Mesh inguinal herniorrhaphy: a ten-year review

Inguinal herniorrhaphy remains one of the most common surgical operations, with approximately 10 to 20 per cent performed for recurrence. Reviews by specialized hernia centers show mesh repair has a recurrence rate of 0.2 per cent. Detractors of this repair include increased cost, technical difficulty, and risk for infection. The purpose of this study was to compare mesh versus nonmesh inguinal herniorrhaphy at a large teaching institution. From 1985 to 1994, 892 patients underwent primary repair for inguinal hernia at the Veterans Administration Hospital at Memphis, TN. Patients were stratified by repair [Lichtenstein (Mesh), open anterior (Bassini, Marcy, McVay, and Shouldice), laparoscopic (Lap), and preperitoneal (Post)]. Operative time for Mesh repair (111 +/- 2 minutes) was longer than for Bassini or McVay (91 +/- 2 and 98 +/- 2 minutes; P < 0.05), and Lap repairs were longer than all others (192 +/- 16 minutes; P < 0.05). Hospital stay averaged 2.2 +/- 0.1 days for Mesh versus 2.6 +/- 0.1 days for all repairs combined (P = not significant). Mesh patients developed four wound infections (1.0%), none requiring mesh removal, versus nine infections (1.8%) in other groups (P = not significant). One Mesh patient (0.3%) developed recurrence, compared with 16 (3.5%) with open anterior repair (P < 0.01). Inguinal herniorrhaphy using an open mesh repair technique provides superior recurrence rates without increasing risk for infection, length of stay, or technical difficulty.     

Clinical and economic outcome of patients undergoing tracheostomy for prolonged mechanical ventilation in New York state during 1993: analysis of 6,353 cases under diagnosis-related group 483

OBJECTIVE: To examine and describe the relation between age and disposition in patients undergoing tracheostomy. DESIGN: Retrospective analysis of a statewide database. SETTING: All acute care hospitals in New York state. PATIENTS: All patients (n = 6,353) > or = 18 yrs of age who were discharged from the hospital during 1993 with a final diagnosis-related groups code of 483. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The final disposition, according to six disposition codes (other acute care facility, residential healthcare facility, other healthcare facility, home, home healthcare services, and death) was examined for the entire population. Cost per case was assumed to equal the average statewide Medicaid rate. An inverse relation between survival rate and age was observed, which resulted in an age-related increased cost per survivor. Also, survivors in older age groups had an increased rate of discharge to residential healthcare facilities. There was a negative, albeit less marked, effect of older age on the rates of survivors discharged to home and to other healthcare facilities. CONCLUSIONS: Care of patients who undergo tracheostomy for prolonged mechanical ventilation is expensive. The older the patient, the less satisfactory the outcome from an economic, clinical, and possibly social perspective.     

Systemic arterial blood pressure and urine protein/creatinine ratio in dogs with hyperadrenocorticism

OBJECTIVE: To determine prevalence and severity of systemic arterial hypertension and proteinuria in dogs with naturally developing hyperadrenocorticism and to determine whether these abnormalities resolve with adequate management of the disease. DESIGN: Case series and cohort study. ANIMALS: 77 dogs with naturally developing hyper-adrenocorticism examined once; 15 dogs examined before and after treatment. RESULTS: Among dogs examined only once, hypertension was diagnosed in 21 of 26 dogs with untreated pituitary-dependent hyperadrenocorticism (PDH), 17 of 21 with inadequately controlled PDH, 8 of 16 with well-controlled PDH, 10 of 10 with an untreated adrenocortical tumor, and 0 of 4 that had undergone adrenalectomy because of an adrenocortical tumor. Untreated dogs and dogs with inadequately controlled PDH had significantly higher blood pressures than did other dogs. Proteinuria was documented in 12 of 26 dogs with untreated PDH, 5 of 16 with inadequately controlled PDH, 3 of 14 with well-controlled PDH, 5 of 8 with an untreated adrenocortical tumor, and 1 of 3 that had undergone adrenalectomy. Dogs with untreated PDH and dogs with an untreated adrenocortical tumor had higher urine protein/creatinine ratios than did dogs with well-controlled PDH. Among dogs evaluated before and after treatment, blood pressure and urine protein/creatinine ratio did not change in 8 dogs with inadequately controlled hyperadrenocorticism, but decreased in 7 dogs with well-controlled disease. CLINICAL IMPLICATIONS: Results suggest that systemic hypertension and proteinuria are common in dogs with untreated hyperadrenocorticism and that successful treatment of hyperadrenocorticism will result in resolution of these abnormalities in many, but not all, dogs.     

Hepatic hemangioma. Analysis of 103 cases. Clinical considerations and imaging methods

Hemangiomas are the most common benign vascular tumor found in the liver. In this study, 103 cases of hepatic hemangiomas were analysed in a retrospective manner. Image aspects such as those seen in ultrassonography, computed tomography, nuclear magnetic resonance and arteriography are discussed. The incidence was higher amongst the female sex, between individuals from 40 to 60 years old, which presented predominantly without symptoms (66%) and localized mainly in the right hepatic lobe (74%). The meaning of those aspects, when adopted, permits the clinicians to differentiate benign from malignant nodular lesions in the liver.     

Medical and psychological aspects of irritable bowel syndrome

To engineer an a non-islet cell capable of glucose-stimulated insulin secretion, a chinese hamster ovary cell line (CHO) was transfected with a mammalian expression vector carrying the human insulin cDNA (pCB/hINS). More proinsulin than insulin was released daily by the stably transformed cell line (CHO-INS). Examination of acid-ethanol extracts confirmed that both insulin and proinsulin were stored. Immunohistochemical analysis of the cells also showed that (pro)insulin was stored. Unlike beta cells, CHO-INS cells did not secrete insulin in response to glucose. To investigate this lack of effect, we examined whether transfection of GLUT2 cDNA, which is ordinarily not expressed in CHO-INS cells, would confer glucose-stimulated insulin secretion. Consequently, we have demonstrated that glucose regulated insulin release occurs in the CHO-INS-GLUT2 cell line and that glucose potentiates the insulin secretory response to non-glucose secretagogues.     

Molded rigid polymer monoliths as separation media for capillary electrochromatography. 2. Effect of chromatographic conditions on the separation

Monolithic columns for capillary electrochromatography have been prepared within the confines of untreated fused-silica capillaries in a single step by a simple copolymerization of mixtures of butyl methacrylate, ethylene dimethacrylate, and 2-acrylamido-2-methyl-1-propane-sulfonic acid (AMPS) in the presence of a porogenic solvent. The use of these novel macroporous monoliths eliminates the need for frits, the difficulties encountered with packed capillaries, and capillary surface functionalization. Since the porous properties of the monolithic materials can be easily tailored through changes in the composition of the ternary porogenic solvent, the effects of both pore size and the percentage of sulfonic acid monomer on the efficiency and the electroosmotic flow velocity of the capillary columns could be studied independently over a broad range. A simple increase in the content of charged functionalities within the monolith leads to an expected acceleration of the flow velocity. However, increasing the pore size leads to a substantial deterioration of the efficiency of the separation. In contrast, monoliths with increasing levels of AMPS in which the pore size remains fixed due to adjustments in the composition of the porogenic solvent show no deterioration in efficiency while maintaining the same increase in flow velocity, thus producing a significant reduction in separation time. Additionally, measurements on monoliths with constant levels of AMPS but different pore sizes suggest that flow velocity may be affected by the flow resistance within the capillary column.     

Effects of chronic administration of alcohol on neural mechanisms of arterial blood pressure regulation]

Metaphor comprehension was studied in schizophrenics as compared to psychiatric and nonpsychiatric controls. Subjects were asked in a two-condition forced-choice response task to detect the metaphor similar or contrary to a proverb with an abstract meaning. Schizophrenic patients were impaired in both conditions. However, the paranoid patients' performances did not differ from psychiatric and nonpsychiatric controls. These results are consistent with the hypothesis that the ability of metaphorizing is preserved in some schizophrenic patients.     

Changes in serum osteocalcin, plasma phylloquinone, and urinary gamma-carboxyglutamic acid in response to altered intakes of dietary phylloquinone in human subjects

The response of osteocalcin and other biochemical markers of vitamin K status to diets formulated to contain different amounts of phylloquinone was assessed in nine healthy subjects aged 20-33 y. Subjects resided in a metabolic ward for two 15-d cycles with a minimum of 6 wk between cycles. A mixed diet containing 100 micrograms phylloquinone/d was fed throughout both cycles; however, the phylloquinone content of one of the cycles was increased to a total of 420 micrograms/d on days 6 through 10 by fortifying corn oil in the diet with phylloquinone (supplemented diet). Total serum osteocalcin concentrations were not affected by either of the dietary treatments. The percentage of undercarboxylated osteocalcin increased an average of 28% over the 15-d cycle with the mixed diet (P < 0.05) and declined significantly an average of 41% with 5 d of the supplemented diet (day 6: 21.9 +/- 1.3%, day 11: 12.8 +/- 1.1%; P = 0.0001) with a rise after the return to the mixed diet (16.7 +/- 1.3%, P < 0.001). Plasma phylloquinone concentrations increased significantly with supplementation (day 6: 0.95 +/- 0.16 nmol/L, day 11: 1.40 +/- 0.29 nmol/L; P < 0.001) and then rapidly returned to presupplementation concentrations on returning to the mixed diet. Twenty-four-hour ratios of urinary gamma-carboxyglutamic acid to creatinine were unchanged with the supplemented diet; however, excretion declined to 91 +/- 2% of baseline after 10 d on the mixed diet (P = 0.01). These results show that undercarboxylated osteocalcin, plasma phylloquinone, and urinary gamma-carboxyglutamic acid excretion appear to be sensitive measures of vitamin K nutritional status because all of these variables were responsive to changes in dietary intake.     

Assessment at one school of students' abilities and confidence in diabetic patients' education

PURPOSE: To determine medical students' experiences in working with diabetic patients, their cognitive competence and their confidence in meeting diabetic patients' educational needs, and changes in their expertise with advancing education. METHOD: The study was conducted in March 1994 at the University of Illinois College of Medicine, where students work with ambulatory patients in a longitudinal primary care experience from their second year through graduation. A combined questionnaire and objective quiz was developed and distributed to 138 second-, third-, and fourth-year students. The students were asked whether they had had experience in seeing a newly diagnosed diabetic patient, in what setting, and whether they felt confident in educating such patients on various common topics. They were also asked about their interests in and preferences for learning about diabetic patients' education. A 50-item objective quiz on the management of diabetes followed the questionnaire. Data were analyzed with several statistical methods. RESULTS: In all, 65 of the students (47%) responded; the majority were third- or fourth-year students. The percentages of students who felt confident ranged from 83% who felt confident about counseling about exercise to only 16% who felt confident about pre-conception counseling. All of the students but one felt that diabetic patients' education was an important topic, and all but two were interested in it. The students' quiz scores showed no significant difference by year of training; for all the students the average score was 39.6% correct, with no increase in score for increased training. Also, the students who were more confident about their abilities to provide patient education on a certain topic were no more likely to have accurate information about that topic than were those who were not confident. CONCLUSION: Although they were clearly interested in diabetic patients' education, the students did not feel confident in providing it, nor did they have the cognitive competence to do so. Medical schools have a responsibility to students and to their patients to formally address the issues of patient education.