Port-Site Hernia Following Laparoscopic Cholecystectomy

Background:

Port-site hernia is a rare but potentially serious complication of laparoscopic cholecystectomy. This study aimed to review the current literature, assess the incidence and causes of port-site hernias, and identify methods to reduce the risk.

Methods:

A systematic search of the literature published in English from 1995 to 2010 was conducted using PubMed to identify all reports of port-site, trocar-site, or incisional hernia following laparoscopic cholecystectomy. Studies in over 100 patients were identified before the application of defined exclusion criteria. The incidence of port-site hernia was calculated and compared with historical data. Predisposing factors were reviewed.

Results:

Seven studies met the search criteria, with 99 port-site hernias in 5984 patients. The overall incidence of port-site hernia was 1.7% (range, 0.3% to 5.4). The most important factors were older age, higher body mass index, preexisting hernia, trocar design, trocar diameter, increased duration of surgery, and extension of the port site for gallbladder extraction.

Conclusion:

The incidence of port-site hernia is low but likely to be underestimated and has not declined over time. Awareness of the predisposing factors and modification of techniques may help to reduce the risk.     

A human antibody that inhibits factor IX/IXa function potently inhibits arterial thrombosis without increasing bleeding

10C12, a human antibody F(ab')2, which specifically binds to the gamma-carboxyglutamic acid domain of factor IX/factor IXa (F.IX/IXa), interferes with all known coagulation processes in which F.IX/IXa is involved. In a rabbit model of carotid artery injury, intravenous administration of 10C12 or heparin decreased thrombosis dose dependently. The dose that resulted in a 90% reduction of thrombus mass (ED90) was a 30-microg/kg bolus of 10C12 or a 100-U/kg bolus plus 1.0 U x kg(-1) x min(-1) infusion of heparin. Heparin, at and below the ED90, significantly prolonged coagulation times and cuticle bleeding times. In contrast, 10C12 had no effect on coagulation or bleeding times at doses up to 4 times the ED90. To further evaluate the effect of 10C12 on bleeding, it was compared with heparin in a novel model of blood loss. At the ED90 of heparin, blood loss induced by a standardized injury to the vasculature of the rabbit tibia increased to more than 2 times that of saline controls. In contrast, the dose of 10C12 required to produce a similar increase in blood loss was more than 30 times the ED90. The antithrombotic potency and relative safety of this fully human antibody suggests that it may have therapeutic value for treatment of thrombotic disorders.     

Assessing Univentricular Function in Adult Fontan Using 3D Echocardiography

Objective: To determine the accuracy of assessing univentricular function in adult Fontan patients using three-dimensional (3D) volumetric echocardiography. Design: A prospective observational study in an adult Fontan patient cohort. Setting: University Hospitals Birmingham, NHS Foundation Trust. Patients: 26 patients were enrolled in the study all aged over 18 years, possessing the Fontan anatomy, with no contraindications to Cardiac Magnetic Resonance (CMR) imaging and in sinus rhythm. Intervention: All patients underwent transthoracic echocardiography using a Philips EPIQ 7 and X5-1 transducer. End diastolic volume (EDV), end systolic volume (ESV), stroke volume (SV) and ejection fraction (EF) were obtained using two dimensional (2D) and 3D acquisitions. CMR was performed within 3 months according to standard protocols. Outcome Measures: The agreement and correlation between 2D, 3D and CMR derived parameters were determined by Bland and Altman analysis and Pearson’s correlation coefficient method. The inter-observer variability was also assessed for all three modalities. Results: 3D volumetric acquisitions of the single ventricle were feasible in 18/26 (69%) patients. 3D volumes strongly correlated with CMR but with a systematic bias to underestimation: EDV r = 0.66, bias = –47.1 (–109.6 to 15.2); ESV r = 0.82, bias = – 19.4 (–59.9 to 21.1); EF r = 0.73, –1.56 (–18.8 to 15.7) and SV r = 0.32, –27.7 (– 70.2 to 14.7). Inter-observer variability was lowest with CMR, when compared to echocardiographic techniques. The inter-observer variability for 3D when compared with 2D echocardiography was lower across all parameters except EDV. Conclusions: 3D volumes correlate strongly with CMR and may be used for serial assessment of univentricular function. However, 3D volumes on echo are not interchangeable with CMR due to systematic underestimation of volume.     

UK National Audit of chlamydial infection management in sexual health clinics. clinic policies audit

There was a wide range of activity and chlamydial diagnoses between the 177 clinics that responded. Most (92%) clinics have nucleic acid tests for chlamydial diagnosis. Different practitioners largely share roles in providing advice to patients about partner notification, treatment adherence, safer sex advice and abstinence. Most (97%) clinics have information leaflets about chlamydia, although about 30% of clinics lack leaflets containing information about antibiotics and hormonal contraception. About two-third clinics follow the National Guideline recommended interval for providing a test of cure where this is indicated. Only 18% of clinics routinely ask patients to reattend, with 40% having a policy of no routine follow-up and 62% using telephone or text follow-up. These categories were not mutually exclusive. Most (86%) of the 146 English clinics had a local Chlamydia Screening Programme coordinator for their Primary Care Trust area, although cooperation varies, with cooperation over treatment of 70% and Programme policy of 62%.     

Comparing patient generated blood glucose diary records with meter memory in type 2 diabetes

Aim

To assess agreement between meter and diary self monitoring of blood glucose (SMBG) records, over a year, in a sample of patients with type 2 diabetes.

Methods

Meter and diary records were available, for 95 individuals, who took part in the Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes study.Pearson's correlation coefficient was used to explore the relationships between the types of error. Maximum likelihood estimation was used to explore changes over time through a structural equation modelling approach. Paired samples t-tests were used to determine if the presence of errors led to a significant difference between the mean diary and meter SMBG concentrations or coefficients of variation. Multiple regression was used to explore possible predictors of the error indices.

Results

Mean over-reporting, under-reporting, concordance and overall reliability were 8.4%, 10.0%, 83.5% and 71.3%, respectively. The first week of monitoring had significantly more under-reporting, over-reporting and less concordance and overall reliability than subsequent weeks. The majority of concordance errors were not clinically significant. Those that were, tended to occur during the first three months of monitoring. Participants’ at one trial site were significantly more likely to have recording errors than those at the largest site.

Conclusions

Error levels were similar to those described previously in type 1 diabetes and there was a suggestion of an initial learning curve for record keeping. For some individuals diary records would not be considered acceptable if held to the same standards as blood glucose meters.