Randomized clinical trial of self-gripping mesh versus sutured mesh for Lichtenstein hernia repair

Background

Many patients develop discomfort after open repair of a groin hernia. It was hypothesized that suture fixation of the mesh is a cause of these symptoms.

Methods

This patient- and assessor-blinded randomized multicentre clinical trial compared a self-gripping mesh (Parietene Progrip®) and sutured mesh for open primary repair of uncomplicated inguinal hernia by the Lichtenstein technique. Patients were assessed before surgery, on the day of operation, and at 1 and 12 months after surgery. The primary endpoint was moderate or severe symptoms after 12 months, including a combination of chronic pain, numbness and discomfort.

Results

The intention-to-treat population comprised 163 patients with self-gripping mesh and 171 with sutured mesh. The 12-month prevalence of moderate or severe symptoms was 17·4 and 20·2 per cent respectively (P = 0·573). There were no significant differences between the groups in postoperative complications (33·7 versus 40·4 per cent; P = 0·215), rate of recurrent hernia within 1 year (1·2 per cent in both groups) or quality of life.

Conclusion

The avoidance of suture fixation using a self-gripping mesh was not accompanied by a reduction in chronic symptoms after inguinal hernia repair. Registration number: NCT00815698 (http://www.clinicaltrials.gov).

Mutant ftsI genes in the emergence of penicillin-binding protein-mediated beta-lactam resistance in Haemophilus influenzae in Norway

The most important mechanism for beta-lactam resistance in beta-lactamase-negative ampicillin-resistant (BLNAR) isolates of Haemophilus influenzae is the alteration of penicillin-binding protein 3 (PBP3) as a result of ftsI gene mutations. The present study aimed to map PBP3 alterations and to determine the correlation to beta-lactam resistance in respiratory tract isolates of H. influenzae in Norway, as well as assess the contribution of clonal spread to the emergence of PBP3-mediated resistance. Twenty-three beta-lactamase negative respiratory tract isolates with resistance to penicillins and 23 susceptible control isolates were examined by determination of beta-lactam MICs, ftsI sequencing and molecular typing by pulsed-field gel electrophoresis (PFGE). Ampicillin MIC ranges in the resistant group and the control group were 1-2 mg/L and 0.125-0.5 mg/L, respectively. All isolates in the resistant group had the PBP3 substitution Asn526-->Lys and were thus categorized as group II low-BLNAR. No control isolate met the genetic BLNAR (gBLNAR) criteria. The PBP3 substitution patterns corresponded well to those observed in previous European studies. Eighty-three percent (19/23) of the resistant isolates belonged to two clones, demonstrating the capability of low-BLNAR strains of clonal dissemination. Combined analysis of ftsI DNA sequences and PFGE patterns revealed distinctly different ftsI alleles in genetically indistinguishable isolates and identical copies of the same ftsI allele in unrelated isolates. A possible explanation of this observation is the recombinational exchange of ftsI alleles. This phenomenon, as well as the possibility of endemic European gBLNAR strains, should be further investigated.

A comparison of phylogenetic group, virulence factors and antibiotic resistance in Russian and Norwegian isolates of Escherichia coli from urinary tract infection

Isolates of Escherichia coli from 31 Norwegian and 31 Russian females with significant bacteruria who presented with clinical signs of urinary tract infection (UTI) were tested for antimicrobial sensitivity, the presence of virulence genes, phylogroup distribution and clonal affinity. Twenty isolates, representing the full clonal diversity of a collection of 138 intestinal isolates of E. coli from healthy Norwegian females, served as a reference group. Russian UTI isolates belonged more often to phylogroup A and possessed fewer virulence genes than did Norwegian isolates. UTI isolates of E. coli were genetically heterogeneous and had a high degree of antimicrobial sensitivity.

Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study

BACKGROUND

Groin hernia repair is one of the most frequent operations, but there is no consensus about surgical or anaesthetic technique. Furthermore, no nationwide studies have been done. Our aim was to investigate outcome results of groin hernia surgery to improve quality of treatment.

METHODS

We prospectively recorded 26304 groin hernia repairs done in Denmark from Jan 1, 1998, to June 30, 2000, in a nationwide Danish hernia database.

FINDINGS

93% of all groin herniorrhaphies done in Denmark in the 30 months of the study were recorded in the database. Kaplan-Meier estimates of reoperation rates 30 months after anterior mesh repair and laparoscopic repair were significantly lower than after sutured posterior wall repairs in primary inguinal hernia (2.2% and 2.6% vs 4.4%; p<0.0001). Reoperation rates were also lower with anterior mesh repair (6.1%; p<0.0001) and laparoscopic repair (3.4%; p<0.0001) than with sutured posterior wall repair (10.6%) after recurrent hernia. Use of Lichtenstein mesh repair increased from 33% in January, 1998, to 62% in June, 2000, whereas use of laparoscopic repair remained constant at about 5%. Kaplan-Meier estimates of reoperation rates were 2.8% in the first 15 months and 1.6% in the second (p=0.03). For elective repairs, only 59% of patients were treated on an outpatient basis, and only 18% had local anaesthesia.

INTERPRETATION

Mesh repairs have a lower reoperation rate than conventional open repairs. Systematic prospective recording of treatment and outcome variables in a national clinical database improved the overall quality of surgical care. However, there is a large potential for cost savings and more efficient patient care with extended use of mesh techniques, outpatient surgery, and local anaesthesia.

Borrelia burgdorferi sensu lato and Ehrlichia spp. in Ixodes ticks from southern Norway

We report the results of a study of the prevalence of Ehrlichia and Borrelia species in 341 questing Ixodes ricinus ticks from two locations in southern Norway. The prevalences of Borrelia burgdorferi sensu lato and Ehrlichia spp. were, respectively, 16 and 11.5% at site 1 and 17 and 6% at site 2. Prevalence and species composition of Borrelia and Ehrlichia varied with location and date of collection. The dominant Borrelia species at both sites was Borrelia afzelii, followed by Borrelia burgdorferi sensu stricto. Borrelia garinii was found in only a single tick. The dominant member of the Ehrlichia group was a recently described Ehrlichia-like organism related to the monocytic ehrlichiae. Variants of Ehrlichia phagocytophila and the agent of human granulocytic ehrlichiosis were also found. The highest prevalences for B. afzelii, B. burgdorferi sensu stricto, and the Ehrlichia-like organism were observed in May. B. afzelii was most prevalent in females, less prevalent in nymphs, and least prevalent in males, while the prevalence of Ehrlichia was highest in nymphs, lower in females, and least in males. Double infections with B. afzelii and B. burgdorferi sensu stricto and with B. afzelii and the Ehrlichia-like organism were significantly overrepresented. Tick densities were highest in May, when densities of more than 200 ticks/100 m2 were observed, and declined during the summer months to densities as low as 20 ticks/100 m2. We conclude that estimates of the prevalence of tick-borne bacteria are sensitive to the choice of date and site for collection of ticks. This is the first study of tick-borne Borrelia and Ehrlichia in Norway and the lowest reported B. garinii prevalence in Northern Europe. The prevalence of the Ehrlichia-like organism is described for the first time in questing ticks.

[Subfascial endoscopic supplementary surgery of perforating veins. Experiences with the first 100 procedures]

INTRODUCTION

Leg ulcers following varicose veins and incompetent perforators have been treated by supplementary surgery of the perforators, originally by open operation, from the early eighties by endoscopic techniques.

METHODS

The endoscopic operation is carried out through a short incision of the skin and fascia well above the skin changes, and consists of subfascial electro-cauterization and cutting of the incompetent perforators.

RESULTS

100 consecutive procedures were performed 1995-1999. Totally, the frequency of complications was 28%, mostly minor and self-limiting: Haematoma/haemorrhage 6%, infection 9%, deep vein thrombosis 1%, sural and saphenous nerve affection 9% and others 3%. With a median follow-up of 10 months, 94% of the patients were satisfied with the treatment, 5% experienced unchanged symptoms, 1% became worse. In 30 ulcer-cases, 80% were without recurrency after a median follow-up of 16 months, the rest having recurrent, but smaller ulcers.

CONCLUSION

The present results are similar to the experience reported by others. It is suggested that the technique may be developed in centers for advanced varicose vein surgery.

[Standardisation of surgical mesh implantation in incisional hernia]

PURPOSE

To describe the relation between risk factors, postoperative complications, recurrence rates and satisfaction before and after the introduction of Stoppas technique in patients operated for incisional hernia with implantation of a surgical mesh.

MATERIAL AND METHODS

The records of 27 patients undergoing an incisional hernia repair using a surgical mesh in the period 1.1.1993-30.6.1998 were reviewed, and 18 living patients were examined.

RESULTS

Among the eight patients operated using Stoppas technique there were no postoperative complications but one recurrence, and among the ten patients operated without using a specific standard technique there were five with complications and four with recurrence.

CONCLUSION

Operation for incisional hernia using implantation of a surgical mesh seems to require a standard surgical technique and care must be taken in patients with risk factors.

[Randomized trial of three types of repair used in 324 consecutive operations of hernia. A study of the frequency of recurrence]

In order to assess the recurrence-rate of the commonly used repairs of inguinal hernia: Bassini, McVay and Shouldice, 324 consecutive non-recurrence hernias were randomly allocated to one of those repairs. The age range 18-65 years. Ninety-six percent of the operations were carried out by the author. After a median observation-period of 32 months (range 5-75), ten recurrences had occurred, two Bassini, four McVay and four Shouldice, showing no significant differences in recurrence rate between the three types of repair. All recurrences were re-operated, five of them suffered a second recurrence. Other complications occurred in 36 patients (11%). With extensive training, low recurrence-rates can be achieved with any of the above-mentioned repairs. It is recommended that herniasurgery be centralised, and that other outcome-measures than recurrence be scrutinized as well.

Record linkage to conduct an epidemiologic study on the association of rheumatoid arthritis and lymphoma in the Province of Saskatchewan, Canada

The objective of this effort was to assess the utility of the large automated database in Saskatchewan as a resource for pharmacoepidemiologic studies. To this end a study was undertaken to test the hypothesis that rheumatoid arthritis (RA) increases the risk of cancer, especially lymphoma. This was done by performing a retrospective cohort study based on record linkage data from Saskatchewan Health. From hospital discharge diagnoses in the hospital file an exposed group (RA) and two comparison groups matched to the RA group by age and sex were identified: (1) the RA group consisted of people with a discharge diagnosis of rheumatoid arthritis; (2) the osteoarthritis (OA) group consisted of people with OA discharge diagnoses; and (3) a comparison (CN) group consisted of hospitalized people with no discharge diagnoses of arthritis. Drug exposures were determined by linkage with the Prescription Drug File, cancer outcomes were determined by linkage with the Cancer Foundation file, and length of eligibility in the health plan and demographics information were determined by linkage with the registration file. The data were checked for quality of linkages across files and consistency with study definitions. Of 13,333 identified subjects, 2.8% were excluded because of apparent incorrect assignment to study group or age group or because of ineligibility in health plan during the study period. In order to decrease the possibility of misclassification of exposure (rheumatoid arthritis), hospital discharge diagnoses were used to exclude subjects with any inflammatory rheumatic diseases (IRD) from the CN (7.8%) and OA (8.3%) groups and subjects with IRD other than rheumatoid arthritis (4.6%) from the RA group. To decrease selection bias, those who had cancer within 1 year of enrollment (to exclude those in hospital because of symptoms of undiagnosed cancer) were excluded. Because RA subjects hospitalized by a rheumatologist were most likely to have valid rheumatoid arthritis diagnoses, each analysis was run twice: once with the entire RA group (N = 1210) and once with those in the RA group who were rheumatologist-hospitalized (N = 646). Logistic regression of incidence was used to control for age, sex, and use of individual disease-modifying anti-rheumatoid drugs (DMARDs). For the rheumatologist-hospitalized RA group compared to the CN group, a significant 4-fold greater risk for lymphoma/myeloma was detected when DMARD use was not controlled for, and a 3.4-fold increase in risk was detected even when use of individual DMARDs was controlled for.(ABSTRACT TRUNCATED AT 400 WORDS)

Incidence of hip fracture in Saskatchewan, Canada, 1976-1985

The authors ascertained the incidence of hip fracture in Saskatchewan, Canada, residents aged 65 years or older for the 10 years 1976-1985 from computerized hospital discharge records and compared it with rates for several other populations in Northern Europe and the United States. In Saskatchewan, the average annual incidence was 5.5 per 1,000 person-years. The incidence in women was twice that in men, the incidence in urban areas was 27% greater than that in nonurban areas, and there was no secular trend of increasing rates. The incidence of hip fracture in Saskatchewan was lower than that for populations in Scandinavia and the United States but was comparable to rates in English populations. Further study is needed to elucidate the genetic, environmental, and behavioral factors responsible for this variation.

A sensitive qualitative pregnancy test (ICON) and ultrasound in the diagnosis of ectopic pregnancy

Three hundred and twenty-four patients presenting to Wellington Women's Hospital with symptoms suspicious of an ectopic pregnancy were first studied by testing serum for HCG using a new simple and sensitive (25 mIU/mL) ICON pregnancy test. One hundred and thirty ICON tests were positive. Subsequent management: (a) Immediate laparoscopy noted 3 intrauterine and 15 ectopic pregnancies. (b) Twenty-five patients discharged on revised clinical grounds without pregnancies. (c) An immediate ultrasound examination of 87 women showed 58 intrauterine pregnancies (including 1 misdiagnosed ectopic pregnancy) and 29 ectopic pregnancies which were later confirmed at laparoscopy. One hundred and ninety-four ICON tests were negative including two false negative results in patients with ectopic pregnancies. To avoid both unnecessary laparoscopy or the discharge of patients with a possible ectopic pregnancy, patients with symptoms and signs suspicious of an ectopic pregnancy and who present to hospital should have a rapid sensitive HCG assay. Then, if the test is positive (sensitivity 96%), an ultrasound examination can assist in determining the likely site of the pregnancy.

Gastrointestinal hemorrhage due to fistula from aortic aneurysm. Case report

Two cases of gastrointestinal bleeding due to aortic aneurysm with fistula to the duodenum are reported. When upper gastrointestinal fiberendoscopy rules out the commonest sources of bleeding but reveals no specific lesion, sonography is advisable. Accurate diagnosis and timely treatment are prerequisites for a successful outcome in this otherwise fatal condition.

Mental alertness in response to hypoglycaemia in normal man: the effect of 12 hours and 72 hours of fasting

To study the influence of hypoglycaemia and starvation on mental functions eight healthy male students age 25-34 years with an ideal body mass of 99.9% +/- 2.5% (mean +/- SEM) were recruited. Hypoglycaemia was induced in random order by an insulin-glucose clamp technique (insulin: 2.4 mU/kg/min + glucose at variable rate) keeping the venous blood glucose at 2.2 mmol/l both after an overnight fast and after 72 h fasting. Mental alertness was assessed by measuring the recognition time, moving time and total reaction time to a visual signal and by a verbal mental clearness test and a synonym learning test during normo- as well as hypoglycaemia. Hypoglycaemia prolonged the total reaction time (p less than 0.05) and the time required for the mental clearness test (p less than 0.05). Compared with a control study performed at normoglycaemia the learning effect of the synonym test was reduced by hypoglycaemia. Fasting, which resulted in a body weight reduction of 2.6 +/- 0.3 kg and ketonuria prolonged the total reaction time (p less than 0.005) by increasing the moving time but did not affect the mental clearness test. When hypoglycaemia was preceded by 72 h fasting it did not increase the total reaction time, nor did it modify the mental clearness test. Moreover, the learning effect of the synonym test was less impaired. In conclusion, mental alertness was reduced by moderate hypoglycaemia after an overnight fast while similar hypoglycaemia did not reduce mental alertness after prolonged fasting. This may illustrate a decrease of the glucose dependency of the central nervous system during prolonged fasting.

Heparin-induced thrombocytopenia in patients with cerebrovascular ischemic disease

We studied 137 patients who were treated with heparin for cerebral infarction (73), partially reversible ischemic neurologic deficit (22), or transient ischemic attack (42). Platelet counts were performed before therapy, twice weekly, and at cessation of therapy. Platelets decreased in 118 patients (86%). In 21 (15.3%), platelets dropped greater than or equal to 40%; 9 of 14 new ischemic events and three of six deaths occurred in this group of patients. Because there was a significant association between poor outcome and platelet drop greater than or equal to 40% (p less than 0.001), we believe that platelets should be monitored frequently when patients are treated with heparin for ischemic cerebrovascular disease.

Observed differences in gentamicin pharmacokinetic parameters and dosage recommendations determined by fluorescent polarization immunoassay and radioimmunoassay methods

Radioimmunoassay (RIA) and fluorescent polarization immunoassay (FPI) methods for quantitative gentamicin serum concentration assay have been shown to be comparable. The purpose of this study was to determine if serum concentration-time data from the same patients assayed by RIA and FPI would provide the same estimates for half-life, elimination rate constant, distribution volume, drug clearance, and gentamicin dose. A total of 99 pre-and postinfusion serum samples were obtained from 30 patients. Samples were divided and assayed by RIA or FPI, and the resultant serum concentration-time data were fitted to a standard one-compartment model. The correlation between the two assay methods was 0.99 (p less than 0.005). A mean difference of 10% was seen in distribution volume, gentamicin clearance, and gentamicin dose from quantitative data from the two methods. These differences were significant (p less than 0.01). Although the two methods appear to be interchangeable, based on in vitro comparison, differences in calculated pharmacokinetic parameters resulted in significant differences in dose recommendations.

Comparison of radioimmunoassay and enzyme immunoassay methods in determining gentamicin pharmacokinetic parameters and dosages

Radioimmunoassay and enzyme immunoassay methods for analysis of serum gentamicin levels have been shown to be comparable. The purpose of this study was to determine if serum concentration-time data from the same patient assayed by radioimmunoassay and enzyme immunoassay would provide the same estimates for half-life, elimination rate constant, distribution volume, drug clearance, and gentamicin dose. A total of 103 pre- and postinfusion serum samples were obtained from 32 patients. The samples were divided and assayed by radioimmunoassay and enzyme immunoassay. Serum concentration-time data were fitted to a one-compartment model, and kinetic calculations were performed using the method of Sawchuk et al. (Clin. Pharmacol. Ther. 21:362-369, 1977). While good correlation was established between the two assay methods, significant (P less than 0.05) mean differences were seen in distribution volume (25%), gentamicin clearance (15%), and half-life (11%), using the quantitative data from both methods. Because of differences noted in these pharmacokinetic parameters, significant differences were also noted in dosage calculations. We conclude that there are differences in the pharmacokinetic parameters obtained using results from the radioimmunoassay and enzyme immunoassay. These differences also translate into significant differences between dosage recommendations when individualization of the gentamicin regimen is attempted.