Commentary: Nationwide analysis of complications related to inguinal hernia surgery in Finland: a 5 year register study of 55,000 operations

Background

The aim of this study was to evaluate the incidence of severe complications of adult inguinal hernia surgery from 2003 to 2007 using data from the Finnish National Patient Insurance Association.

Methods

All major surgical complications are reported to the association because it handles financial compensation for patients' injuries without proof of malpractice. The number of inguinal hernioplasties was obtained from the National Hospital Discharge Registry.

Results

The association received reports of 115 major and 135 moderate complications from 55,000 hernia operations. The overall complication rate was 4.5 per 1,000 hernia procedures. The distribution of injuries consisted of chronic pain (32%), infections (22%), bleeding complications (13%), urologic complications (12%), recurrence (8%), intestinal complications (7%), and miscellaneous disorders (6%). Altogether, 94 patients (38%) received financial compensation from their hospitals. On multivariate analysis, significant associations with chronic pain were found for general anesthesia, length of operation, and the presence of wound complications.

Conclusions

Chronic inguinal pain and deep infections were associated with severe long-term discomfort and financial compensation to patients with inguinal hernias in Finland.     

During treatment protocol for univentricular heart serum levels of natriuretic peptides decrease

Objective: In children treated for univentricular heart (UVH), prospective evaluation of serum levels of N-terminal proatriopeptide (ANPN) and N-terminal pro-brain natriuretic peptide (NT-proBNP) was performed. Methods: Serum samples were analysed in 19 children before the first operation, before the bi-directional Glenn (BDG) operation, at age 1 year and before total cavopulmonary connection (TCPC). In addition, we performed cross-sectional measurement of peptide levels in 32 children: 22 hypoplastic left ventricle (LV), 10 hypoplastic right ventricle (RV) before; and in 12 children: nine hypoplastic LV, three hypoplastic RV, 2 (range: 0.5–5.3) years after the TCPC operation. Controls comprised 12 children aged less than 6 months and 41 children aged from 6 months to 7 years. Results: Between the first and second operations, peptide levels decreased. Before TCPC, further decreases had occurred. Throughout follow-up, peptide levels were higher than in controls. In the cross-sectional study, before TCPC, median ANPN concentration measured 0.37 (range: 0.18–1.00) nmol l⁻¹ (P = 0.059, compared with controls) and NT-proBNP 155 (range: 13–718) ng l⁻¹ (P < 0.001). After TCPC, median ANPN concentration measured 0.39 (range: 0.09–0.98) nmol l⁻¹ (P = ns) and NT-proBNP 201 (range: 76–1406) ng l⁻¹ (P < 0.001). Before TCPC, levels of NT-proBNP were higher in patients with RV than with LV morphology. Conclusions: Natriuretic peptide levels decreased during treatment protocol for UVH, but NT-proBNP levels remained higher than in controls. These reflect reduction of volume overload of the single ventricle and can prove useful for haemodynamic monitoring.     

A comparison of aripiprazole, methylphenidate, and placebo for amphetamine dependence

OBJECTIVE: Problems related to illegal amphetamine use have become a major public health issue in many developed countries. To date, evidence on the effectiveness of psychosocial treatments has remained modest, and no pharmacotherapy has proven effective for amphetamine dependence. METHOD: Individuals meeting DSM-IV criteria for intravenous amphetamine dependence (N=53) were randomly assigned to receive aripiprazole (15 mg/day), slow-release methylphenidate (54 mg/day), or placebo for 20 weeks. The study was terminated prematurely due to unexpected results of interim analysis. An intention-to-treat analysis was used. The primary outcome measure was the proportion of amphetamine-positive urine samples. RESULTS: Patients allocated to aripiprazole had significantly more amphetamine-positive urine samples than patients in the placebo group (odds ratio=3.77, 95% CI=1.55-9.18), whereas patients who received methylphenidate had significantly fewer amphetamine-positive urine samples than patients who had received placebo (odds ratio=0.46, 95% CI=0.26-0.81). CONCLUSIONS: Methylphenidate is an effective treatment for reducing intravenous drug use in patients with severe amphetamine dependence.     

Formulation and in-vivo evaluation of L-cysteine chewing gums for binding carcinogenic acetaldehyde in the saliva during smoking

Cigarette smoke contains toxic amounts of acetaldehyde that dissolves in saliva, posing a significant risk of developing oral, laryngeal and pharyngeal carcinomas. L-cysteine, a non-essential amino acid, can react covalently with carcinogenic acetaldehyde to form a stable, non-toxic 2-methylthiazolidine-4-carboxylic acid. The main aim of this study was to find out whether it is possible to develop a chewing gum formulation that would contain cysteine in amounts sufficient to bind all the acetaldehyde dissolved in saliva during the smoking of one cigarette. The main variables in the development process were: (1) chemical form of cysteine (L-cysteine or L-cysteine hydrochloride), (2) the amount of the active ingredient in a gum and (3) manufacturing procedure (traditional or novel compression method). Saliva samples were taken over 2.5 minutes before smoking and since smoking was started for 2.5 minutes periods for 10 minutes. During a five minutes smoking period with a placebo chewing gum, acetaldehyde levels increased from 0 to 150-185 microM. Once smoking was stopped, the acetaldehyde levels quickly fell to levels clearly below the in-vitro mutagenic level of 50 microM. All chewing gums containing cysteine could bind almost the whole of the acetaldehyde in the saliva during smoking. However, elimination of saliva acetaldehyde during smoking does not make smoking completely harmless. Cysteine as a free base would be somewhat better than cysteine hydrochloride due to its slower dissolution rate. Both traditional and direct compression methods to prepare chewing gums can be utilized and the dose of L-cysteine required is very low (5 mg).     

Tetracycline susceptibility of the ingested Lactobacillus acidophilus LaCH-5 and Bifidobacterium animalis subsp. lactis Bb-12 strains during antibiotic/probiotic intervention

We investigated the effects of oral therapy with doxycycline, a tetracycline group antibiotic, on the gastrointestinal (GI) survival and tetracycline susceptibility of probiotic strains Lactobacillus acidophilus LaCH-5 and Bifidobacterium animalis subsp. lactis Bb-12. In addition, the influence of doxycycline therapy on the diversity of the predominant faecal microbiota was evaluated by polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE). Faecal samples from the antibiotic group (receiving antibiotics and probiotics) and the control group (receiving probiotics only) were analysed for anaerobically and aerobically growing bacteria, bifidobacteria and lactic acid bacteria as well as for the dominant microbiota. Although doxycycline consumption did not have a large impact on GI survival of the probiotics, it had a detrimental effect on the bifidobacteria and on the diversity of the dominant faecal microbiota. A higher proportion of tetracycline-resistant anaerobically growing bacteria and bifidobacteria was detected in the antibiotic group than in the control group. Several antibiotic group subjects had faecal B. animalis subsp. lactis Bb-12-like isolates with reduced tetracycline susceptibility. This was unlikely to be due to the acquisition of novel tetracycline resistance determinants, since only tet(W), which is also present in the ingested B. animalis subsp. lactis Bb-12, was found in the resistant isolates. Thus, concomitant ingestion of probiotic L. acidophilus LaCH-5 and B. animalis subsp. lactis Bb-12 with the antibiotic did not generate a safety risk regarding the possible GI transfer of tetracycline resistance genes to the ingested strains.     

Gender and age affect NK1 receptors in the human brain - a positron emission tomography study with [18F]SPA-RQ

Substance P (SP) is a neurotransmitter and neuromodulator that mediates its effects in the brain predominantly via the neurokinin-1 receptors (NK1Rs). NK1Rs and SP have been shown clinically to be involved in nausea and emesis after chemotherapy (CINV) and have been implicated preclinically in a range of neuropsychiatric disorders but unlike CINV their blockade in these conditions does not have proven clinical value. We investigated whether age and gender affects NK1R binding potential (NK1R-BP; an index of receptor availability) in the living human brain using PET and [18F]SPA-RQ, a highly specific NK1R antagonist. Forty-five healthy volunteers (35 male and 10 female), aged between 19 and 55 years were studied. NK1R-BP was estimated using the simplified reference tissue model with cerebellum as a reference region. A regression analysis indicated that that a loss of NK1R is associated with normal ageing as shown by decreased NK1R-BP (average rate 7% per decade). Statistically significant negative associations between age and NK1R-BP were observed in temporal, parietal and frontal cortex, hippocampus and parahippocampal formation. In addition preliminary data were obtained suggesting possible gender differences in NK1R-BP in the cortex and putamen with females having a lower NK1R-BP. The exact physiological significance of these results remains to be elucidated but conceptually they could be involved in age-related CNS disorders or those with gender differences in prevalence.     

Community-Associated Methicillin-Resistant Staphylococcus aureus Isolated in Finland in 2004 to 2006

A nationwide population-based study on community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in Finland during 2004 to 2006 showed that both incidence (1.9/100,000 population) and strain variation increased in comparison to years 1997 to 1999. There were 7 community-associated epidemic and 25 sporadic MRSA strain types. Half of these had Panton-Valentine leukocidin genes.Few population-based estimates of the burden of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) have previously been published (1-3, 12, 14). In Finland, the incidence of MRSA has been low. During 1997 to 1999, one-fifth of the 526 Finnish MRSA isolations were from persons without any connection to a hospital, and three strain types were associated with community acquisition (14). However, the total number of MRSA findings reported to the National Infectious Disease Register in Finland in 2004 to 2006 increased eightfold since 1997 to 1999. This increase has mostly been due to outbreaks and active screening in hospitals and hospital-associated strains (6, 15).In this study, we estimated the proportion of CA-MRSA strains among the MRSA isolates obtained either by screening or from a clinical specimen and determined the incidence and type of clinical CA-MRSA infections during 2004 to 2006. The MRSA strain types obtained from persons with and without hospitalization were compared.In Finland (population, 5.3 million), all clinical microbiology laboratories notify MRSA findings, including only the first isolate from a person, to the National Infectious Disease Register and send the corresponding isolates to the reference laboratory. During 2004 to 2006, a total of 4,054 (97%) isolates from 4,166 newly detected MRSA-positive persons were received.For each MRSA isolate, pulsed-field gel electrophoresis (PFGE) and antimicrobial drug susceptibility testing were performed (6, 10, 15). Multilocus sequence type (MLST), spa type, and SCCmec determinations were performed for isolates with a PFGE type shared by five or more persons (15). Panton-Valentine leukocidin (PVL) genes (lukS-PV, lukF-PV) were tested for by PCR in all CA-MRSA isolates. Identical or closely related PFGE types, MLSTs, and spa types (4) defined a strain type designated by a FIN number. A sporadic strain was shared by five or fewer persons.For all 4,030 persons with an MRSA isolate from 2004 to 2006, excluding 24 persons with an erroneous national identity code, data on previous hospitalizations were retrieved from the National Hospital Discharge Register. Background information was obtained for each person with MRSA isolated outside a hospital setting or within 2 days of hospital admission and who had not been hospitalized within 2 years of a positive MRSA culture by sending a questionnaire to infection control nurses at the relevant health care facilities. These data included risk factors for MRSA acquisition, the reason for obtaining the culture (screening or infection), and the type and treatment of a possible infection as recorded in medical charts by the patient''s primary health care provider. The Ministry of Social Affairs and Health, the Finnish data protection authority, and the National Research and Development Center for Welfare and Health approved the use of data from the National Hospital Discharge Register.Community association was calculated for each MRSA strain type carried by at least 10 persons. The chi-square test with Yates correction or Fisher''s exact test, as appropriate, was used for categorical variables. The means and medians of the continuous variables were compared by Student''s t test or the Mann-Whitney U test, depending on the sample distribution.A total of 570 persons without previous hospitalization in the last 2 years were identified. Based on the survey, 94 health care workers, 158 long-term care facility residents, and 20 newborns less than 28 days old were excluded. Thus, 298 (7.4%) of the 4,030 MRSA-positive persons and isolates were community associated (range by year, 5.8 to 8.9%); 185 (62%) and 113 (38%) were obtained as clinical specimens and by screening, respectively. Ultimately, 191 (64%) had a clinical infection. The mean annualized incidences of all CA-MRSA findings and CA-MRSA infections, respectively, were 1.9 and 1.2/100,000 population (ranges of annual incidences, 1.6 to 2.1 and 1.0 to 1.4). Persons with a CA-MRSA isolate were younger (median, 37 versus 75 years, P < 0.001) and more often males (56 versus 49%, P < 0.05) than those with previous hospitalization.Among the 4,030 MRSA isolates, our typing scheme showed a total of 148 strain types, of which 109 (74%) were sporadic and 39 (26%) were shared by at least five persons. Twenty-five strain types, each of which was isolated from ≥10 persons, represented 3,971 (99%) of the 4,030 isolates. Seven of these strain types, including two of the three old CA-MRSA strain types and 25 sporadic strain types, were associated with community acquisition (Table ​(Table11).

TABLE 1.

MRSA strain types significantly more often isolated in persons without previous hospitalization, i.e., CA-MRSA strain types, in Finland in 2004 to 2006