Predictors of chronic pain after laparoscopic inguinal hernia repair

BackgroundMultiple studies have analyzed predictors for chronic pain after open hernia repair. The purpose of this study is to determine which factors predict the development of chronic pain after a laparoscopic inguinal hernia repair.MethodsWe identified patients who underwent laparoscopic inguinal hernia repair between 2008 and 2020 at a single institution. Quality of life was measured using the Surgical Outcomes Measurement System and Carolinas Comfort Scale. We categorized patients with chronic pain if their score on Carolinas Comfort Scale was greater than or equal to 3. Multivariable logistic regression analysis was used to identify predictors of chronic pain.ResultsA total of 960 patients met inclusion criteria. Mean age was 59 (± 14, standard deviation) years, 89 (9.3%) of whom were female. Six percent of patients met criteria for chronic pain (Carolinas Comfort Scale ≥3). On multivariable analysis, predictors for chronic pain were age 45 (P < .001), female sex (P = .006), preoperative pain visual analog scale ≥1 (P = .025), prior inguinal hernia repair (P = .045), higher American Society of Anesthesiologists class (P = .041), use of multifilament polyester mesh (P = .0448), and intraoperative placement of a urinary catheter (P = .009).ConclusionLaparoscopic inguinal hernia repair results in 6.0% of patients experiencing chronic pain. We identified multiple predictors for chronic pain.     

ASO Visual Abstract: Male Breast Cancer Patients and Surgeon Experience: The Male WhySurg Study

Annals of Surgical Oncology -     

Update on the Human Broad Tapeworm (Genus Diphyllobothrium), Including Clinical Relevance

Summary: Tapeworms (Cestoda) continue to be an important cause of morbidity in humans worldwide. Diphyllobothriosis, a human disease caused by tapeworms of the genus Diphyllobothrium, is the most important fish-borne zoonosis caused by a cestode parasite. Up to 20 million humans are estimated to be infected worldwide. Besides humans, definitive hosts of Diphyllobothrium include piscivorous birds and mammals, which represent a significant zoonotic reservoir. The second intermediate hosts include both freshwater and marine fish, especially anadromous species such as salmonids. The zoonosis occurs most commonly in countries where the consumption of raw or marinated fish is a frequent practice. Due to the increasing popularity of dishes utilizing uncooked fish, numerous cases of human infections have appeared recently, even in the most developed countries. As many as 14 valid species of Diphyllobothrium can cause human diphyllobothriosis, with D. latum and D. nihonkaiense being the most important pathogens. In this paper, all taxa from humans reported are reviewed, with brief information on their life history and their current distribution. Data on diagnostics, epidemiology, clinical relevance, and control of the disease are also summarized. The importance of reliable identification of human-infecting species with molecular tools (sequences of mitochondrial genes) as well as the necessity of epidemiological studies aimed at determining the sources of infections are pointed out.     

Polymerization of 2'-fluoro- and 2'-O-methyl-dNTPs by human DNA polymerase alpha, polymerase gamma, and primase

Studies were undertaken to assess the ability of human polymerase alpha (pol alpha) and polymerase gamma (pol gamma) to incorporate 2'-fluoro- and 2'-O-methyldeoxynucleotides into DNA. In vitro DNA synthesis systems were used to detect incorporation and determine K(m) and V(max) for 2'-FdATP, 2'-FdUTP, 2'-FdCTP, 2'-FdGTP, 2'-O-MedATP, 2'-O-MedCTP, 2'-O-MedGTP, 2'-O-MedUTP, dUTP, UTP, and FIAUTP, in addition to normal deoxynucleotides. Pol alpha incorporated all 2'-FdNTPs except 2'-FdATP, but not 2'-O-MedNTPs. Pol gamma incorporated all 2'-FdNTPs, but not 2'-O-MedNTPs. In general, 2'-fluorine substitution decreased V(max)/K(m) 2'-FdUTP. Because kinetics of insertion of pol alpha can be affected by the nature of the primer, we examined the ability of pol alpha to polymerize 2'-fluoro- and 2'-O-MedATP and dGTP when elongating a primer synthesized by DNA primase. Under these conditions, both 2'-FdATP and 2'-FdGTP were polymerized, but 2'-O-MedATP and 2'-O-MedGTP were not. Primase alone could not readily polymerize these analogs into RNA primers. Previous studies showed that 2'-deoxy-2'-fluorocytosine (2'-FdC) is incorporated by several non-human DNA polymerases. The current studies showed that human polymerases can polymerize numerous 2'-FdNTPs but cannot polymerize 2'-O-MedNTPs.     

Microcystic adnexal carcinoma induced by multiple radiation therapy

We present an 84‐year‐old Caucasian man (Fitzpatrick classification: skin type II) with microcystic adnexal carcinoma (MAC) on his left cheek and a 15‐year history of recurrent squamous cell carcinoma (SCC) of the head, treated with numerous surgical interventions and multiple palliative 60‐Gy radiation therapy. In 1996, the patient developed a nontender, indurated, irregularly marked, erythematous lesion on his left cheek (1.5 × 1 cm). Furthermore, the patient suffered from radiodermatitis due to previous radiotherapy ( Fig. 1 ). Punch biopsy and a subsequent wedge excision showed features of both SCC and eccrine carcinoma. Histopathologic and immunohistochemical tests of the tumor revealed a diagnosis of MAC. The patient underwent Mohs' micrographically controlled surgery to obtain tumor‐free peripheral soft tissue margins. There was no evidence of any lymphatic invasion or distant metastasis in the physical and laboratory examination. So far, the patient has not developed any recurrences.

Figure 1 Open in figure viewer PowerPoint Clinical picture of MAC showing features of radiodermatitis     

Use of anti-infective agents during lactation: Part 2--Aminoglycosides, macrolides, quinolones, sulfonamides, trimethoprim, tetracyclines, chloramphenicol, clindamycin, and metronidazole.

Because many antibiotics are excreted into breast milk, it can be difficult for a practitioner to choose an antibiotic for a lactating patient that will have minimal risks to her nursing infant. This article is the second of a three-part series discussing the use of anti-infective agents during lactation. The authors review general information regarding use and common side effects for several classes of antibiotics. They also summarize information, including documented milk concentrations, milk-to-plasma ratios, and other pharmacokinetic properties, in a table that can help practitioners choose antibiotics that may be considered safe to use in the lactating mother.     

Patterns and timing of artificial urinary sphincter failure

Purpose

To assess population-based trends in artificial urinary sphincter (AUS) placement after prostatectomy and determine the effect of timing on device survival and complications.

Methods

We identified patients who underwent prostatectomy and AUS placement in SEER-Medicare from 2002 to 2011. We analyzed factors affecting the time of reoperation from AUS implantation and prostatectomy using multivariable Cox proportional hazard models.

Results

In total, 841 men underwent AUS placement at a median 23 months after prostatectomy. Patients who underwent reoperation (28.5%) had higher clinical stage, more likely underwent open prostatectomy, or had prior sling placement (p < 0.03). There were no differences in rates of diabetes, smoking status, prior radiation therapy, or Charlson Comorbidity Index between those requiring reoperation vs. not (all p > 0.15). Patients with AUS placement > 15 months after prostatectomy (75%) initially experienced less need for operative reinterventions. Patients with later AUS placement were significantly more likely to have received radiation therapy [22.9 vs. 3.8% (p < 0.01)]. Nonetheless, late implantation was confirmed to be protective on multivariate analysis during the first 5 years after AUS placement [HR 0.79 (95% CI 0.67–0.92); p < 0.01]. Factors independently associated with a shorter interval time until reoperation included history of radiation [HR 1.93 (95% CI 1.33–2.80); p < 0.01] and history of prior sling [HR 1.70 (95% CI 1.08–2.68); p = 0.02]. Even for patients who underwent radiation therapy, delayed AUS implantation reduced reoperative risk.

Conclusions

Late AUS implantation in the Medicare population is associated with prolonged device survival initially, while radiation and prior sling surgery predict for earlier reoperation. Patients with delayed AUS implantation experience less immediate complications. Further work is required to identify patient-specific factors which may explain variability in timing for AUS.

     

Neoadjuvant Chemoradiation Shows No Survival Advantage to Chemotherapy Alone in Stage IIIA Patients

1. Download high-res image (218KB)
2. Download full-size image

     

Medication use in the elderly patient: Focus on the perioperative/perianesthesia setting

As the population ages, the use of multiple medications also increases. Polypharmacy (taking multiple drugs at a time) presents concerns to the perianesthesia nurse who is caring for the geriatric patient. The pharmacokinetics and pharmacodynamics of drugs are often altered in older adult patients. Adverse drug reactions and drug interactions occur more often in geriatric patients than in younger patients. For these reasons, the benefits and risks of multiple medications and the administration of certain types of drugs must be carefully considered in the elderly patient. The selection of any medication should be individually based on the benefits and risks. Adverse drug reactions play a significant role in hospitalization for the general population, and the elderly are more susceptible to these. These drug reactions often contribute to significant morbidity as well as mortality. Medications need to be considered carefully in the older adult patient, but perhaps more so in the perioperative/perianesthesia period. Drug interactions are diverse. The type of anesthesia may influence the patient's outcome, depending on the medications the patient is currently taking. The patient's response to the stress of surgery is also affected by individual medical conditions as well as medications the patient is currently receiving Polypharmacy, inappropriate medications, adverse drug reactions, drug-disease issues, and drug interactions in the geriatric population are concerns in the perioperative/perianesthesia setting.