Laparoscopic ventral hernia repair is safe and cost effective

BACKGROUND: Ventral hernia repair is increasingly performed by laparoscopic means since the introduction of dual-layer meshes. This study aimed to compare the early complications and cost effectiveness of open hernia repair with those associated with laparoscopic repair. METHODS: Open ventral hernia repair was performed for 92 consecutive patients using a Vypro mesh, followed by laparoscopic repair for 49 consecutive patients using a Parietene composite mesh. RESULTS: The rate of surgical-site infections was significantly higher with open ventral hernia repair (13 vs 1; p = 0.03). The median length of hospital stay was significantly shorter with laparoscopic surgery (7 vs 6 days; p = 0.02). For laparoscopic repair, the direct operative costs were higher (2,314 vs 2,853 euros; p = 0.03), and the overall hospital costs were lower (9,787 vs 7,654 euros; p = 0.02). CONCLUSIONS: Laparoscopic ventral hernia repair leads to fewer surgical-site infections and a shorter hospital stay than open repair. Despite increased operative costs, overall hospital costs are lowered by laparoscopic ventral hernia repair.

Starting a carotid artery stenting program is safe

BACKGROUND: Little is known on the performance of newly initiated carotid artery stenting (CAS) programs. The safety of the procedure is being questioned following the publication of the EVA-3S trial, a study criticized for the limited interventional experience required to enroll patients. METHODS: Within a newly started academic CAS program, patient data and outcomes were collected prospectively. The outcomes of the first 100 consecutive patients treated are reported. A CAS-fellowship-trained interventionalist was involved in all procedures. All patients underwent clinical assessment by a neurologist before and after the procedure, and serial ECG and cardiac enzymes were routinely obtained. Primary outcome measures included 30-day major adverse events (MAE), defined as death, stroke, or myocardial infarction, while on follow-up deaths and ipsilateral strokes were added. RESULTS: Between July 2003 and November 2006, 92 patients had a single internal carotid artery treated, while 7 underwent staged bilateral CAS. In one patient, the procedure was aborted prior to lesion treatment. The 30-day MAE rate per procedure was 1.9% (one major and one minor stroke). By a mean follow-up of 16 months (range 2-42 months), one patient had died of refractory heart failure, while one patient had a minor ipsilateral stroke and three had minor contralateral strokes, corresponding to total MAE per patient of 4%. The rate of any stroke or death was 7%. The rate of restenosis >or=50% per lesion by ultrasound was 3.8%. CONCLUSION: This single center experience suggests that it is safe to start a CAS program following dedicated fellowship.

Characterization of legacy organic carbon in a culturally eutrophic lake : the role of the historic carbon deposition in the time course and extent of lake recovery

The time course of lake recovery after a reduction in external loading of nutrients is often controlled by conditions in the sediment. Remediation of eutrophication is hindered by the presence of legacy organic carbon deposits, that exert a demand on the terminal electron acceptors of the lake and contribute to problems such as internal nutrient recycling, absence of sediment macrofauna, and flux of toxic metal species into the water column. Being able to quantify the timing of a lake’s response requires determination of the magnitude and lability, i.e., the susceptibility to biodegradation, of the organic carbon within the legacy deposit. This characterization is problematic for organic carbon in sediments because of the presence of different fractions of carbon, which vary from highly labile to refractory. The lability of carbon under varied conditions was tested with a bioassay approach. It was found that the majority of the organic material found in the sediments is conditionally-labile, where mineralization potential is dependent on prevailing conditions. High labilities were noted under oxygenated conditions and a favorable temperature of 30 °C. Lability decreased when oxygen was removed, and was further reduced when the temperature was dropped to the hypolimnetic average of 8° C . These results indicate that reversible preservation mechanisms exist in the sediment, and are able to protect otherwise labile material from being mineralized under in situ conditions. The concept of an active sediment layer, a region in the sediments in which diagenetic reactions occur (with nothing occurring below it), was examined through three lines of evidence. Initially, porewater profiles of oxygen, nitrate, sulfate/total sulfide, ETSA (Electron Transport System Activity- the activity of oxygen, nitrate, iron/manganese, and sulfate), and methane were considered. It was found through examination of the porewater profiles that the edge of diagenesis occurred around 15-20 cm. Secondly, historical and contemporary TOC profiles were compared to find the point at which the profiles were coincident, indicating the depth at which no change has occurred over the (13 year) interval between core collections. This analysis suggested that no diagenesis has occurred in Onondaga Lake sediment below a depth of 15 cm. Finally, the time to 99% mineralization, the t99, was viewed by using a literature estimate of the kinetic rate constant for diagenesis. A t99 of 34 years, or approximately 30 cm of sediment depth, resulted for the slowly decaying carbon fraction. Based on these three lines of evidence , an active sediment layer of 15-20 cm is proposed for Onondaga Lake, corresponding to a time since deposition of 15-20 years. While a large legacy deposit of conditionally-labile organic material remains in the sediments of Onondaga Lake, it becomes clear that preservation, mechanisms that act to shield labile organic carbon from being degraded, protects this material from being mineralized and exerting a demand on the terminal electron acceptors of the lake. This has major implications for management of the lake, as it defines the time course of lake recovery following a reduction in nutrient loading.

A safe and simple solution for intravesical tension-free vaginal tape erosion: removal by standard transurethral resection

OBJECTIVE: To report our experience with the successful removal of visible tension-free vaginal tape (TVT) by standard transurethral electroresection, as intravesical tape erosion after TVT is a rare complication, and removal can be challenging, with few cases reported. PATIENTS AND METHODS: Five patients presenting with TVT erosion into the bladder were treated at our institutions from December 2004 to July 2007; all had standard transurethral electroresection. Their records were reviewed retrospectively to retrieve data on presenting symptoms, diagnostic tests, surgical procedures and outcomes. RESULTS: The median (range) interval between the TVT procedure and the onset of symptoms was 17 (1-32) months. The predominant symptoms were painful micturition, recurrent urinary tract infection (UTI), urgency and urge incontinence. There were no complications during surgery. The storage symptoms and UTI resolved completely after removing the eroded mesh in all but one patient. Cystoscopy at 1 month after surgery showed complete healing of the bladder mucosa. CONCLUSION: Although TVT erosion into the bladder is rare, persistent symptoms, particularly recurrent UTIs, must raise some suspicion for this condition. Standard transurethral electroresection seems to be a safe, simple, minimally invasive and successful treatment option for TVT removal.

Esophageal strictures in adult eosinophilic esophagitis: dilation is an effective and safe alternative after failure of topical corticosteroids

Strictures are a frequent complication of eosinophilic esophagitis. The efficacy and safety of topical corticosteroids and of dilation of eosinophilic esophagitis-associated strictures have not yet been thoroughly clarified. We present a retrospective analysis of 10 adult patients with eosinophilic esophagitis who had symptomatic esophageal stenosis that was unresponsive to topical corticosteroids, and who were treated using bougienage. Eight patients had one single stricture, one patient had two, and another had three strictures; mean stricture length was 2.1 cm (range 1 - 6 cm). Bougienage led to prompt symptom relief. Apart from transient postprocedural odynophagia, no severe complications occurred. During the follow-up (mean 6 months; range 2 - 11 months), all patients enjoyed sustained treatment response.

Management Challenges in Nurturing a Safe Work Environment

As engineers, we are trained to use logical, rational problem solving to insure our mines operate at maximum efficiency. We tend to use the same technical approach to design safety into all mining systems. This works well for machines, but not so much for the human component. Recent insights in the field of behavioral economics provide useful ideas for addressing the fact that we are driven by emotions more often than by rational thought. Understanding the nonrational aspect of human behavior is an important piece of any safety system design.

Coronary bypass surgery in patients treated with clopidogrel. Is it safe?

PURPOSE OF REVIEW: Current guidelines for the management of acute coronary syndrome clearly recommend that clopidogrel should be started before diagnostic coronary angiography. If patients undergo coronary artery bypass grafting (CABG) early after clopidogrel loading or during continued exposure, it seems reasonable to expect an increase in bleeding complications. RECENT FINDINGS: Earlier studies may have overestimated the risk of bleeding in patient undergoing CABG with prior clopidogrel exposure (5-10-fold increase). Some conflicting results are reported in literature. As reexploration because of excessive bleeding is concerned, a two to three-fold increase must be expected, which is demonstrated in actual trials properly matched to confounding factors. Discontinuation of clopidogrel for 5-7 days prior to urgent CABG as recommended by guidelines is not well adopted in clinical practice for several reasons. SUMMARY: There is a moderately elevated risk of bleeding complications after CABG due to prior clopidogrel exposure alone. However, in clinical practice this risk is added often to patients who carry already elevated surgical risks (urgent procedures, worse coronary anatomy, history of previous myocardial infarction and prior percutaneous intervention), and after bleeding complications singular patients may suffer from consecutive adverse outcome. Cessation of clopidogrel in patients before CABG clearly prolongs hospitalization time and has an estimated 1% risk of coronary events during the waiting period. Risk and benefit have to be balanced in every individual case.