18.8) (p = 0.0001).

CONCLUSIONS

In spite of advanced age, a small proportion of elderly rest home residents consumed quantities of alcohol that put them at risk of future damage to physical or mental health. Lifetime prevalence of alcohol dependence was comparable to the general population estimates and was higher in men than women.

Rural and remote Australian general practitioners' educational needs in radiology

BACKGROUND

The Australian College of Rural and Remote Medicine (ACRRM) was funded by the Commonwealth Department of Health and Aged Care to set up a quality assurance and continuing medical education program for rural and remote general practitioners in radiology to begin in January 2001. An extensive literature search failed to uncover any previous publications on the specific educational or quality assurance needs for rural general practitioners in radiology. Broader educational needs assessments of rural general practitioners in Australia had identified radiology as an important skill for which improvement was desired.

METHOD

A national steering committee consisting of four rural general practitioners and three radiologists, with the assistance of a program manager, developed and piloted a self-administered postal questionnaire to determine the educational and quality assurance needs of rural and remote general practitioners. The questionnaire was sent to all rural and general practitioners holding a remote radiology exemption using the Health Insurance Commission database.

RESULTS

A total of 287 completed questionnaires were returned from all states in the country, except the Australian Capital Territory. The information gave a comprehensive picture of the self-reported radiology education needs of these doctors, who practice in isolation from radiologists and other specialists. The three areas in which the general practitioners were least confident in radiology were chest, cervical spine, and skull radiology. Their highest priority areas of need for education were chest radiology, film interpretation, and spinal radiology. The top preferred quality assurance activity was image review with a radiologist, followed by clinical audit, image review by peers, and measuring practice against guidelines.

FINDINGS

Local ownership of education is important to successful program development and evaluation. Information obtained from the educational needs assessment was used to develop the Radiology Quality Assurance and Continuing Medical Education Program for Rural and Remote General Practitioners.

Three-dimensional dose distribution of tangential breast irradiation: results of a multicentre phantom dosimetry study

BACKGROUND AND PURPOSE

One aspect of good radiotherapeutic practice is to achieve dose homogeneity. Dose inhomogeneities occur with breast tangent irradiation, particularly in women with large breasts.

MATERIALS AND METHODS

Ten Australian radiation oncology centres agreed to participate in this multicentre phantom dosimetry study. An Alderson radiation therapy anthropomorphic phantom with attachable breasts of two different cup sizes (B and DD) was used. The entire phantom was capable of having thermoluminescent dosimeters (TLD) material inserted at various locations. Nine TLD positions were distributed throughout the left breast phantom including the superior and inferior planes. The ten centres were asked to simulate, plan and treat (with a prescription of 100 cGy) the breast phantoms according to their standard practice. Point doses from resultant computer plans were calculated for each TLD position. Measured and calculated (planning computer) doses were compared.

RESULTS

The dose planning predictability between departments did not appear to be significantly different for both the small and large breast phantoms. The median dose deviation (calculated dose minus measured dose) for all centres ranged from 2. 3 to 5.3 cGy on the central axis and from 2.1 to 7.5 cGy for the off-axis planes. The highest absolute dose was measured in the inferior plane of the large breast (128.7 cGy). The greatest dose inhomogeneity occurred in the small breast phantom volume (median range 93.2-105 cGy) compared with the large breast phantom volume (median range, 100.1-107.7 cGy). There was considerable variation in the use (or not) of wedges to obtain optimized dosimetry. No department used 3D compensators.

CONCLUSION

The results highlight areas of potential improvement in the delivery of breast tangent radiotherapy. Despite reasonable dose predictability, the greatest dose deviation and highest measured doses occurred in the inferior aspects of both the small and large breast phantoms.

Supporting placement‐based learning using networked technologies

The growth in the use of networked technologies provides educators with mechanisms to add value to learning experiences where learners and educators are geographically distributed. Increasingly, placements are used within the more vocational disciplines to provide students with a reflective learning experience within the context of the work environment. Such remote learning can be supported through the use of networked technology, enabling a high degree of interactivity and helping learners to enhance their learning styles. A case study is presented that considers the design and implementation of such networked support, focusing on the learner’s evaluation of this experience. The results from this study identify that networked technologies, such as audio conferencing and Web‐based support, have a beneficial role in the learning experience, and that considerable advantages can be derived from their use for placement‐based learners.

Meeting the International Conference on Harmonisation's Guidelines on Validation of Analytical Procedures: quantification as exemplified by a near-infrared reflectance assay of paracetamol in intact tablets

This Perspective explains how the International Conference on Harmonisation's Guidelines on Validation of Analytical Procedures for quantitative methods can be met by near-infrared (NIR) assays of intact pharmaceutical products. Each of the validation characteristics (accuracy, precision, specificity, detection limit, quantification limit, linearity, range, robustness and system suitability testing) is defined, examined for their relevance to quantitative methods and examples given on how they may be used to demonstrate that near-infrared assays are fit for purpose. Methods for preparing samples for calibration are given in detail. The intention is to provide information so that a pharmaceutical manufacturer could validate a method suitable for an application for a variation of a marketing authorisation for an existing product and use a NIR assay instead of the previous method. The perspective is illustrated in detail using a NIR reflectance assay of paracetamol in intact tablets. This proven assay gives results comparable to the British Pharmacopeia ultraviolet assay for paracetamol, the standard errors of calibration and prediction for the NIR method being 0.48% w/w and 0.71% w/w respectively. The method is also precise, the standard deviation and coefficient of variation for six NIR assays on the same day being 0.14% w/w and 0.16% w/w respectively, while measurements over six consecutive days gave 0.31% w/w and 0.36% w/w respectively.

Armrest versus vacuum bag immobilization in the treatment of breast cancer by radiation therapy: a randomized comparison

Thirty patients in randomized sequence were simulated in both an arm-rest and a vacuum bag immobilization device and also randomized to treatment in one of the two devices. Overall patient comfort significantly favoured the use of the arm-rest, although both were acceptable. Lung exposed in the tangential beams was less in the vacuum bag device. Supraclavicular skin folding was greater in the vacuum bag, but this is probably related to the angle of arm abduction. Treatment times and stability of the setups were not significantly different. This is a small study piloting a technical comparison and the findings require confirmation in a larger sample.

Treatment interventions and findings from research: bridging the chasm in child psychiatry

BACKGROUND

Along with all other branches of medicine, child and adolescent psychiatry is faced with the need to consider its evidence base and justify its activities accordingly.

AIMS

To consider critically the use of the term 'evidence', to suggest limits to the value of conventionally defined evidence and to point to possible ways forward to bridge the gap between research findings and clinical practice.

METHOD

A review of the literature relating to the use of evidence-based methods.

RESULTS

The term 'evidence' needs to be used more widely than is conventionally the case. Substantial evidence exists from controlled trials, but there are barriers to its use.

CONCLUSIONS

A move away from nonvalidated methods of intervention is both desirable and feasible. The use of qualitative methods of enquiry, both in situations where controlled trials are unlikely to be feasible and as adjuncts to quantitative methods, should be considered more seriously.

Bayesian inference for a generalized population attributable fraction: the impact of early vitamin A levels on chronic lung disease in very low birthweight infants

In this paper, the population attributable fraction is studied using the potential responses framework of Rubin's causal model. This framework facilitates definition of a general measure of population attributable effect which can accommodate many-valued and multivariate exposures as well as many-valued responses. Inferential issues are considered from the Bayesian perspective. Finite population inference is emphasized with inference in the case of a fully observed population given particular attention. The key inferential issue concerns computation of the posterior distribution of unobserved potential responses, given observed responses, exposures and covariates. A dependency on model parameters about which observed data are uninformative is highlighted and this reflects the unobservable nature of causal effects. In an application to a small cohort study of respiratory problems in very low birthweight infants, posterior inferences were found to be insensitive to assumptions concerning the joint distribution of potential response variables but sensitive to the assumption of weak ignorability, a weaker form of the more familiar assumption of no confounding by omitted covariates. In a model-based set-up, the weak ignorability assumption is identified with setting a model parameter to zero, and consequently uncertainty concerning this assumption can, in principle, be handled via the prior distribution for the model parameters.

Heart or heart-lung transplantation: psychosocial outcome

The psychosocial outcome of 23 heart and 21 heart-lung transplant recipients, aged 5-17 yrs, was determined and compared with the psychosocial outcome of a group of 46 children and adolescents who underwent conventional cardiac surgery. Preoperatively, and 12 months post-operatively, the patients' physical health status, mental state (ICD-9) and level of psychosocial functioning (GAF scale, DSM-IIIR) were assessed. There was an improvement in physical health in all groups. Preoperatively, psychiatric disorder, including anxiety and phobic states, depression and adjustment reaction, was noted in 6/23 (26%) children assessed for heart transplantation, 6/21 (28.5%) children assessed for heart-lung transplantation, and 12/46 (26%) children undergoing conventional cardiac surgery. The prevalence of psychiatric disorder remained in the transplant group but decreased in the non-transplant comparison group (6.5%). Improvement in overall levels of psychosocial functioning were found in all groups, but over 40% of all the participants were still functioning below normal levels. In summary, children with end-stage cardio-respiratory disease benefit physically and psychologically from heart or heart-lung transplantation treatment but there is a need for systematic psychosocial support both before and after transplantation.