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ASO Visual Abstract: A Randomized Single-Blinded Study Comparing Pre- and Post-Mastectomy PECS Block for Postoperative Pain Management in Bilateral Mastectomy With Immediate Reconstruction. Ann Surg Oncol 2023; 30:6022-6023. [PMID: 37606838 DOI: 10.1245/s10434-023-13991-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
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A Randomized Single-Blinded Study Comparing Preoperative with Post-Mastectomy PECS Block for Post-operative Pain Management in Bilateral Mastectomy with Immediate Reconstruction. Ann Surg Oncol 2023; 30:6010-6021. [PMID: 37526752 DOI: 10.1245/s10434-023-13890-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/06/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Ultrasound-guided pectoralis muscle blocks (PECS I/II) are well established for postoperative pain control after mastectomy with reconstruction. However, optimal timing is unclear. We conducted a randomized controlled single-blinded single-institution trial comparing outcomes of block performed pre-incision versus post-mastectomy. METHOD Patients with breast cancer undergoing bilateral mastectomy with immediate expander/implant reconstruction were randomized to receive ultrasound-guided PECS I/II either pre-incision (PreM, n = 17) or post-mastectomy and before reconstruction (PostM, n = 17). The primary outcome was the average pain score using the Numerical Rating Score during post-anesthesia care unit (PACU) and inpatient stay, with the study powered to detect a difference in mean pain score of 2. Secondary outcomes included mean pain scores on postoperative day (POD) 2, 3, 7, 14, 90, and 180; pain catastrophizing scores; narcotic requirements; PACU/inpatient length of stay; block procedure time; and complications. RESULT No significant differences between the two groups were noted in average pain score during PACU (p = 0.57) and 24-h inpatient stay (p = 0.33), in the 2 weeks after surgery at rest (p = 0.90) or during movement (p = 0.30), or at POD 90 and 180 at rest (p = 0.42) or during movement (p = 0.31). Median duration of block procedure (PreM 7 min versus PostM 6 min, p = 0.21) did not differ. Median PACU and inpatient length of stay were the same in each group. Inpatient narcotic requirements were similar, as were length of stay and post-surgical complication rates. CONCLUSION Intraoperative ultrasound-guided PECS I/II block administered by surgeons following mastectomy had similar outcomes to preoperative blocks. TRIAL REGISTRATION This trial is registered with Clinical Research Information Service (NCT03653988).
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Return to Sport After Knee Injuries in Collegiate Wrestling. THE IOWA ORTHOPAEDIC JOURNAL 2023; 43:131-135. [PMID: 37383862 PMCID: PMC10296484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Background Wrestling is known to be a sport of relatively high injury incidence, and knee injuries account for a large percentage of those injuries. Treatment of these injuries varies considerably depending on injury and wrestler characteristics, leading to variability in complete recovery and return to sport (RTS). The purpose of this study was to evaluate injury trends, treatment strategies, and RTS characteristics after knee injuries in competitive collegiate wrestling. Methods NCAA Division I collegiate wrestlers who sustained knee injuries between January 2010 and May 2020 were identified using an institutional Sports Injury Management System (SIMS). Wrestling-related knee, meniscus, and patella injuries were identified, and treatment strategies were documented to investigate potential recurrent injury trends. Descriptive statistics were used to quantify the number of days, practices, and competitions missed, return to sport times, and recurrent injuries among wrestlers. Results Overall, 184 knee injuries were identified. After excluding non-wrestling injuries (n=11), 173 injuries remained (77 wrestlers). The mean age at time of injury was 20.8 ± 1.4 years, and the mean BMI was 25.9 ± 3.8 kg/m2. There were 135 primary injuries (74 wrestlers), which consisted of 72 (53%) ligamentous injuries, 30 (22%) meniscus injuries, 14 patellar injuries (10%), and 19 other injuries (14%). The majority of ligamentous injuries (93%) and patellar injuries (79%) were treated non-operatively, while the majority of meniscus tears (60%) underwent surgery. Twenty-three wrestlers (22%) sustained recurrent knee injuries, of which 76% were treated non-operatively after their initial injury. Recurrent injuries consisted of 12 (32%) ligamentous injuries, 14 (37%) meniscus injuries, eight (21%) patellar injuries, and four (11%) other injuries. Fifty percent of recurrent injuries were treated operatively. When comparing recurrent injuries to primary injuries, recurrent injuries had a significantly longer return to sport time (Recurrent 68.3 ± 96.0 days vs. Primary 26.0 ± 56.4 days, p=0.01). Conclusion The majority of NCAA Division I collegiate wrestlers who sustained knee injuries were initially treated non-operatively, and approximately one in five wrestlers sustained recurrent injuries. Return to sport time was significantly increased after a recurrent injury. Level of Evidence: IV.
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COVID-19 Increased Residency Applications and How Virtual Interviews Impacted Applicants. Cureus 2022; 14:e26096. [PMID: 35875277 PMCID: PMC9298600 DOI: 10.7759/cureus.26096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2022] [Indexed: 11/05/2022] Open
Abstract
Background The number of residency applications submitted by medical students has risen at an alarming rate, causing increased cost of applications and subsequent interview travel. These both contribute to increased cost for medical students. In light of these concerns, specialty governing bodies have proposed ideas to fight these trends including, application limits, interview limits, using a preference signaling system, and continuing virtual interviews. During the Covid-19 pandemic, all residency interviews were performed virtually, essentially making travel expenses negligible. However, this created a new concern with regards to assessing program and applicant compatibility, as compared to in-person interactions and did nothing to combat the increases in application numbers. Therefore, we want to critically assess the effects of virtual interviews on number of applications submitted, number of interview invites received, and number of interviews attended. We also aim to analyze how applicants viewed the virtual process. Methods 600 medical students were eligible to participate. 456 students from years 2018-2020 were eligible to be surveyed following the NRMP match. 144 students were eligible to be surveyed following 2021 NRMP match. The survey was distributed to medical school graduates just prior to graduation and asked how many programs each student applied to, how many interview invites they received, and how many interviews they attended. The 2021 survey also asked, “How did virtual interviews affect your interview experience?” The quantitative results were compared with student's t-test and qualitative results are presented below. Results The average number of programs each applicant applied to increased from 35.4 to 47.7 (p-value=0.002) when residency interviews switched from in-person to virtual. However, interview invites received and interviews attended did not change (16.8 vs 16.3, p-value=0.91, 11.8 vs 12.7, p-value=0.18). There were 188 participants in the in-person interview group (response rate=41.2%) and 128 participants in the virtual interview group (response rate=83.3%). The standard deviation and range also increased for number of applications, number of interview invites received, and number of interviews attended. There were 123 responses to the free response question. 36 had a positive experience, 44 were neutral, 47 were negative. The positive themes included 15 noted less expenses, 18 noted more convenient/less time, and 18 were able to attend more interviews. Negative themes included, 38 noted difficulty assessing program fit, 19 wanted to see the program or city in person, eight had increased interest in home/local programs, six found it difficult to make connections or stand out. Conclusion Sixty-three percent of students reported a positive or neutral experience with virtual interviews. Students applied to more programs when interviews were virtual, but did not receive more interview invites or attend more interviews. These results suggest that virtual interviews are sufficient to conduct residency interviews, however the number of applications continues to rise with no increase in the number interview invites received or number of interviews attended. The increase in the standard deviation and range for all three variables may point to some applicants being able to get more invites and attend more interviews leaving less available spots for other applicants.
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Educational Factors and Financial Implications of Medical Students Choosing and Matching Into Orthopedic Surgery. THE IOWA ORTHOPAEDIC JOURNAL 2022; 42:8-21. [PMID: 36601231 PMCID: PMC9769355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Mentorship and research have been shown to be important decision factors influencing medical students to pursue a particular specialty. The cost of applying to orthopedic surgery residency is at an all-time high. The purpose of this study is to identify the factors which increase the likelihood of medical students matching into orthopedic surgery, identify the timing and strength of impact these factors have on medical students' career choices, determine how many students have chosen orthopedic surgery prior to beginning medical school, and compare the financial impact of applying to orthopedics. Methods 608 medical students were surveyed 5 times during medical school (at the start of M1, M2, M3, M4 year and after the match process) to identify ongoing factors that influence their career choice and ultimately matching in orthopedic surgery. Unadjusted odds ratios and cost analysis were used to determine the factors influencing specialty choice. Level of evidence: III. Results Students who matched into orthopedic surgery were more likely to be mentored by an orthopedic surgeon at all 5 survey points (M1 OR=30.93, M2 OR=12.38, M3 OR=17.96, M4 OR=65.2, Match OR=215.45) and involved in orthopedic surgery research at the last 4 survey points (M2 OR=20.05, M3 OR=14.00, M4 OR=12.00, Match OR=1566.60) compared to students who did not match into orthopedic surgery. 10 out of 19 students (52.6%) who matched into orthopedic surgery listed the specialty as their preference in the M1 survey. Students who matched into orthopedic surgery spent $8,838.80 on applications and interviews, while students applied to and matched into other specialties spent an average of $6,173.4 (p-value=0.007). Conclusion Many students have a predetermined plan to enter orthopedic surgery prior to medical school. Mentorship and research are important factors increasing students' interest in orthopedic surgery and ultimately leading to a successful match process. Going through the orthopedic surgery match process is significantly more expensive than other specialties. Level of Evidence: IV.
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Factors Associated with Matching into Surgical Specialties. J Surg Res 2021; 270:300-312. [PMID: 34731727 DOI: 10.1016/j.jss.2021.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 09/09/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The United States medical education system has a vested interest in understanding medical student specialty choice. The purpose of this study is to identify the demographic, educational, lifestyle preference, and other factors associated with matching into surgical specialties. METHODS An annual survey was given to students at the University of Iowa Carver College of Medicine from 2013-2019. 456 medical students were eligible to participate and 374 completed at least one survey. Surveys were distributed 5 times; M1, M2, M3, and M4 years and after the residency match process. Logistic regression was used to estimate the association between various factors and the likelihood of matching into a surgical specialty. RESULTS Exposure to surgical fields, through a family member practicing surgery (aOR = 3.21), mentorship (aOR = 2.78), or research (aOR = 2.96) increase the likelihood of matching into a surgical specialty. Married students are less likely to pursue surgical specialties (aOR = 0.246). White students interested in surgery in their first two years of medical school were more likely (aOR = 6.472) to match into surgery than non-white students also interested in surgery (aOR = 0.155). CONCLUSIONS Factors associated with an increased likelihood of matching into surgical specialties include having surgical mentors, performing surgical research, and having family members in surgical specialties. Of the students interested in surgery early in medical school, being of Caucasian ethnicity is associated with higher rates of matching into surgery. Students who are married without children are less likely to enter a surgical field.
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Analysis of model development strategies: predicting ventral hernia recurrence. J Surg Res 2016; 206:159-167. [DOI: 10.1016/j.jss.2016.07.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/18/2016] [Accepted: 07/25/2016] [Indexed: 12/30/2022]
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YouTube is the Most Frequently Used Educational Video Source for Surgical Preparation. JOURNAL OF SURGICAL EDUCATION 2016; 73:1072-1076. [PMID: 27316383 PMCID: PMC7263439 DOI: 10.1016/j.jsurg.2016.04.024] [Citation(s) in RCA: 182] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 04/23/2016] [Accepted: 04/29/2016] [Indexed: 05/06/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate surgical preparation methods of medical students, residents, and faculty with special attention to video usage. DESIGN Following Institutional Review Board approval, anonymous surveys were distributed to participants. Information collected included demographics and surgical preparation methods, focusing on video usage. Participants were questioned regarding frequency and helpfulness of videos, video sources used, and preferred methods between videos, reading, and peer consultation. Statistical analysis was performed using SAS. SETTING Surveys were distributed to participants in the Department of Surgery at the University of Iowa Hospitals and Clinics, a tertiary care center in Iowa City, Iowa. PARTICIPANTS Survey participants included fourth-year medical students pursuing general surgery, general surgery residents, and faculty surgeons in the Department of Surgery. A total of 86 surveys were distributed, and 78 surveys were completed. This included 42 learners (33 residents, 9 fourth-year medical students) and 36 faculty. RESULTS The overall response rate was 91%; 90% of respondents reported using videos for surgical preparation (learners = 95%, faculty = 83%, p = NS). Regarding surgical preparation methods overall, most learners and faculty selected reading (90% versus 78%, p = NS), and fewer respondents reported preferring videos (64% versus 44%, p = NS). Faculty more often use peer consultation (31% versus 50%, p < 0.02). Among respondents who use videos (N = 70), the most used source was YouTube (86%). Learners and faculty use different video sources. Learners use YouTube and Surgical Council on Resident Education (SCORE) Portal more than faculty (YouTube: 95% versus 73%, p < 0.02; SCORE: 25% versus 7%, p < 0.05). Faculty more often use society web pages and commercial videos (society: 67% versus 38%, p < 0.03; commercial: 27% versus 5%, p < 0.02). CONCLUSIONS Most respondents reported using videos to prepare for surgery. YouTube was the preferred source. Posting surgical videos to YouTube may allow for maximal access to learners who are preparing for surgical cases.
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Do risk calculators accurately predict surgical site occurrences? J Surg Res 2016; 203:56-63. [PMID: 27338535 DOI: 10.1016/j.jss.2016.03.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/10/2016] [Accepted: 03/18/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Current risk assessment models for surgical site occurrence (SSO) and surgical site infection (SSI) after open ventral hernia repair (VHR) have limited external validation. Our aim was to determine (1) whether existing models stratify patients into groups by risk and (2) which model best predicts the rate of SSO and SSI. METHODS Patients who underwent open VHR and were followed for at least 1 mo were included. Using two data sets-a retrospective multicenter database (Ventral Hernia Outcomes Collaborative) and a single-center prospective database (Prospective)-each patient was assigned a predicted risk with each of the following models: Ventral Hernia Risk Score (VHRS), Ventral Hernia Working Group (VHWG), Centers for Disease Control and Prevention Wound Class, and Hernia Wound Risk Assessment Tool (HW-RAT). Patients in the Prospective database were also assigned a predicted risk from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Areas under the receiver operating characteristic curve (area under the curve [AUC]) were compared to assess the predictive accuracy of the models for SSO and SSI. Pearson's chi-square was used to determine which models were able to risk-stratify patients into groups with significantly differing rates of actual SSO and SSI. RESULTS The Ventral Hernia Outcomes Collaborative database (n = 795) had an overall SSO and SSI rate of 23% and 17%, respectively. The AUCs were low for SSO (0.56, 0.54, 0.52, and 0.60) and SSI (0.55, 0.53, 0.50, and 0.58). The VHRS (P = 0.01) and HW-RAT (P < 0.01) significantly stratified patients into tiers for SSO, whereas the VHWG (P < 0.05) and HW-RAT (P < 0.05) stratified for SSI. In the Prospective database (n = 88), 14% and 8% developed an SSO and SSI, respectively. The AUCs were low for SSO (0.63, 0.54, 0.50, 0.57, and 0.69) and modest for SSI (0.81, 0.64, 0.55, 0.62, and 0.73). The ACS-NSQIP (P < 0.01) stratified for SSO, whereas the VHRS (P < 0.01) and ACS-NSQIP (P < 0.05) stratified for SSI. In both databases, VHRS, VHWG, and Centers for Disease Control and Prevention overestimated risk of SSO and SSI, whereas HW-RAT and ACS-NSQIP underestimated risk for all groups. CONCLUSIONS All five existing predictive models have limited ability to risk-stratify patients and accurately assess risk of SSO. However, both the VHRS and ACS-NSQIP demonstrate modest success in identifying patients at risk for SSI. Continued model refinement is needed to improve the two highest performing models (VHRS and ACS-NSQIP) along with investigation to determine whether modifications to perioperative management based on risk stratification can improve outcomes.
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Sublay versus underlay in open ventral hernia repair. J Surg Res 2015; 202:26-32. [PMID: 27083944 DOI: 10.1016/j.jss.2015.12.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/03/2015] [Accepted: 12/11/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The ideal location for mesh placement in open ventral hernia repair (OVHR) remains under debate. Current trends lean toward underlay or sublay repair. We hypothesize that in patients undergoing OVHR, sublay versus underlay placement of mesh results in fewer surgical site infections (SSIs) and recurrences. MATERIALS AND METHODS A multi-institution database of all OVHRs performed from 2010 to 2011 was accessed. Patients with mesh placed in the sublay or underlay position and at least 1 mo of follow-up were included. Primary outcome was SSI. Secondary outcome was hernia recurrence. Multivariate analysis was performed using logistic regression for SSI and Cox regression for recurrence. Subgroup analysis of elective, midline ventral incisional hernias was also performed. RESULTS Of 447 patients, 139 (31.1%) had a sublay repair. The unadjusted analysis showed no difference in SSI and lower recurrence using sublay compared with underlay. On multivariate analysis, there was no difference in SSI using sublay compared with underlay (odds ratio 1.5, 95% confidence interval [CI] 0.8-2.8). Recurrence was less common with sublay (hazard ratio 0.4, 95% CI 0.2-0.8). On subgroup analysis of elective, midline incisional hernias only (n = 247), there were more SSIs with sublay compared with underlay repair (28.0% versus 15.1%, P = 0.018); however, there was no difference in major SSI (sublay 9.3% versus underlay 5.8%, P = 0.315). There were fewer recurrences using sublay repair compared with underlay repair (10.7% versus 25.0%, P = 0.010). CONCLUSIONS In this multi-center, risk-adjusted study, sublay repair was associated with fewer recurrences than underlay repair and no difference in SSI. Randomized controlled trials are warranted to validate these findings.
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Component Separation vs. Bridged Repair for Large Ventral Hernias: A Multi-Institutional Risk-Adjusted Comparison, Systematic Review, and Meta-Analysis. Surg Infect (Larchmt) 2015; 17:17-26. [PMID: 26375422 DOI: 10.1089/sur.2015.124] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Repair of large ventral hernia defects is associated with high rates of surgical site occurrences (SSO), including surgical site infection (SSI), site dehiscence, seroma, hematoma, and site necrosis. Two common operative strategies exist: Component separation (CS) with primary fascial closure and mesh reinforcement (PFC-CS) and bridged repair (mesh spanning the hernia defect). We hypothesized that: (1) ventral hernia repair (VHR) of large defects with bridged repair is associated with more SSOs than is PFC, and (2) anterior CS is associated with more SSOs than is endoscopic, perforator-sparing, or posterior CS. METHODS Part I of this study was a review of a multi-center database of patients who underwent VHR of a defect ≥8 cm from 2010-2011 with at least one month of follow-up. The primary outcome was SSO. The secondary outcome was recurrence. Part II of this study was a systematic review and meta-analysis of studies comparing bridged repair with PFC and studies comparing different kinds of CS. RESULTS A total of 108 patients were followed for a median of 16 months (range 1-50 months), of whom 84 underwent PFC-CS and 24 had bridged repairs. Unadjusted results demonstrated no differences between the groups in SSO or recurrence; however, the study was underpowered for this purpose. On meta-analysis, PFC was associated with a lower risk of SSO (odds ratio [OR] = 0.569; 95% confidence interval [CI] = 0.34-0.94) and recurrence (OR = 0.138; 95% CI = 0.08-0.23) compared with bridged repair. On multiple-treatments meta-analysis, both endoscopic and perforator-sparing CS were most likely to be the treatments with the lowest risk of SSO and recurrence. CONCLUSIONS Bridged repair was associated with more SSOs than was PFC, and PFC should be used whenever feasible. Endoscopic and perforator-sparing CS were associated with the fewest complications; however, these conclusions are limited by heterogeneity between studies and poor methodological quality. These results should be used to guide future trials, which should compare the risks and benefits of each CS method to determine in which setting each technique will give the best results.
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Suture, synthetic, or biologic in contaminated ventral hernia repair. J Surg Res 2015; 200:488-94. [PMID: 26424112 DOI: 10.1016/j.jss.2015.09.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 08/24/2015] [Accepted: 09/03/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Data are lacking to support the choice between suture, synthetic mesh, or biologic matrix in contaminated ventral hernia repair (VHR). We hypothesize that in contaminated VHR, suture repair is associated with the lowest rate of surgical site infection (SSI). METHODS A multicenter database of all open VHR performed at from 2010-2011 was reviewed. All patients with follow-up of 1 mo and longer were included. The primary outcome was SSI as defined by the Centers for Disease Control and Prevention. The secondary outcome was hernia recurrence (assessed clinically or radiographically). Multivariate analysis (stepwise regression for SSI and Cox proportional hazard model for recurrence) was performed. RESULTS A total of 761 VHR were reviewed for a median (range) follow-up of 15 (1-50) mo: there were 291(38%) suture, 303 (40%) low-density and/or mid-density synthetic mesh, and 167(22%) biologic matrix repair. On univariate analysis, there were differences in the three groups including ethnicity, ASA, body mass index, institution, diabetes, primary versus incisional hernia, wound class, hernia size, prior VHR, fascial release, skin flaps, and acute repair. The unadjusted outcomes for SSI (15.1%; 17.8%; 21.0%; P = 0.280) and recurrence (17.8%; 13.5%; 21.5%; P = 0.074) were not statistically different between groups. On multivariate analysis, biologic matrix was associated with a nonsignificant reduction in both SSI and recurrences, whereas synthetic mesh associated with fewer recurrences compared to suture (hazard ratio = 0.60; P = 0.015) and nonsignificant increase in SSI. CONCLUSIONS Interval estimates favored biologic matrix repair in contaminated VHR; however, these results were not statistically significant. In the absence of higher level evidence, surgeons should carefully balance risk, cost, and benefits in managing contaminated ventral hernia repair.
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The Association for CPE: who needs it? JOURNAL OF PASTORAL CARE 1975; 29:202-3. [PMID: 10238057 DOI: 10.1177/002234097502900310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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