OC-034 EVIDENCE-BASED CHANGES IN PERI-OPERATIVE PATIENT CARE IN A TERTIARY HERNIA CENTER(THC): PROSPECTIVE STUDY OF OUTCOMES OVER 18 YEARS AND 1842 OPEN PREPERITONEAL VENTRAL HERNIA REPAIRS(OPPVHR)

Background

Over 18 years, a THC frequently changed patient-care protocols according to repeated reviews of our prospectively collected data outcomes, which have been published in peer-reviewed journals. This study aimed to describe these progressive, evidence-based changes and the subsequent results in PP-VHR.

Methods

Prospective, tertiary hernia center data(2004–2021) was examined for patients undergoing midline open PP-VHR with mesh. “Early”(2004–2012) and “Recent”(2013–2021) groups were based on surgery date.

Results

Comparison of Early(n=675) versus Recent(n=1,167) groups showed that Recent patients were older (56.9±12.6vs58.7±12.1 years;p<0.001), more comorbid(3.6±2.2vs5.2±2.6 diagnoses;p<0.001), lower BMI(33.5±8.3 vs 32.0±6.8 kg/m2; p=0.003), more prior failed VHR(46.5% vs 60.8%; p<0.001), larger hernia defects(199.7±232.8vs214.4±170.5 cm2;p<0.001), more CDC-class 3/4 wounds(11.3%vs18.6%;p<0.001), more biologic mesh(10.5% vs 25.4%;p<0.001), component separations(CST; 22.5%vs45.7%;p<0.001), and more pre-op Botox(0%vs12.3%;p<0.01). Wound complication(26.7%vs13.2%;p<0.001), mesh infection(3.1%vs0.9%;p<0.01), and hernia recurrence rates decreased over time(7.1%vs2.4%;p<0.001) with long-term follow-up(4.2±4.1vs2.2±1.8years;p<0.001).

Comparing respective multivariable analyses (Early vs Recent), wound complications were associated with panniculectomy(OR[95%CI]:2.9[1.9–4.5],p<0.001 vs 2.1[1.4–3.3],p<0.01), contaminated wounds(2.1[1.1–3.7],p=0.02 vs 1.8[1.1–3.1],p=0.02), anterior CST(1.8[1.1–2.9], p=0.02 vs 3.2[1.9–5.3],p<0.01), and operative time(per minute:1.01[1.008–1.015], p<0.01 vs 1.004[1.001–1.007], p<0.01) in both time periods. Diabetes(2.6[1.7–4.0],p<0.01) and tobacco(1.8[1.1–2.9], p=0.02) were only significant in the Early group with the Recent group requirements for preop smoking cessation and a HgbA1C of <7.2. In both groups, recurrence was associated with wound complication(8.9[4.1–20.1],p<0.01 vs 3.4[1.3–8.2].p<0.01) and prior failed VHR hernias(4.9[2.3–11.5],p<0.01 vs 2.1[1.1–4.2],p=0.036).

Conclusion

Despite increased patient and hernia complexity over time, detecting and implementing best practices, as determined by repeated self-analysis of a THC's data, significantly improved patient outcomes, including wound and mesh complications and recurrence.

OC-077 OPEN REPAIR OF FLANK AND LUMBAR HERNIAS (FLH): 145 CONSECUTIVE REPAIRS AT A HIGH-VOLUME, TERTIARY HERNIA CENTER

Aim

FLH present a surgical challenge due to their anatomic location, proximity to boney structures, and lack of elasticity of the surrounding muscle. With less than 1,000 cases reported, there is no uniform operative management. This is the largest study to date evaluating FLH repair (FLHR).

Materials & Methods

A prospective, single-center, hernia specific database was queried for patients who underwent open flank or lumbar hernia repair from 2004–2021. Demographics, operative characteristics, and outcomes were evaluated. Standard statistical methods were used.

Results

145 patients included 109 flank hernias and 36 lumbar hernias. The hernias resulted from prior surgery (73.3%), blunt trauma (19.7%), or primary defects (7.0%). The mean defect size was 125.7±166.8cm2, 46.9% were recurrent, and 11.0% of patients visited a pain specialist preoperatively. Mesh was commonly synthetic (92.4%), a mean of 755.9±373.4 cm2, and placed in the preperitoneal space (92.7%). Component separation technique was utilized in 16.8% of cases and pelvic bone anchor fixation in 13.8%. Preoperative chronic pain was present in 75% of patients receiving bone anchors and only 6.6% postoperatively. Complete defect closure occurred in each case. Wound infection (8.1%) and mesh infection (1.4%) were uncommon. Prolonged, postoperative discomfort was reported in 22%, half of which had chronic pain preoperatively (p<0.01). Hernia recurrence was 3.4% at 29.3±13.2 months follow-up. Recurrences occurred posteriorly in 3 and in 2 mesh infections requiring explantation.

Conclusions

Open preperitoneal repair of FLHs with synthetic mesh results in low rates of postoperative complications and hernia recurrence. Postoperative pain correlated closely with preoperative pain.

Measurement and correlates of family caregiver self-efficacy for managing dementia

Researchers in the aging field are paying increasing attention to the importance of perceived self-efficacy in understanding experiences and health-related outcomes of family caregivers. This paper details the strategy we used to measure family caregiver self-efficacy for managing dementia, and reports on observed associations between the resulting self-efficacy measures, caregiver depressive symptoms, and caregiver physical health symptoms. Family caregivers (n = 197) were interviewed after calling a local Alzheimer's Association chapter in the mid-western USA. Nine items inquiring about caregivers' certainty that they could carry out specific behaviors related to dementia care clustered into two distinct self-efficacy factors: symptom management self-efficacy (4 items) and community support service use self-efficacy (5 items). Internal consistency reliability for both factors was high (Cronbach's alpha = 0.77 and 0.78, respectively). Symptom management self-efficacy demonstrated a much stronger correlation with a published global caregiver competence measure than did service use self-efficacy (r = 0.49 and 0.27, respectively). In a multivariate regression model predicting caregiver depression symptoms, higher symptom management self-efficacy scores were associated with fewer depressive symptoms (beta = -0.17, p < 0.05). In a separate model, higher service use self-efficacy scores (beta = -0.20, p < 0.01) and higher symptom management self-efficacy scores (beta = -0.16, p < 0.05) were associated with fewer physical health symptoms. These new measures of dementia management self-efficacy hold promise for use in future studies.

Hand-assisted laparoscopic donor nephrectomy minimizes warm ischemia

OBJECTIVES

Traditional open donor nephrectomy is associated with good donor outcomes and excellent allograft function. Laparoscopic donor nephrectomy may accomplish these same goals with less morbidity. We report our initial experience with hand-assisted laparoscopic living donor nephrectomy using a commercially available hand-assist device.

METHODS

Donor and allograft outcomes for the first 30 patients undergoing hand-assisted laparoscopic live donor nephrectomy in our institution were prospectively analyzed.

RESULTS

Hand-assisted laparoscopic donor nephrectomy was successfully completed in 29 (97%) of 30 donors. Organ dissection was carried out purely laparoscopically. Vessel division and allograft extraction were performed using a hand-assisted technique. The average operative time was 275 minutes (range 193 to 360), with an estimated blood loss of 99 mL (range 50 to 300). Pneumoperitoneum was consistently maintained during the hand-assisted portion of the procedure. The mean warm ischemic time was 72.5 seconds (range 30 to 165). On average, the regular diet was resumed after 2.2 days (range 1 to 3), and patients were discharged home 3.4 days (range 2 to 5) after surgery. Eight minor complications occurred in the donor group. Immediate graft function occurred in all 30 cases. No ureteral complications occurred. The recipient creatinine levels ranged from 0.6 to 2.4 mg/dL at an average follow-up of 11.5 months (range 1 to 23).

CONCLUSIONS

Laparoscopic donor nephrectomy is technically feasible and can be performed with minimal morbidity. Hand-assisted kidney extraction may help to facilitate immediate allograft function by minimizing the warm ischemic time.

History and mobility exam index to identify community-dwelling elderly persons at risk of falling

BACKGROUND

Falls are common in community-dwelling elderly persons and are a frequent source of morbidity. Simple indices to prospectively stratify people into categories at different fall-risk would be useful to health care practitioners. Our goal was to develop a fall-risk index that discriminated between people at high and low risk of falling.

METHODS

We evaluated the risk of falling over a one-year period in 557 elderly persons (mean age 81.6) living in a retirement community. On the baseline interview, we asked subjects if they had fallen in the previous year and evaluated risk factors in six additional conceptual categories. On the follow-up interview one year later, we again asked subjects if they had fallen in the prior year. We evaluated risk factors in the different conceptual categories and used logistic regression to determine the independent predictors of falling over a one-year period. We used these independent predictors to create a fall-risk index. We compared the ability of a prior falls history with other risk factors and with the combination of a falls history and other risk factors to discriminate fallers from nonfallers.

RESULTS

A fall in the previous year (OR = 2.42, 95% CI = 1.49-3.93), a symptom of either balance difficulty or dizziness (OR = 1.83, 95% CI = 1.16-2.89), or an abnormal mobility exam (OR = 2.64, 95% CI = 1.64-4.26) were independent predictors of falling over the subsequent year. These three risk factors together (c statistic =.71) discriminated fallers from nonfallers better than previous history of falls alone (c statistic =.61) or the symptomatic and exam risk factors alone (c statistic =.68). When combined into a risk index, the three independent risk factors stratify people into groups whose risk for falling over the subsequent year ranges from 10% to 51%.

CONCLUSION

A history of falling over the prior year, a risk factor that can be obtained from a clinical history (balance difficulty or dizziness), and a risk factor that can be obtained from a physical exam (mobility difficulty) stratify people into groups at low and high risk of falling over the subsequent year. This risk index may provide a simple method of assessing fall risk in community-dwelling elderly persons. However, it requires validation in other subjects before it can be recommended for widespread use.

Predictors of attitudes toward three target groups of elderly persons: the well, the physically ill, and patients with Alzheimer's disease

This research compared attitudes of 143 nursing home employees toward three hypothetical target groups of older adults: well elderly persons, physically ill elderly persons, and elderly persons with Alzheimer's disease. Staff provided successively less positive evaluations of physically ill elderly persons and elderly persons with Alzheimer's disease compared to well elderly persons. Age, education, and contact with grandparents differentially predicted positive evaluations toward well and physically ill older adults. Self-efficacy was a significant predictor of positive evaluations across all target groups. Findings suggest that interventions designed to increase staff members' feelings of self-efficacy may lead to more positive evaluations of elderly clients and, ultimately, improved quality of care.

Caregiver burden and generic well-being: opposite sides of the same coin?

Caregiver burden is one of the most commonly used variables in caregiving research, both as a predictor and as an outcome. It has been suggested that caregiver burden can be measured in terms of discrete dimensions of well-being and that burden and well-being represent opposite sides of the same coin. The goal of this study was to explore this issue further by comparing commonly used dimensions of burden with parallel dimensions of well-being, both as outcome variables and as predictors of other outcomes, in a sample of caregivers. The findings suggest that burden may tap a unique domain of caregiving outcomes that is not represented by more objective indicators of these effects. Dismissing burden as an unnecessary or redundant construct seems premature.

Health and illness behavior of Type A persons

The complex and controversial relationship of type A behavior to myocardial infarction and other illnesses may be mediated through health habits and illness behavior. We hypothesized that type A persons tend to reject the sick role, delay in seeking medical care, seek convenient medical care facilities, are impatient for recovery, return to work before they have fully recovered, and are less likely to engage in positive health habits. A cross-sectional survey was conducted at a large corporation in Cleveland, Ohio. A detailed questionnaire that examined health-promoting and illness behaviors was sent to 385 managers, 54% of whom responded. Models tested using path analysis supported the hypotheses that type A persons are more likely than are type B employees to reject the sick role, delay in seeking medical care, be impatient for recovery, and return to work before a full recovery. The study findings imply that type A employees may be less likely to miss work for minor illnesses, but they may be prone to adverse outcomes from illnesses that require early care or assumption of the sick role. The hypothesis that type A persons are less likely to engage in positive health-habits behavior was not supported.

Reconsideration of fear of personal aging and subjective well-being in later life

In a study of older Alabamians, Klemmack and Roff (1984) identified fear of aging as both an important correlate of subjective well-being and an intervening process through which physical health influences well-being. The present study examined the possibility that fear of aging, as a reflection of personal worries (frequently designated as "negative affect"), is actually an indicator rather than a determinant of subjective well-being. According to this alternative explanation, fear of aging was essentially used to predict itself. A factor analysis of Klemmack and Roff's original data supported this alternative interpretation. As predicted, fear of aging items loaded as a factor with other indicators of "negative affect" and, thus, should have been designated as part of the dependent variable. Furthermore, and contrary to Klemmack and Roff's treatment of subjective well-being as unidimensional, the factor analysis indicated two additional dimensions of well-being--Happiness and Plans for the Future. The results of this study demonstrate the importance of subjecting items to factor analysis and related techniques when developing and validating constructs.

The causes and correlates of crime committed by the elderly

There is a need to understand the variables that influence the illegal behavior of older persons, and whether these predictors differ from those of younger age groups. This article attempts to address these issues through a review of the relevant literature. An analysis of elderly-specific theories of crime provides few suggestions where one might anticipate different predictors for older versus younger persons. And a comparison of research on youths with results from surveys of the general population indicates that the causes and correlates of crime generally do not change as individuals grow older.