Management and outcomes of obturator hernias: a systematic review and meta-analysis

PURPOSE

Obturator Hernia (OH) is a rare type of abdominal wall hernia. It usually occurs in elderly women with late symptomatic presentation, increasing mortality rates. Surgery is the standard of care for OH, and laparotomy with simple suture closure of the defect is commonly used. Given the rarity of this disease, large studies are lacking, and data to drive management are still limited. This systematic review and meta-analysis aimed to describe current surgical options for OHs, with a focus on comparing the effectiveness and safety of mesh use with primary repair.

METHODS

PubMed, EMBASE, and Cochrane were searched for studies comparing mesh and non-mesh repair for OH. Postoperative outcomes were assessed by pooled analysis and meta-analysis. Statistical analysis was performed using RevMan 5.4.

RESULTS

One thousand seven hundred and sixty studies were screened and sixty-seven were thoroughly reviewed. We included 13 observational studies with 351 patients surgically treated for OH with mesh or non-mesh repair. One hundred and twenty (34.2%) patients underwent mesh repair and two hundred and thirty-one (65.81%) underwent non-mesh repair. A total of 145 (41.3%) underwent bowel resection, with the majority having a non-mesh repair performed. Hernia recurrence was significantly higher in patients who underwent hernia repair without mesh (RR 0.31; 95% CI 0.11-0.94; p = 0.04). There were no differences in mortality (RR 0.64; 95% CI 0.25-1.62; p = 0.34; I² = 0%) or complication rates (RR 0.59; 95% CI 0.28-1.25; p = 0.17; I² = 50%) between both groups.

CONCLUSION

Mesh repair in OH was associated with lower recurrence rates without an increase in postoperative complications. While mesh in clean cases is more likely to offer benefits, an overall recommendation regarding its use in OH repair cannot be made due to potential bias across studies. Given that many OH patients are frail and present emergently, the decision to use mesh is complex and should consider the patient's clinical status, comorbidities, and degree of intraoperative contamination.

The single-syringe versus the double-syringe techniques of adenosine administration for supraventricular tachycardia: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Intravenous double-syringe technique (DST) of adenosine administration consists of an intravenous bolus of adenosine via three-way stopcock followed by an immediate 10-20ml sodium chloride 0.9% flush and is the recommended first-line treatment for stable supraventricular tachycardia (SVT). However, an alternative single-syringe technique (SST) method for adenosine administration has been described. This consists of diluting adenosine with sodium chloride 0.9% to a total volume of 15-20ml and was recently found to be potentially beneficial in several studies.

Purpose

We aimed to perform a meta-analysis of the SST versus the DST of adenosine administration as treatments for SVT.

Methods

We systematically searched EMBASE, PubMed, Cochrane, and ClinicalTrials.gov databases for randomised controlled trials (RCTs) and non-randomised studies of intervention (NRSIs) comparing the DST to SST adenosine administration in patients with SVT. The risk of bias was assessed by RoB-2 for RCTs and ROBINS-I for NRSIs. Outcomes included termination rate, termination rate at first dose, total administered dose, adverse effects, and discharge rate.

Results

We included four studies (three RCTs and one NRSI) with a total of 180 (60.55% female) patients, of whom 100 (55.55%) underwent the SST of adenosine administration. The three RCTs were considered of some concerns due to no pre-specified analysis in all studies and deviation from the intended intervention in one study. The NRSI was considered to carry a serious risk of bias by no analysis method that controlled for confounding, the possible influence of the outcome measure by knowledge of the intervention received, and no pre-specified analysis. No significant difference was found between treatment groups regarding termination rate (p = 0.22, Fig 1a), termination rate restricted to RCTs (p = 0.49, Fig 1b), total administered dose (p = 0.29, Fig 2a) and discharge rate (p = 0.1, Fig 2b). Termination rate at first dose (OR 2.87; CI 1.11-7.41; p = 0.03; I² = 0%, Fig 1c) was significantly increased in patients who received the SST. Major adverse effects were observed in only one study, with one patient suffering extravasation and phlebitis in the DST group.

Conclusion

To our knowledge, this is the first meta-analysis studying SST versus conventional DST for the management of SVT. This study suggests that the SST may be as safe as DST, equally effective for SVT termination, or even potentially more effective with the first dose. The SST would represent a simpler and more rapid approach, obviating the need for syringe switching or three-way stopcock, and reducing the margin of error in adenosine administration. To our knowledge, this is the highest quality evidence to date. Our results demonstrate that the current evidence is sufficient to support both SST and DST. However, favouring one technique over the other is not feasible given the limited sample size.

Hyperphosphatemia is associated with cardiac valve calcification in chronic hypoparathyroidism

PURPOSE

To evaluate the association between metabolic abnormalities and cardiovascular risk factors in patients with chronic hypoparathyroidism (HPP).

PATIENTS AND METHODS

Patients 18 years and older, glomerular filtration > 30 mL/min/1.73 m² and no documented coronary artery disease were selected. Serum calcium, phosphorus, glucose, lipids, PTH, 25(OH)D and FGF23 were measured. Cardiovascular risk was estimated by the European Society of Cardiology (ESC) calculator. Transthoracic echocardiogram and carotid ultrasound were performed to detect carotid plaques (CP), carotid intima-media thickness (IMT), cardiac valve calcification (CVC), and left ventricular hypertrophy (LVH).

RESULTS

Thirty-seven patients (94.6% female), aged 56.0 ± 13.5 years and HPP duration 7.0 (4.0; 11.3) years, were included. Fifteen were classified as low cardiovascular risk, 9 as intermediate risk, 9 as high risk and none as very high risk. The prevalence of CP, CVC and LVH was 24.3%, 24.3% and 13.5%, respectively. IMT values were within normal ranges in all cohort. FGF23 were not associated with CP, IMT, CVC or LVH. After logistic regression, phosphorus was the only significant metabolic variable impacting CVC in univariate analysis (OR 2.795; 95% CI 1.132-6.905; p = 0.026), as well as in the multivariate analysis (OR 3.572; 95% CI 1.094-11.665; p = 0.035). Analysis by ROC curve showed serum phosphorus > 5.05 mg/dL (AUC 0.748; CI 0.584-0.877; p = 0.05) as the best cutoff point associated with valve heart calcification (sensitivity 78%; negative predictive value 91.3%).

CONCLUSION

Hyperphosphatemia was associated with CVC in HPP patients. Further studies are needed to investigate whether the control of hyperphosphatemia may reduce cardiovascular risk in this population.

Crosstalk between the signaling pathways triggered by angiotensin II and adenosine in the renal proximal tubules: implications for modulation of Na(+)-ATPase activity

We have previously demonstrated that adenosine (Ado) reverses the stimulatory effect of angiotensin II (Ang II) on Na(+)-ATPase activity via the A(2A) receptor. In this work, the molecular mechanism involved in Ado-induced shutdown in the signaling pathway triggered by 10(-8)M Ang II was investigated. It was observed that: (1) both 10(-12)M PMA (a PKC activator) and 5x10(-8)M U73122 (an inhibitor of PI-PLCbeta) prevent the reversion effect induced by 10(-6)M Ado (only observed in the presence of 10(-6)M DPCPX (an A(1) receptor antagonist)) on Ang II-stimulated Na(+)-ATPase and PKC activities; (2) Ang II-stimulated PKC activity was reversed by 10(-6)M forskolin (an adenylyl cyclase activator) or 10(-8)M PKA inhibitory peptide and 10(-8)M DMPX (an A(2) receptor-selective antagonist). Considering that PMA prevents the inhibitory effect of Ado on Ang II-stimulated Na(+)-ATPase and PKC activities, it is likely that the PMA-induced effect, i.e. PKC activation, is downstream of the target for Ado-induced reversion of Ang II stimulation of Na(+)-ATPase activity. We investigated the hypothesis that PI-PLCbeta could be the target for Ado-induced PKA activation. Our data demonstrate that Ang II-stimulated PI-PLCbeta activity was reversed by Ado or 10(-7)M cAMP; the reversibility of the Ado-induced effect was prevented by either DMPX or PKA inhibitory peptide. These data demonstrate that Ado-induced PKA activation reduces Ang II-induced stimulation of PI-PLCbeta.

Genetic variation and recombination of RdRp and HSP 70h genes of Citrus tristeza virus isolates from orange trees showing symptoms of citrus sudden death disease

BACKGROUND

Citrus sudden death (CSD), a disease that rapidly kills orange trees, is an emerging threat to the Brazilian citrus industry. Although the causal agent of CSD has not been definitively determined, based on the disease's distribution and symptomatology it is suspected that the agent may be a new strain of Citrus tristeza virus (CTV). CTV genetic variation was therefore assessed in two Brazilian orange trees displaying CSD symptoms and a third with more conventional CTV symptoms.

RESULTS

A total of 286 RNA-dependent-RNA polymerase (RdRp) and 284 heat shock protein 70 homolog (HSP70h) gene fragments were determined for CTV variants infecting the three trees. It was discovered that, despite differences in symptomatology, the trees were all apparently coinfected with similar populations of divergent CTV variants. While mixed CTV infections are common, the genetic distance between the most divergent population members observed (24.1% for RdRp and 11.0% for HSP70h) was far greater than that in previously described mixed infections. Recombinants of five distinct RdRp lineages and three distinct HSP70h lineages were easily detectable but respectively accounted for only 5.9 and 11.9% of the RdRp and HSP70h gene fragments analysed and there was no evidence of an association between particular recombinant mosaics and CSD. Also, comparisons of CTV population structures indicated that the two most similar CTV populations were those of one of the trees with CSD and the tree without CSD.

CONCLUSION

We suggest that if CTV is the causal agent of CSD, it is most likely a subtle feature of population structures within mixed infections and not merely the presence (or absence) of a single CTV variant within these populations that triggers the disease.

PTEN and p53 expression in primary ovarian carcinomas: immunohistochemical study and discussion of pathogenetic mechanisms

Proapoptotic molecules have been studied in epithelial ovarian neoplasms as possible indicators of the pathogenetic pathways, as targets for new therapeutic approaches, and as prognostic markers. PTEN and p53 are proteins that have many different regulatory functions, including apoptosis. We have studied their immunohistochemical expression in 70 cases of primary ovarian carcinomas (26 serous, 27 endometrioid, and 17 mucinous) and compared the results with morphologic parameters (histologic grade, subtype) and clinical data (age, stage, tumor size). Statistical analyses showed a significantly higher expression of p53 in histologically high-grade tumors (grades 2 and 3), mainly of the serous subtype. A statistical tendency of higher expression of p53 in older patients (P= 0.08) was also observed. The loss of expression of PTEN was significantly more frequent in grade 1 endometrioid adenocarcinomas. These markers did not show association with volume or stage of the tumor. p53 is associated with serous carcinoma, loss of differentiation, and older patients, whereas PTEN inactivation is an early event in carcinogenesis of the endometrioid subtype, as observed in type I endometrial carcinoma. Our results are in keeping with different pathogenetic pathways in subtypes of ovarian carcinoma, prompting the search for new strategies of prevention and treatment.

Adenosine reverses the stimulatory effect of angiotensin II on the renal Na+-ATPase activity through the A2 receptor

In the present paper, we report the modulation of the Angiotensin II (Ang II)-stimulated Na+-ATPase activity of the proximal tubule basolateral membrane by adenosine (Ado). Preincubation of isolated basolateral membrane with 10(-8)M Ang II increases the Na+-ATPase activity from 7.5+/-0.3 (control) to 14.6+/-0.9 nmol Pi x mg(-1)x min(-1)nmol Pi x mg(-1) x min(-1) (p<0.05). Incubation of Ang II-stimulated enzyme with 10(-6)M Ado, in the presence of the A1 receptor antagonist DPCPX (10(-6)M), completely reverses the Ang II-induced effect bringing the Na+-ATPase activity to the basal level. The following evidences demonstrate involvement of the A2 receptor/Gs protein/adenylyl cyclase/PKA signaling pathway in the inhibitory effect induced by Ado on the Ang II-stimulated Na+-ATPase activity in the presence of the DPCPX: 1) the inhibitory effect of Ado is abolished by the A2 receptor selective antagonist DMPX (10(-8)M); 2) the effect induced by Ado is blocked by 10(-8)M GDPbetaS and mimicked by 10(-9)M cholera toxin and 10(-8)M GTPgammaS; 3) the stimulatory effect of Ang II is reduced by 10(-6)M forskolin, an activator of adenylyl cyclase, or 10(-6)M cAMP; 4) Ado stimulates PKA activity; 5) the inhibitory effect induced by this nucleoside is reversed by the PKA inhibitor peptide.

Expression of p53, c-erbB-2, Ki-67, and CD34 in granulosa cell tumor of the ovary

The purpose of this study is to investigate the expression of p53, c-erbB-2, Ki-67, and angiogenic activity and their correlation with the clinicopathologic characteristics in a series of granulosa cell tumors of the ovary (GCTO). Eighteen GCTO cases assisted at the Department of Obstetrics and Gynecology, School of Medical Science, UNICAMP, after diagnostic confirmation by three pathologists, were submitted to immunohistochemistry for assessment of p53, c-erbB-2, Ki-67, and CD34 expressions. The mean tumor size was 13 cm (range: 4-30 cm). Six (33%) cases presented with extraovarian disease. Thirteen (72%) cases presented some solid diffuse or sarcomatoid pattern and six (33%) moderate or strong atypia. Fourteen cases presented </=2 mitoses/10 HPF. Thirteen cases were focally positive for Ki-67. The mean Ki-67 proliferative index was 1.0%. One case presented positive expression for mutant p53 but all cases were negative for c-erbB-2 expression. The mean microvascular density was 28.9/mm2 (range: 0-50). No significant correlations could be established between the biologic markers and clinicopathologic variables. GCTO showed a markedly low rate of immunohistochemical staining for p53 or c-erbB-2 overexpression/amplification, as well as low proliferative and angiogenic activities. Further studies are urgently needed to elaborate the factors responsible for the highly unpredictable clinical course of GCTO.