A survey of inguinal hernia repair in Wales with special emphasis on laparoscopic repair

Background The National Institute of Clinical Excellence (NICE) recently published its guidance on the use of laparoscopic repair for inguinal hernias. This study aimed to assess the likely uptake of laparoscopic surgery for inguinal hernias in Wales. In addition the current practice with regards to day case surgery, use of local anaesthesia, antibiotic prophylaxis, thromboembolic prophylaxis and advice regarding convalescence was assessed. Methods A postal questionnaire survey of all consultant surgeons (n = 91) in Wales was performed. Results There was a 70% (n = 67) response to the questionnaire. Fifteen percent of surgeons (n = 9) perform laparoscopic inguinal hernia repair in Wales; 10% of surgeons in Wales agreed with the NICE guidance. Lichtenstein hernia repair was the most commonly used the technique to repair primary inguinal hernias in Wales (82%). No surgeon currently is using a laparoscopic repair as the technique of choice for repair of primary inguinal hernias. Eighteen percent of surgeons perform all the procedures as day cases; 15% of surgeons perform more than 90% of the procedures under local anaesthesia; 44% of surgeons do not use any form of thromboprophylaxis for elective inguinal hernia repair, while 78% of the surgeons used routine antibiotic prophylaxis. Post-operative advice regarding return to sedentary work and driving was highly variable (1–4 weeks), as was advice regarding heavy work and sport (2–12 weeks). Conclusions The uptake of laparoscopic surgery for inguinal hernia repair in Wales is low. Only a minority of surgeons agree with the NICE guidance. Similarly the uptake of day case repair and the use of local anaesthesia are minimal. The use of antibiotic and thromboembolic prophylaxis is empirical and inconsistent. There is a need for evidence-based guidelines to standardise the antibiotic prophylaxis, TE prophylaxis and advice regarding post-operative advice. Presented at the Association of Surgeons of Great Britain and Ireland, Edinburgh 2006.     

Serum and cerebrospinal fluid magnesium in severe traumatic brain injury outcome

Serum magnesium concentration has a neuroprotective effect in experimental models of traumatic brain injury (TBI). This study was designed to assess the relationship between initial serum magnesium, cerebrospinal fluid (CSF) magnesium, neurological outcome and the efficacy of magnesium replacement therapy (MgSO4). A retrospective analysis was performed on a prospectively collected dataset from 216 patients admitted during 1996-2006 to the University of Pittsburgh Medical Center with severe TBI. Admission serum and CSF magnesium were dichotomized into low and normal magnesium concentration groups for serum and normal and high concentration groups for CSF. A logistic-regression analysis was performed with 6-month Glasgow Outcome Scale (GOS) scores as outcome variable. The outcome of a subset of 31 patients who presented with low serum magnesium and who were rapidly corrected within 24 h of admission was also analyzed. Low initial serum magnesium was measured in 56.67% of all patients. Patients with an initial serum magnesium of <1.3 mEq/L were 2.37 times more likely to have a poor outcome (CI: 1.18-4.78, p = 0.016). The prognostic significance of depressed serum magnesium remained, even in patients whose serum magnesium levels were corrected within 24 h (OR = 11.03, CI: 1.87-68.14, p = 0.008). Patients with an initial high CSF magnesium were 7.63 more likely to have a poor outcome (p = 0.05). Elevated CSF magnesium correlated with depressed serum magnesium only in patients with poor outcome (p = 0.013). Patients with low serum magnesium and high CSF magnesium are most likely to have poor outcome after severe TBI. Rapid correction of serum magnesium levels does not reverse the prognostic value of these markers.     

Alloantibody-associated chronic rejection of MHC class I-disparate heart grafts is modulated by intravenous soluble donor alloantigen

Increasing evidence suggests that there may be a causal relationship between the development of donor-specific alloantibodies and chronic allograft vasculopathy (CAV). PVG.RT1(u) rat heart allografts spontaneously undergo chronic rejection when transplanted into unmodified PVG.R8 congenic recipients that differ only at the classical MHC class I RT1.A locus. Here we show that development of vasculopathy in this experimental model is associated with production of a strong anti-A(u) antibody response. Perioperative intravenous administration of recombinant soluble RT1.A(u) heavy chain that is sequence identical to donor MHC class I, or chimaeric A(u/a) (donor/recipient) protein had a variable effect resulting generally in either sensitisation and accelerated rejection, or abrogation of alloantibody and attenuation of chronic rejection. These findings highlight the potential for soluble donor MHC class I alloantigen given at the time of heart transplantation to influence alloantibody production and graft outcome.     

Expression in L cells of transfected class I genes from the mouse major histocompatibility complex.

One of the major surprises of the molecular analysis of major histocompatibility complex (MHC) genes is the large number of class I (K/D)-related sequences in the genome. Both restriction fragment length polymorphisms and cosmid cloning experiments showed them all to be closely linked to the MHC. Until now little information was available concerning either their expression or recognition by the immune system. Here we report that these non-K/D genes can provoke antibody responses and be recognized by cytolytic T cells. Immunization of C3H mice with L cells transfected with class I genomic clones resulted in antisera that reacted preferentially with cells from strain B10.P (the gene donor). Thus, these genes can be expressed by L cells. These products were recognized by cytolytic T cells produced by mixed lymphocyte culture with B10.P stimulators. One gene, represented in clone lambda 3a, was chosen for further analysis. A restriction fragment length polymorphism, detected between B10.P (KpDp) and B10.F(14R) (KbDp) and between B10 (KbDb) and B10.F(13R) (KpDb), has enabled us to map the lambda 3a sequence to the D or Tla region. Restriction endonuclease mapping of the lambda 3a clone shows that the gene is intact and that, although many restriction sites are conserved, the gene in lambda 3a differs from other class I genes. When the lambda 3a clone was transfected into mouse L cells, a new product was expressed. Cells expressing this product (designated L3a cells) were killed by primary D-end-reactive, allospecific cytolytic T lymphocytes. The L3a cells were unreactive with monoclonal antibodies specific for the Kp,Dp,Qa-2, Tla.3, and Tla.5 molecules.     

Effect of some free radical scavengers on reperfusion induced arrhythmias in the isolated rat heart

The possible role of oxygen free radicals in the development of reperfusion arrhythmias was investigated using a 10-min period of coronary ligation followed by reperfusion in the isolated rat heart. Superoxide dismutase (5 to 20 u/ml) glutathione (10(-5) to 10(3)M) and ascorbic acid (10(-4) to 5 X 10(-4) M) when given before coronary ligation attenuated the development of reperfusion arrhythmias. Mannitol (2 X 10(-2)M) and catalase (100 and 300 u/ml) did not have any significant effect on reperfusion arrhythmias when given alone but they did potentiate the antiarrhythmic effect of superoxide dismutase. Glutathione, and a combination of superoxide dismutase, catalase and mannitol also reduced the incidence of reperfusion induced ventricular fibrillation when given just before reperfusion. By perfusing hearts with ferricytochrome C it was possible to show an increased reduction of ferricytochrome C during the first minute of reperfusion which could be prevented by the addition of superoxide dismutase. These results provide evidence that oxygen free radicals are produced and may be important in the genesis of reperfusion induced arrhythmias in the isolated rat heart.     

ACR appropriateness criteria(®) ductal carcinoma in situ

Abstract: Ductal carcinoma in situ (DCIS) describes a wide spectrum of non‐invasive tumors which carry a significant risk of invasive relapse, thus prevention of local recurrence is vital. For appropriate patients with limited disease, management with breast conserving surgery (BCS) followed by whole‐breast radiation (RT) is supported by multiple Phase III studies, but mastectomy may be appropriate in selected patients. Omission of RT may also be reasonable in some patients, though which criteria are to be utilized remain unclear, and the existing data are contradictory with limited follow‐up. Various RT techniques such as boost to the tumor bed, partial breast radiation or hypofractionated, whole‐breast RT are increasingly utilized but the data to support their use specifically in DCIS is limited. Tamoxifen also increases local control for ER + DCIS, adding to the complexity of the local treatment management. This article reviews the existing scientific evidence, the controversies surrounding local management, and clinical guidelines for DCIS based on the group consensus by the ACR Breast Expert Panel. The American College of Radiology Appropriateness Criteria are evidence‐based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer‐reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.     

Designing a workplace return-to-work program for occupational low back pain: an intervention mapping approach

Background  

Despite over 2 decades of research, the ability to prevent work-related low back pain (LBP) and disability remains elusive. Recent research suggests that interventions that are focused at the workplace and incorporate the principals of participatory ergonomics and return-to-work (RTW) coordination can improve RTW and reduce disability following a work-related back injury. Workplace interventions or programs to improve RTW are difficult to design and implement given the various individuals and environments involved, each with their own unique circumstances. Intervention mapping provides a framework for designing and implementing complex interventions or programs. The objective of this study is to design a best evidence RTW program for occupational LBP tailored to the Ontario setting using an intervention mapping approach.     

Sex-specific alterations in neutrophil apoptosis: the role of estradiol and progesterone

Women are conferred with greater immunologic and survival benefits compared to men. Female sex steroids contribute to this sexual dimorphism. Furthermore, during human pregnancy when female sex hormones are elevated, neutrophil apoptosis is delayed. This study examines the specific effects of estradiol and progesterone on neutrophil apoptosis and function in healthy adult men and women. We also examined the contribution of these hormones to the persistence and resolution of an inflammatory response. Spontaneous apoptosis was significantly decreased in women compared with men. Physiologic doses of estradiol and progesterone caused a further delay in spontaneous apoptosis in both men and women but did not diminish Fas antibody-induced apoptosis. The delay in apoptosis was mediated at the level of the mitochondria with decreased release of cytochrome c, which may alter caspase cleavage and activity. There were no associated alterations in neutrophil CD11b, but production of reactive oxygen intermediates (ROIs) in women was increased. Thus, female sex hormones mediate delayed neutrophil apoptosis in both sexes and enhance female intracellular production of ROIs. Modulating hormonal responses may be an effective therapeutic tool in combating inflammatory diseases.