Open vs. robot-assisted preperitoneal inguinal hernia repair. Are they truly clinically different?

INTRODUCTION

Inguinal hernia repair lacks a standard repair technique, with laparo-endoscopic and open preperitoneal methods showing similar outcomes. Despite higher costs, the popularity of robotic surgery is on the rise, driven by technological advantages. Controversies persist in comparing open repair techniques with the robotic approach, given contradictory results. The objective of this study was to compare postoperative outcomes, including complications, chronic pain, and recurrence, between open and robotic-assisted preperitoneal inguinal hernia repair.

METHODS

This single-center retrospective study encompassed patients undergoing elective inguinal hernia repair in a specialized unit, employing both open preperitoneal and robotic-assisted laparoscopic approaches from September 2018 to May 2023. Comparative analysis of short- and long-term outcomes between these techniques was conducted. Additionally, multivariate logistic regression was employed to explore predictors of postoperative complications.

RESULTS

A total of 308 patients met the inclusion criteria. 198 (64%) patients underwent surgery using an open preperitoneal approach and 110 (36%) using robot-assisted laparoscopy. Patients in the robot-assisted group were younger (P = 0.006) and had fewer comorbidities (P < 0.001). There were no differences between the groups in terms of postoperative complications (P = 0.133), chronic pain (P = 0.463) or recurrence (P = 0.192). Multivariate analysis identified ASA ≥ III (OR, 1.763; 95%CI, 1.068-3.994; P = 0.027) and inguinoscrotal hernias (OR, 2.371, 95%CI, 1.407-3.944; P = 0.001) as risk factors of postoperative complications.

CONCLUSIONS

Both open preperitoneal and robotic-assisted laparoscopic approaches show similar outcomes for complications, chronic pain, and recurrence when performed by experienced surgeons. The open preperitoneal approach, with its quicker operative time, may be advantageous for high-comorbidity cases. Treatment choice should consider patient factors, surgeon experience, and healthcare resources.

Scissors and tweezers: A skin-picking disorder case report

Introduction

Skin-Picking Disorder (SPD) is psychiatric condition characterized by recurrent and excessive picking of the skin. There are several attempts to stop the behavior and it causes negative consequences such as dermatological complications and functional impairment.

Objectives

The aim of this study is to describe a case report of SPD.

Methods

Data was collected retrospectively from case notes.

Results

A 30 year-old male, married with 2 children, currently on sick leave, was admitted to the Day Hospital at Centro Hospitalar Psiquiátrico de Lisboa (CHPL) with worsen skin-picking behaviour and functional impairment. During childhood the patient would “cut my toe nails the wrong way so that I could fix them”. By adolescence the patient suffered from acne and felt the need to “solve” them and take out the pus. Over the years the skin-picking behaviour spread to other areas of the body, mainly dorsal and chest areas. Before being admitted to the Day Hospital the episodes were daily and had 2-3 hours duration, using scissors and tweezers and evolving his family, asking his wife’s help with picking. He is being treated with fluoxetine 80 mg, risperidone 2 mg and N-acetylcysteine 1200 mg and Cognitive Behavioural Therapy. He is also participating in the Day Hospital activities that include occupational therapy, movement therapy, psychoeducation. After 2 months he has a few 20 minutes episodes per week, spends more time with his children and thinks about coming back to work.

Conclusions

SPD is a severe and debilitating illness that benefits from a multidisciplinary approach.

Disclosure

No significant relationships.

New software for cervical vertebral geometry assessment and its relationship to skeletal maturation--a pilot study

OBJECTIVES

In the present study, we developed new software for quantitative analysis of cervical vertebrae maturation, and we evaluated its applicability through a multinomial logistic regression model (MLRM).

METHODS

Digitized images of the bodies of the second (C2), third (C3) and fourth (C4) cervical vertebrae were analysed in cephalometric radiographs of 236 subjects (116 boys and 120 girls) by using a software developed for digitized vertebrae analysis. The sample was initially distributed into 11 categories according to the Fishman's skeletal maturity indicators and were then grouped into four stages for quantitative cervical maturational changes (QCMC) analysis (QCMC I, II, III and IV). Seven variables of interest were measured and analysed to identify morphologic alterations of the vertebral bodies in each QCMC category.

RESULTS

Statistically significant differences (p < 0.05) were observed among all QCMC categories for the variables analysed. The MLRM used to calculate the probability that an individual belonged to each of the four cervical vertebrae maturation categories was constructed by taking into account gender, chronological age and four variables determined by digitized vertebrae analysis (Ang_C3, MP_C3, MP_C4 and SP_C4). The MLRM presented a predictability of 81.4%. The weighted κ test showed almost perfect agreement (κ = 0.832) between the categories defined initially by the method of Fishman and those allocated by the MLRM.

CONCLUSIONS

Significant alterations in the morphologies of the C2, C3 and C4 vertebral bodies that were analysed through the digitized vertebrae analysis software occur during the different stages of skeletal maturation. The model that combines the four parameters measured on the vertebral bodies, the age and the gender showed an excellent prediction.

The seroprevalence of human infection withRickettsia slovaca, in an area of northern Spain

An epidemiological survey was undertaken to explore human exposure to Rickettsia slovaca in two provinces of northern Spain. When IFAT were used to test 200 members of the general population for antibodies to rickettsiae of the spotted-fever group, six (3.3%) were found positive, presumably, since Dermacentor is one of the most common genera of human-biting tick in the study area, for antibodies to R. slovaca. Thirty-one (16.9%) of an additional 183 subjects who presented shortly after being bitten by ticks were also found seropositive. The difference in seroprevalence between the general and the tick-bitten populations was significant. Subject gender had no influence on seroprevalence in either population, although, in the tick-bitten group, age and occupation did have a significant influence on the prevalence recorded. Immunoblotting was used to confirm the presence of antibodies in the five subjects, all from the tick-bitten group, found to have acute infections. Three D. marginatus ticks obtained from three of these acute cases were found PCR-positive for R. slovaca DNA.

Olfactory reference syndrome - A case report

Introduction

Olfactory reference syndrome (ORS), first described by Pryse-Phillips in 1971, is a rare psychiatric condition whose defining characteristic is a preoccupation with the belief that one emits a foul or offensive body odor, which is not perceived by others. Although the existence of ORS is now widely accepted, current classifications do not explicitly mention ORS as an independent category, but consider it as a delusional disorder, somatic type. Nonetheless, given this syndrome's consistent description along time and cultures, and the associated substancial distress and disability, many authors debate the possibility of a new classification in order to establish its nosological status.

Objectives/aims

The aim of this paper is to show and discuss some troublesome and complex issues of diagnosis and management of patients with ORS.

Methods

Herein we report a case of a 38-year-old woman who presented with ORS.

Results/conclusions

Improvement in ORS can take place, in some extent, with a variety of different modalities of treatment, with the disorder responding to antidepressants and psychotherapy more frequently than to neuroleptics. Data on ORS are still limited and more research in this field is needed. Awareness of this particular diagnosis allows appropriate treatment to be administered.

Zn²(+) -containing protein S inhibits extrinsic factor X-activating complex independently of tissue factor pathway inhibitor

BACKGROUND

Protein S (PS) has direct anticoagulant activity, independently of activated protein C (APC). The mechanisms underlying this activity remain unclear, because PS preparations differ in activity, giving rise to conflicting results. Some purification procedures result in loss of intramolecular Zn²(+) , which is essential for inhibition of prothrombinase.

OBJECTIVE

To investigate the inhibition of extrinsic factor (F)Xase by Zn²(+) -containing PS.

METHODS

Purified component extrinsic FXase assays were used to determine FXa generation in the presence and absence of PS and/or tissue factor pathway inhibitor (TFPI). Binding assays, immunoblots and thrombin generation assays in plasma supported the FXase data.

RESULTS

Zn²(+) -containing PS potently inhibited extrinsic FXase in the presence of saturating phospholipids, independently of TFPI, whereas inhibition of extrinsic FXase by Zn²(+) -deficient PS required TFPI. Immunoblots for FXa and functional assays showed that Zn²(+) -containing PS inhibited primarily the quantity of FXa formed by tissue factor (TF)-FVIIa, rather than FXa amidolytic activity. Zn²(+) -containing PS, but not Zn²(+) -deficient PS, bound to TF with high affinity (K(dapp) = 41 nm) and targeted TF function. Binding of PS to FVIIa was negligible, whereas PS showed appreciable binding to FX. Increasing FX concentrations 10-fold reduced PS inhibition five-fold, suggesting that PS inhibition of FXase is FX-dependent. PS also exhibited TFPI-independent and APC-independent anticoagulant activity during TF-initiated thrombin generation in plasma.

CONCLUSIONS

PS that retains native Zn²(+) also retains anticoagulant functions independently of APC and TFPI. Inhibition of extrinsic FXase by PS at saturating levels of phospholipids depends on PS retention of intramolecular Zn²(+) , interaction with FX, and, particularly, interaction with TF.

The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) : characterization of the cohort

The Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD) was launched in December 2004 aiming to collect data monthly and continuously from a representative cohort, allowing for a continuous snapshot of the peritoneal dialysis (PD) reality in the country. This is an observational study of PD patients comprising follow-up from December 2004 to February 2007 (mean follow-up of 13.6 months-ranging from 1 to 26 months) in 114 Brazilian centers. All centers report data through a central web-based database. After an initial baseline retrospective data collection, all patients are followed prospectively every month until they drop out from the PD program. Total number of patients recruited until February 2007 was 3226 (2094 incident patients). Mean age was 54+/-19 years (37% above 65 years old), with 55% females and 64% Caucasians. The more frequent causes of renal failure were diabetic nephropathy (34%), renal vascular disease associated with hypertension (26%), and glomerulopathies (13%). The most common comorbidities were hypertension (76%), diabetes (36%), and ischemic heart disease (23%). Automated PD (APD) was the modality utilized in 53%. The estimated overall peritonitis rate was 1 episode per 30 patient-months (most frequently due to Staphylococcus aureus). The total dropout rate was 33%, mainly due to deaths, whereas 20% of dropouts were due to renal transplant. The gross mortality was 17.6% and the main causes of mortality were cardiovascular diseases (40%) and infections (15%). The initial results of this first Brazilian PD registry provide a unique opportunity to develop future clinical studies addressing specific PD questions in the Brazilian reality and context.

Myths in the assessment of progression: How frequently should we assess patients in clinical trials?

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Background: It is often believed that within a clinical trial a patient’s progression status should be assessed as frequently as practically possible if the primary objective is to compare progression-free survival (PFS). However, the statistical analysis of PFS data compares rates of progression rather than a specific percentile such as a median, and results in an estimate of the hazard ratio (HR)—the ratio of event rates. Methods: We provide results of simulations assessing the power and bias of an analysis of PFS in controlled trials according to visit frequency, rate of progression and analysis method. The simulations assume a true HR of 0.8 and that data are analyzed after 630 patients have an event to provide a nominal power of 80%. All simulations assume patients are assessed according a symmetric visit schedule as otherwise, if data are analyzed asymmetrically, bias will follow (Proc Am Assoc Cancer Res 2002; abst 975). Results: If patients are assessed at a time interval equal to the median divided by two, there is a negligible (=2%) loss of power for the analysis of PFS data. Data presented in the table show that in a disease with a comparator median of 4 and 8 months when 1,000 patients are randomized, there is little increase in power if patients are assessed more often than every 2 and 4 months, respectively, using a standard log- rank test. The simulations presented assume there is some variability (SD=1 week) of the actual assessment date around the protocolled date. If PFS data are analyzed by moving PFS times to the scheduled assessment time, alternative methods of analysis (grouped survival techniques) preserve power and avoid bias by appropriately handling the excessively tied PFS times. Conclusions: Within the context of a clinical trial, a fully powered analysis of PFS is possible if patients are assessed at a frequency which is one-half of the median of the disease under study, and therefore patients need not be assessed more frequently unless clinical practice outside of a clinical trial would dictate otherwise.

[Table: see text] [Table: see text]

Sexuality and Chronic Respiratory Disease

Background: At the admission in rehabilitation program, some patients with chronic respiratory disease were asked by a health professional to to answer a questionnaire about their sexuality. The objectives of the study were 1) to determine if sexual problems occurred in patients with respiratory chronic disease ; 2) to assess if these survey problems were linked to respiratory disease; 3) to explore the motivation to speak about sexuality during rehabilitation program. Methods: 52 consecutive respiratory disease subjects (58.3 ± 9 yr; FEV1 = 65.5 ± 21 % predicted, mean ± SD) answered a sexuality questionnaire survey with rehabilitation team (psychologists, nurses, physiotherapists). This group comprised 26 men and 26 women. Results: 70% of patients estimated that respiratory disease had an impact on their sexuality. A visual analog scale showed that 62% of patients were not satisfied. The severity of obstruction (FEV1) was not correlated to satisfaction (r=.017, P=0.90), or frequency (r=.08, P=0.55). Breathlessness was the most important factor of discomfort in sexual activity (61.5%). Tiredness and cough came second (32% and 21% respectively). 63% of respiratory patients never spoke about their sexuality with a health professional. 60% would like the health professional to begin to talk about their sexuality. 36% of patients spoke about it with a professional. In this group, 94% of patients told the professional about their sexual activity on their own initiative. Conclusion: More than one of two chronic respiratory disease patients (77%) participating in a rehabilitation program want sexuality to be taken into consideration during their program.

Kruppel-like factor 4 regulates laminin alpha 3A expression in mammary epithelial cells

Laminin-5, the major extracellular matrix protein produced by mammary epithelial cells, is composed of three chains (designated alpha3A, beta3, and gamma2), each encoded by a separate gene. Laminin-5 is markedly down-regulated in breast cancer cells. Little is known about the regulation of laminin gene transcription in normal breast cells, nor about the mechanism underlying the down-regulation seen in cancer. In the present study, we cloned the promoter of the gene for the human laminin alpha3A chain (LAMA3A) and investigated its regulation in functionally normal MCF10A breast epithelial cells and several breast cancer cell lines. Using site-directed mutagenesis of promoter-reporter constructs in transient transfection assays in MCF10A cells, we find that two binding sites for Kruppel-like factor 4 (KLF4/GKLF/EZF) are required for expression driven by the LAMA3A promoter. Electrophoretic mobility shift assays reveal absence of KLF4 binding activity in extracts from T47D, MDA-MB 231, ZR75-1, MDA-MB 436, and MCF7 breast cancer cells. Transient transfection of a plasmid expressing KLF4 activates transcription from the LAMA3A promoter in breast cancer cells. A reporter vector containing duplicate KLF4-binding sites in its promoter is expressed at high levels in MCF10A cells but at negligible levels in breast cancer cells. Thus, KLF4 is required for LAMA3A expression and absence of laminin alpha3A in breast cancer cells appears, at least in part, attributable to the lack of KLF4 activity.

Peroneal latency in normal and injured ankles at varying angles of perturbation

The aim of this study was to determine whether there was a difference in latency of the peroneus longus muscle at varying amplitudes of ankle inversion perturbation and between individuals with and without a history of ankle injury. Thirty-four male athletes from different football codes (soccer, rugby) received four random tilts to their left ankles at 5 degrees, 10 degrees, and 15 degrees in the frontal plane on a dual platform trap door. Peroneal latency was defined as the time difference between onset of the trap door movement, as detected by an accelerometer, and the onset of muscle activation above a resting baseline, as recorded using surface electromyography. Latency was determined using an algorithm. A series of repeated measures analyses of variance indicated that the latency was reliable between trials. There was no statistical evidence that history of injury or subjective ankle instability influenced the latency; however, there was a systematic difference between dominant and nondominant legs (dominant, 6.3 ms faster), and there was a small systematic effect (3 ms) for the angle of inversion perturbation. Muscle latency responses in male football players are thought to be influenced more by dominance than by history of injury or amplitude of perturbation.

[Hepatic schistosomiasis: diagnostic difficulties in a non endemic area]

Schistosomiasis is a major cause of liver damage and portal hypertension, especially in tropical countries, affecting about 200 million people in the world. We report the cases of two patients presenting persistent alterations of serum liver enzymes. We enhance the importance of considering the history of past travels and a liver biopsy to diagnose an infrequent parasite induced liver disease in a non endemic area such as Portugal. Some observations are made about the diagnosis and treatment of this parasitic disease.

Reliability of the peroneal latency in normal ankles

The aim of this study was to determine the reliability of peroneal latency between trials and to compare the right and left sides in healthy subjects. A dual platform trapdoor was constructed to tilt the right or the left ankle by 30 degrees in the frontal plane. Electromyography recorded the onset of peroneal activity in response to this perturbation, and an accelerometer detected the onset of trapdoor movement. Peroneal latency was determined algorithmically as the time difference between the onset of trapdoor movement and the onset of peroneal activity. Twenty trials were recorded from 31 right leg dominant, healthy subjects. Peroneal latency was measured successfully for 613 trials (99% success rate). A repeated measures analysis of variance showed a main effect for side with the right, dominant side recording a longer latency. Intertrial reliability of the peroneal latency was high (intraclass correlation coefficients for the right and left legs were .91 and .82, respectively). Thus, peroneal latency is a reliable measure of the polysynaptic reflex ares involved in the response of these muscles to a sudden inversion stress.

Gastrointestinal actions of buprenorphine: are different receptors involved?

The effects of buprenorphine on castor-oil-induced diarrhoea, gastrointestinal transit and ethanol-induced gastric lesions in rats were compared to the same effects of morphine. Like morphine, buprenorphine prevented castor-oil-induced diarrhoea. However, it has no effect on gastrointestinal transit per se but prevented the inhibitory action of morphine. While morphine protected against ethanol-induced gastric lesions, buprenorphine aggravated them. It is suggested that different types/subtypes of opioid receptors may be involved in the gastrointestinal actions of buprenorphine.