Should we abandon regional anesthesia in open inguinal hernia repair in adults?

Inguinal hernia repair is a common worldwide surgical procedure usually done in the outpatient setting. The purpose of this systematic review is to make an evidence-based meta-analysis to determine the possible benefits of regional (neuraxial block) anesthesia compared to general anesthesia in open inguinal hernia repair in adults. Cochrane Library, Medline, EMBASE, CINAHL, SCI-EXPANDED, SCOPUS as well as trial registries, conference proceedings and reference lists were searched. Only randomized controlled trials (RCT) that compare neuraxial block (spinal or/and epidural) anesthesia (NABA) and general anesthesia (GA) were included. Main outcome measures were postoperative complications, urinary retention and postoperative pain. Seven RCTs were included in this review. A total of 308 patients were analyzed with 154 patients in each group. Overall complications were evenly distributed in NABA and in GA group [OR 1.17, 95 % CI (0.52-2.66)]. Urinary retention was statistically less frequent in GA group compared to NABA group [OR 0.25, 95 % CI (0.08-0.74)]. Movement-associated pain score 24 h after surgery was significantly lower in NABA group [SMD 5.59, 95 % CI (3.69-7.50)]. Time of first analgesia application was shorter in GA group [SMD 8.99, 95 % CI 6.10-11.89]. Compared to GA, NABA appears to be a more adequate technique in terms of postoperative pain control. However, when GA is applied, patients seem to have less voiding problems.

Microstructural alterations of femoral head articular cartilage and subchondral bone in osteoarthritis and osteoporosis

OBJECTIVE

Explore whether osteoporosis (OP) in humans influences the morphological status of the articular cartilage and the subchondral bone. Explore the relationship between the macroscopic aspect of the articular surface and the rate of microscopic changes of both the cartilage and the subchondral bone in OP and osteoarthritis (OA).

METHODS

Femoral heads after total hip replacement were obtained from patients with OP or hip OA (OP, n = 56; OA, n = 12). Cartilage degeneration was assessed using the Mankin grading system whereas subchondral bone was evaluated using histomorphometry and Micro-computed Tomography (μCT) scanning system. Thickness of the cartilage layers and subchondral cortical bone (SCB) was measured.

RESULTS

Samples with higher total Mankin score have significantly reduced cartilage thickness. Mankin score differed between all OP specimens. In OP samples with lower Mankin scores the thickness of SCB shows a trend of an increase caused by increased levels of bone remodeling. In OP samples with higher Mankin scores we observed thinning of SCB. Structural indices of subchondral trabecular bone (STB) were significantly lower in OP than in OA samples.

CONCLUSION

Thinning of SCB, found in OP samples with higher Mankin scores could be related with the progression of the cartilage degeneration indicating an early-stage OA. Increased levels of bone remodeling and evidently changed morphology of subchondral bone found in OP samples with lower Mankin score indicated that bony bed level must have a role in the progression of the cartilage degeneration.

Tumour necrosis factor alpha and nuclear factor kappaB inhibit transcription of human TFF3 encoding a gastrointestinal healing peptide

BACKGROUND

and aims: Tumour necrosis factor alpha (TNF-alpha) induction of nuclear factor kappaB (NFkappaB) activation plays a major role in the pathogenesis of inflammatory bowel disease (IBD). Trefoil factor family peptides TFF1, TFF2, and TFF3 exert protective, curative, and tumour suppressive functions in the gastrointestinal tract. In this study, we investigated effects of the TNF-alpha/NFkappaB regulatory pathway by TNF-alpha on expression of TFFs.

METHODS

After TNF-alpha stimulation, expression of TFF genes was analysed by quantitative real time polymerase chain reaction and by reporter gene assays in the gastrointestinal tumour cell lines HT-29 and KATO III. Additionally, NFkappaB subunits and a constitutive repressive form of inhibitory factor kappaB (IkappaB) were transiently coexpressed. In vivo, morphological changes and expression of TFF3, mucins, and NFkappaB were monitored by immunohistochemistry in a rat model of 2,4,6-trinitrobenzene sulphonic acid induced colitis.

RESULTS

TNF-alpha stimulation evoked up to 10-fold reduction of TFF3 expression in the colon tumour cell line HT-29. Downregulation of reporter gene transcription of TFF3 was observed with both TNF-alpha and NFkappaB, and was reversible by IkappaB. In vivo, the increase in epithelial expression of NFkappaB coincided with reduced TFF3 expression during the acute phase of experimental colitis.

CONCLUSIONS

Downregulation of intestinal trefoil factor TFF3 is caused by repression of transcription through TNF-alpha and NFkappaB activation in vitro. In IBD, perpetual activation of NFkappaB activity may contribute to ulceration and decreased wound healing through reduced TFF3.