Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias

Introduction

In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias.

Methods

A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type.

Results

The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03–2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04–6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher’s exact test).

Conclusions

Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.     

7-溴乙氧苯四氢巴马汀对离体豚鼠工作心脏的作用

用Tris-丙酮酸钠液灌流离体豚鼠工作心脏,记录左室压的导管从左房灌流管插入,可使心脏有效工作时间达70min。用Tris-丙酮酸钠液加0.5%的氟碳液能使有效工作时间延长至90min。7-溴乙氧苯四氢巴马汀(7-bromoethyoxybenzene tetrahydropalmatine,EBP)及哌唑嗪0.1μmol/L对工作心脏各项指标均无显著影响。甲氧胺1μmol/L,多巴胺1μmol/L对LVP,ABF,T-CO等指标均有明显的药理作用。EBP 10μmol/L能对抗甲氧胺、多巴胺对上述指标的影响。     

四肢关节专用低场强MRI评估对膝关节损伤的诊断价值

目的：分析四肢关节专用低场强MRI诊断膝关节损伤的临床应用价值。 方法：于2004-12/2005-10解放军总医院全军骨科研究所收治经手术、关节镜检查或临床证实的膝关节损伤患者40例（43个膝关节）。应用Atorscan0.2T永磁型四肢关节专用低场强磁共振机,对膝关节损伤的MRI表现进行分析。 结果：四肢关节专用低场强MRI对半月板、前交叉韧带、骨挫伤等均可作出正确诊断。 结论：四肢关节专用低场强MRI对膝关节损伤的综合诊断具有重要意义,是膝关节损伤较理想的一种非创伤性检查方法。     

组织因子刺激体外培养人脐静脉内皮细胞肿瘤坏死因子α、白细胞介素1的表达

目的:组织因子介导了细胞凝集、组织损伤、血栓形成,从而参与"凝血-炎症-血栓形成"网络。组织因子是否为一种独立的前炎症介质介导炎症反应,刺激人脐静脉内皮细胞使之分泌肿瘤坏死因子α、白细胞介素1。方法:实验于2004-09/2006-02在贵阳医学院组织工程与干细胞实验中心(省级重点实验室)完成。利用重组的组织因子刺激体外培养的人脐静脉内皮细胞,并设立空白对照组、0.2mg/L组织因子刺激组和0.8mg/L组织因子刺激组,用ELISA检测不同组织因子刺激浓度在同一刺激时间(6h)其炎症介质(肿瘤坏死因子α、白细胞介素1)的表达分泌情况。结果:①组织因子可以刺激人脐静脉内皮细胞使之分泌肿瘤坏死因子α,0.2mg/L组织因子刺激组与0.8mg/L组织因子刺激组肿瘤坏死因子α水平高于空白对照组(P<0.05);0.8mg/L组织因子刺激组肿瘤坏死因子α水平高于0.2mg/L组织因子刺激组(P<0.05)。②与空白对照组相比较,0.2mg/L组织因子刺激组白细胞介素1水平未升高,0.8mg/L组织因子刺激组略有升高,但差异无显著性意义(P>0.05)。结论:组织因子可以作为一种前炎症介质介导炎症反应,使内皮细胞肿瘤坏死因子α表达增强。     

重组结缔组织生长因子对体外培养成骨细胞核结合因子α1基因表达的影响

目的:研究发现,结缔组织生长因子可促进软骨细胞和成骨细胞的增殖及其表型的发生,在骨骼发育以及骨量维持方面发挥重要作用,但其对成骨细胞的作用机制目前尚不清楚。观察重组结缔组织生长因子对体外培养人成骨细胞核结合因子α1基因表达的影响。方法:实验于2006-01/2007-01在日照市人民医院完成。①实验材料:外科手术取正常成人髂骨松质骨,患者对试验知情同意。②实验方法:体外培养正常人成骨细胞,用不同浓度0,50,100,200,1000μg/L的重组结缔组织生长因子(0μg/L作为空白对照组)干预48h后,抽提细胞总RNA和总蛋白。③实验评估:采用半定量反转录-聚合酶链反应和蛋白免疫印迹分析方法观察不同浓度重组结缔组织生长因子对体外培养人成骨细胞核结合因子α1基因表达的影响。结果:半定量反转录-聚合酶链反应和蛋白免疫印迹结果显示,50,100,200,1000μg/L重组结缔组织生长因子干预后均可显著上调成骨细胞核结合因子α1的表达,并呈明显剂量依赖关系,与空白对照组比较,差异显著(P<0.01)。结论:重组结缔组织生长因子可剂量依赖性上调成骨细胞核结合因子α1基因的表达,核结合因子α1可能参与了结缔组织生长因子对成骨细胞增殖和分化的调节。     

Hypothalamic orexin, OX1, αMSH, NPY and MCRs expression in dopaminergic D2R knockout mice

In 5-month-old male and female dopamine receptor 2 (D2R) knockout mice food intake per animal was unaltered while food per g BW was increased. We wished to evaluate the effect of D2R disruption on different components of energy balance and food intake regulation. We determined hypothalamic orexin precursor (PPO) expression, its receptor OX1, serum leptin levels, hypothalamic leptin receptor (OBR), circulating and pituitary α MSH levels, as well as central MC3 and MC4 receptors and NPY mRNA in wildtype and D2R knockout mice (KO).Loss of D2R caused a marked increase in serum prolactin levels, to higher levels in females compared to male KO mice. On the other hand, it produced a female-specific increase in circulating αMSH, and hypothalamic αMSH content, while neurointermediate αMSH content was decreased in both sexes. No differences were found in hypothalamic NPY, MC3R or MC4R concentration. Hypothalamic PPO mRNA expression was significantly decreased only in female KOs, while OX1 mRNA was not different between genotypes. Serum leptin levels were also similar in both genotypes.Our results show that in female and not in male mice disruption of the D2R produces two potentially anorexigenic events: an increase in serum and hypothalamic αMSH, and a decrease in hypothalamic orexin expression. Very high prolactin levels, which are orexigenic, probably counterbalance these effects, so that food intake is slightly altered. In males, on the other hand, hypothalamic PPO, and serum or hypothalamic αMSH are not modified, and increased prolactin levels may account for increased food intake per g BW. These results suggest a sexually dimorphic participation of the D2R in food intake regulation.     

苄基四氢巴马汀对表达于非洲爪蟾卵母细胞及中华大蟾蜍卵母细胞的延迟整流钾电流的抑制作用

苄基四氢巴马汀对表达于非洲爪蟾卵母细胞及中华大蟾蜍卵母细胞的延迟整流钾电流的抑制作用童秋生，夏国瑾，姚伟星，江明性，白小川，包永德（同济医科大学基础医学院药理学教研室，武汉４３００３０；中国科学院上海生理学研究所，上海２０００３１）苄基四氢巴马汀（ｂ...