Patient satisfaction,chronic pain,and quality of life after elective incisional hernia repair: effects of recurrence and repair technique

Purpose  

To determine the effects of repair technique and hernia recurrence on patient-reported outcomes after incisional hernia repair.     

The use of vesicostomy as permanent urinary diversion in the child with myelomeningocele.

PURPOSE: Treatment of the child with myelomeningocele presents the urologist with many challenges. While vesicostomies are usually used for temporary bladder drainage until continent reconstruction is performed, we have a population of postpubertal patients with myelomeningocele in whom vesicostomies have been preserved. We review our experience with these older children. MATERIALS AND METHODS: A search of our database of 350 patients with myelodysplasia identified 23 with urinary diversion accomplished by permanent vesicostomy. Those who had undergone vesicostomy after age 11 years were designated as group 1. Those who received a vesicostomy early in life that was maintained post puberty were designated as group 2. Indications for vesicostomy, upper tract status before and after vesicostomy, recurrent infections and complications were noted. Upper tract status was determined by serial ultrasounds during routine followup. RESULTS: Group 1 was comprised of 5 patients with mean age at vesicostomy of 17 years and a mean followup interval of 5.2 years. Group 2 was comprised of 18 patients with mean age of vesicostomy at 2.6 years and mean followup interval of 13 years. Hydronephrosis resolved in all children from both groups. Vesicostomy revision was required in 1 patient secondary to prolapse. Other complications included mild prolapse that did not require revision, stenosis requiring revision 5 months after the initial procedure and an early bilateral ureterovesical obstruction that resolved. Of the patients 33% had recurrent upper tract calculi. CONCLUSIONS: While the goal of achieving urinary continence is well worth striving for in the child with myelomeningocele, it is not realistic for all patients. We believe that permanent cutaneous vesicostomy is an acceptable alternative that the reconstructive surgeon should consider. This reliable and simple technique ensures safe decompression of the upper urinary tracts, while avoiding the complications of urinary diversion using segments of bowel.     

A financial analysis of pediatric laparoscopic versus open fundoplication

INTRODUCTION: Laparoscopic fundoplication (LF) is rapidly replacing open fundoplication (OF) for correcting symptomatic gastroesophageal reflux (GER) in infants and children. In this study, we compared various clinical and financial parameters to determine if one technique is superior. METHODS: With Institutional Review Board approval, charts and charge data for 50 consecutive patients undergoing elective LF or OF were reviewed in 2003 and 2004 (n = 100). Clinical variables evaluated included gender, age, weight, length of stay (LOS), operating time (OT), and time to initial (IF) and full (FF) feedings. Financial charges that were reviewed included anesthesia, central supply and sterilization, equipment, operating suite, hospital room and board, pharmacy, and total charges. RESULTS: The groups were equally matched in relation to gender, age, and weight. The table below illustrates the statistically significant differences (P < 0.05) between the groups. Favoring LNF LOS (1.2 vs. 2.9 days) IF (7.3 vs. 27.9 hours) FF (21.8 vs. 42.9 hours) Equipment ($1,006 vs. $1,609) Hospital Room ($1,290 vs. $2,847) Pharmacy ($180 vs. $461), Favoring OF OT (77 vs. 91 minutes) Anesthesia ($389 vs. $475) Central Supply and Sterilization ($1,367 vs. $2,515) Operating Suite ($4,058 vs. $5,142) Total charges were similar (LF, $11,449; OF, $11,632). CONCLUSIONS: Interestingly, although there were statistical differences in every charge category, total charges for LF and OF did not differ significantly. Thus, traditionally higher expenses from longer OT for LF seem to be offset by financial benefits, such as shorter LOS, reduced discomfort as evidenced by lower narcotic charges, and earlier IF/FF.     

Thermal injury resulting from application of a granular mineral hemostatic agent

BACKGROUND: Uncontrolled hemorrhage accounts for the majority of deaths in combat. Effective topical hemostatic agents suitable for use on the battlefield may be valuable in controlling hemorrhage until definitive surgical intervention is possible. In an effort to identify a hemostatic agent suitable for battlefield use, we evaluated several potential hemostatic agents in a swine injury model and noted thermal injury to tissues with a granular mineral hemostatic agent (QuikClot). METHODS: Anesthetized swine were maintained with a mean arterial pressure in excess of 60 mm Hg. Cutaneous, muscular, hepatic, splenic, venous, and arterial wounds were created in a standardized fashion. Topical hemostatic agents were immediately applied to the wounds and the amount of bleeding and time to hemostasis were noted. RESULTS: The results reported here are part of a larger study in which a variety of hemostatic agents were evaluated. Only the findings related to the granular mineral hemostatic agent are discussed here. Application of the agent resulted in elevated tissue surface temperatures in excess of 95 degrees C and internal tissue temperatures exceeding 50 degrees C, 3 mm deep to the bleeding surface. Necrosis of fat and muscle were noted as well as full and partial thickness cutaneous burns. CONCLUSIONS: Topical administration of a granular mineral hemostatic agent to a variety of wounds in an experimental swine model resulted in thermal tissue injury and necrosis. Suggestions for reducing the extent of injury with this product are offered.     

Prevalence of malignancy within cytologically indeterminate thyroid nodules

BACKGROUND: The optimal management of cytologically indeterminate thyroid nodules is controversial given the variable malignancy rates reported in this patient population. We examined the prevalence of malignancy within cytologically indeterminate follicular thyroid lesions in an attempt to predict malignancy based on cytologic features. METHODS: Cytopathology reports obtained after fine-needle aspiration biopsy (FNAB) examination of indeterminate follicular thyroid lesions were examined over a 4-year period. The prevalence of malignancy on final histology was determined in 4 indeterminate cytologic categories. RESULTS: A total of 107 records were available (91 women, 16 men). The mean patient age was 45.4 +/- 16 years. Forty-eight patients (45%) underwent surgery and had histopathologic diagnosis, while 57 patients did not have surgery. The prevalence of malignancy in patients who underwent thyroidectomy was 42% (20 of 48). CONCLUSIONS: The high prevalence of malignancy within indeterminate follicular lesions may necessitate thyroidectomy for patients with indeterminate follicular lesions on FNAB examination.     

Protein kinase C regulates ionic conductance in hippocampal pyramidal neurons: electrophysiological effects of phorbol esters.

The vertebrate central nervous system contains very high concentrations of protein kinase C, a calcium- and phospholipid-stimulated phosphorylating enzyme. Phorbol esters, compounds with inflammatory and tumor-promoting properties, bind to and activate this enzyme. To clarify the role of protein kinase C in neuronal function, we have localized phorbol ester receptors in the rat hippocampus by autoradiography and examined the electrophysiological effects of phorbol esters on hippocampal pyramidal neurons in vitro. Phorbol esters blocked a calcium-dependent potassium conductance. In addition, phorbol esters blocked the late hyperpolarization elicited by synaptic stimulation even though other synaptic potentials were not affected. The potencies of several phorbol esters in exerting these actions paralleled their affinities for protein kinase C, suggesting that protein kinase C regulates membrane ionic conductance.     

Subcellular sites of synthesis of phosphatidylglycerol and phosphatidylinositol in type II pneumonocytes

The subcellular sites of synthesis of phosphatidylinositol and phosphatidylglycerol in type II pneumonocytes isolated from lungs of adult rats were investigated. Microsomes contained approximately 34% of the total cellular activity of CDP-diacylglycerol: inositol 3-phosphatidyltransferase (EC 2.7.8.11) but less than 10% of the total activity of CDP-diacylglycerol: glycerol 3-phosphate phosphatidyltransferase (EC 2.7.8.5) and the latter activity could be attributed to mitochondrial contamination of the microsomal fraction. A crude mitochondrial fraction contained approximately 90% of the total cellular activity of CDP-diacylglycerol: glycerol 3-phosphate phosphatidyltransferase and also contained more than 50% of the total CDP-diacylglycerol: inositol 3-phosphatidyltransferase activity. When the crude mitochondrial fraction was subfractionated by use of discontinuous density gradient centrifugation, the distribution of CDP-diacylglycerol: inositol 3-phosphatidyltransferase activity was similar to that of NADPH: cytochromec reductase activity but dissimilar to the distribution of CDP-diacylglycerol: glycerol 3-phosphate phosphatidyltransferase activity which resembled that of succinate dehydrogenase. Electron microscopy of subcellular fractions revealed that fractions rich in CDP-diacylglycerol: inositol 3-phosphatidyltransferase activity contained numerous smooth membrane vesicles, whereas fractions rich in CDP-diacylglycerol: glycerol 3-phosphate phosphatidyltransferase activity contained mainly mitochondria. We conclude that the subcellular sites of synthesis of phosphatidylinositol and phosphatidylglycerol in type II pneumonocytes are most likely the endoplasmic reticulum and mitochondria, respectively. The results of this investigation were presented, in part, at the 73rd annual meeting of the American Society of Biological Chemists     

Peripheral-type benzodiazepine receptors in endocrine organs: autoradiographic localization in rat pituitary, adrenal, and testis

We have used [3H]Ro5-4864, a ligand selective for peripheral-type benzodiazepine receptors, to identify and localize peripheral-type benzodiazepine receptors in endocrine organs. Autoradiographic studies reveal an uniform distribution of [3H]Ro5-4864 binding sites within the anterior, intermediate, and posterior lobes of the pituitary gland, with highest concentrations present in the posterior pituitary. In rat adrenal gland, specific binding sites for [3H]Ro5-4864 are found only in the adrenal cortex, with highest density in the zona glomerulosa and significantly lower concentrations in the zona fasciculata and zona reticularis. [3H]Ro5-4864-associated silver grains in the testis are intensely localized over the interstitial tissue; low concentrations of silver grains are present over the epithelium of the seminiferous tubules but are absent from the tubular lumen. These studies demonstrate a differential and discrete localization of peripheral-type benzodiazepine receptors in rat pituitary, adrenal, and testis.     

Barotrauma and hypotension resulting from jet ventilation in critically ill patients

We present the first reports of pneumoperitoneum secondary to jet ventilation, barotrauma secondary to jet ventilation through the suction port of a fiberoptic laryngoscope, and hypotension due to jet ventilation via nasotracheal and orotracheal catheters. We suggest that minimizing airway pressure and using jet catheters with side holes may help decrease the risk of such complications. We cannot, at present, recommend the use of hand-held jet ventilators unless both adequate exhalation space is guaranteed and direct impingement of the catheter's tip on the mucosal surface is avoided.