Posterior mesh inguinal hernia repairs: a propensity score matched analysis of laparoscopic and robotic versus open approaches.

PURPOSE: International guidelines suggest the use of lapro-endoscopic technique for primary unilateral inguinal hernia (IHR) because of lower postoperative pain and reduction in chronic pain. It is unclear if the primary benefit is due to the minimally invasive approach, the posterior mesh position or both. Further research evaluating posterior mesh placement using open preperitoneal techniques is recommended. A potential benefit of open preperitoneal repair is the avoidance of general anesthesia, as these repairs can be performed under local anesthesia. This study compares clinical and patient-reported outcomes after unilateral laparo-endoscopic, robotic, and open posterior mesh IHRs. METHODS: We performed a propensity score matched analysis of patients undergoing IHR between 2012 and 2021 in the Abdominal Core Health Quality Collaborative registry. 10,409 patients underwent a unilateral IHR via a posterior approach. Hernia repairs were performed via minimally invasive surgery (MIS) which includes laparoscopic and robotic transabdominal preperitoneal (TAPP), laparoscopic totally extraperitoneal (TEP), or open transrectus preperitoneal/open preperitoneal (TREPP/OPP) approaches. Propensity score matching (PSM) utilizing nearest neighbor matching accounted for differences in baseline characteristics and possible confounding variables between groups. We matched 816 patients in the MIS cohort with 816 patients in the TREPP/OPP group. Outcomes included patient reported quality of life, hernia recurrence, and postoperative opioid use. RESULTS: Improvement was seen after TREPP/OPP as compared to MIS IHR in EuraHS at 30 days (Median(IQR) 7.0 (2.0-16.64) vs 10 (2.0-24.0); OR 0.69 [0.55-0.85]; p = 0.001) and 6 months (1.0 (0.0-4.0) vs 2.0 (0.0-4.0); OR 0.63 [0.46-85]; p = 0.002), patient-reported opioid use at 30-day follow-up (18% vs 45% OR 0.26 [0.19-0.35]; p < 0.001), and rates of surgical site occurrences (0.8% vs 4.9% OR 0.16 [0.06-0.35]; p < 0.001). There were no differences in EuraHS scores and recurrences at 1 year. CONCLUSIONS: This study demonstrates a potential benefit of open posterior mesh placement over MIS repair in short-term quality of life and seroma formation with equivalent rates of hernia recurrence. Further study is needed to better understand these differences and determine the reproducibility of these findings outside of high-volume specialty centers.

The Sjögren's Syndrome Damage Index--a damage index for use in clinical trials and observational studies in primary Sjögren's syndrome.

OBJECTIVE: To validate a tool for assessment of accumulated damage in patients with Primary SS (PSS). METHODS: Of the total 114 patients fulfilling American-European Consensus Group (AECG) criteria for PSS 104 were included in the study and assessed by rheumatologists at T (time) = 0 months and T = 12 months. On each occasion, damage and activity data, and autoantibody status were collected. SF-36 and Profile of Fatigue and Discomfort-Sicca Symptoms Inventory (PROFAD-SSI) questionnaires were completed. Cross-sectional analysis of this data was subject to a process of expert validation by 11 ophthalmologists, 14 oral medicine specialists and 8 rheumatologists. Items were removed from the index if >or= 50% of respondents recommended exclusion. Statistical validation was performed on remaining items. Spearman's rank analysis was used to investigate associations between damage scores and other disease status measures and Wilcoxon matched-pair analysis to assess sensitivity to change in the damage score. RESULTS: Based on the expert validation, a 29-item damage score was agreed incorporating ocular, oral and systemic domains. Total damage score correlated with disease duration at study entry (r = 0.436; P < 0.001), physical function as measured by SF-36 (r = 0.250, T = 0 months; r = 0.261 T = 12 months) and activity as measured by the Sjögren's Systemic Clinical Activity Index (r = 0.213, T = 0 months; r = 0.215, T =12 months). Ocular damage score correlated with the 'eye dry' domain of PROFAD-SSI (r = 0.228, T = 0 months; r = 0.365, T = 12 months). Other associations not present on both assessments were considered clinically insignificant. On Wilcoxon analysis, the index was sensitive to change over 12 months (z = -3.262; P < 0.01). CONCLUSION: This study begins validation of a tool for collection of longitudinal damage data in PSS. We recommend further trial in both the experimental and clinical environment.

Sjögren's Systemic Clinical Activity Index (SCAI)--a systemic disease activity measure for use in clinical trials in primary Sjögren's syndrome.

OBJECTIVE: This article describes the development of the Sjögren's Systemic Clinical Activity Index (SCAI) for the measurement of systemic disease activity in patients with primary Sjögren's syndrome (PSS). METHODS: A pilot tool was developed based on expert consensus and previous published data. One hundred and four patients with PSS were evaluated in a cross-sectional analysis, of whom 65 were reviewed at 3-monthly intervals, using this index, over a 12-month period. Factor analysis was used to evaluate the proposed domain structure. External validation was assessed by comparison with relevant domains of the Profile of Fatigue and Discomfort (PROFAD), Medical Outcomes Study Short Form-36 (SF-36) and The World Health Organization Quality of Life-Bref (WHOQOL-BREF). Sensitivity to change was assessed by comparing SCAI-derived flares with physician-designated disease flare and intention-to-treat analysis. A reliability and repeatability workshop was also held. RESULTS: Factor analysis supported the proposed domain structure. There were strong correlations between the SCAI fatigue, musculoskeletal and Raynaud's components and the PROFAD fatigue, arthralgia and vascular domains. There was a significant correlation between change in therapy and SCAI-defined flares (P = 0.01). The mean kappa-test results both for reliability of the SCAI and for physician repeatability were 0.71. CONCLUSION: This initial evaluation supports the potential for the SCAI as a tool for systemic activity assessment in patients with PSS but additional work is required to assess sensitivity to change in clinical therapeutic trials.

Induction of protective immunity to Dictyocaulus viviparus in calves while under treatment with endectocides.

Three groups of five parasite-naive calves were used. The treatments were: (a) Group 1 calves were weighed on Day 0 and injected with doramectin at 200 microg/kg. From Day 1 to 19 they were dosed orally with 2000 infective larvae of Dictyocaulus viviparus. On Day 28 they were again injected with doramectin, and infected with D. viviparus larvae from Days 33 to 41. They were then left untreated until Day 81 when they were infected with 20 infective larvae of D. viviparus per kg body weight. They were killed on Day 110 and lungworms were counted; (b) Group 2 calves were immunised with oral lungworm vaccine on Days 0 and 28, and infected and slaughtered as Group 1 on Days 81 and 110, respectively; (c) Group 3 calves acted as infection controls. Blood samples were taken at Days 0, 21, 49, 77 and 110 for antibody tests to D. viviparus. At autopsy there were no significant differences between the number of lungworms from Groups 1 and 2 (Means 17.4 and 31.3, respectively); Group 1 had significantly less value than Group 3 (Mean 228) (p < 0.05). Increased antibody titres to the larval sheath of the infective larvae were observed from Groups 1 and 2, showing that the larvae in Group 1 had penetrated the intestine before being killed by the circulating anthelmintic. This experiment shows that if calves are exposed to infective larvae while under systemic endectocide cover, an immune reaction is stimulated.

Motor learning by imagery is differentially affected in Parkinson's and Huntington's diseases.

Studies of motor imagery and motor learning have thus far been concerned only with its effects on healthy subjects. Therefore, in order to investigate the possible involvement of the basal ganglia, the effectiveness of motor imagery in the acquisition of motor constants in a graphomotor trajectorial learning task was examined in 11 non-demented mildly affected Huntington's disease (HD) patients and 12 non-demented Parkinson's disease (PD) patients. The patients received, after baseline, 10 min of motor imagery training, followed by a motor practice phase. Additionally, a test battery for visual imagery abilities was administered in order to investigate possible relations between visual and motor imagery. The results showed that imagery training alone enabled the HD patients to achieve a significant approach to movement isochrony, whereas the PD patients showed no marked improvements, either with motor imagery or with motor practice. Furthermore, the PD patients had more difficulties than the HD patients in solving the visual imagery tasks. Subsequent correlational analysis revealed significant relationships between the degree of caudate atrophy in the HD patients and their performance in the visual imagery tasks. However, there were no substantial correlations between the performance on the visual imagery tasks and the improvement of motor performance through motor imagery, which indicates that visual and motor imagery are independent processes. It is suggested that the dopaminergic input to the basal ganglia plays an important role in the translation of motor representations into motor performance, whereas the caudate nucleus atrophy of the HD patients does not seem to affect motor imagery, but only the visual imagery process. Furthermore, the deficits found in PD patients might also be related to their limited attentional resources and difficulties in employing predictive motor strategies.

Impaired vagal reflex activity in insulin-resistant rats.

Insulin resistance, without frank diabetes, is associated with sudden cardiac death. We postulated that a potential mechanism for this association is autonomic dysfunction. Male Sprague-Dawley rats were randomized into one of two groups: (a) insulin resistant (IR; n = 15), or (b) control (n = 11). Animals were made insulin resistant with a fructose-rich diet, whereas control animals received standard rat chow. Four weeks after randomization, arterial pressure and baroreceptor reflex were assessed. Baroreflex sensitivity was defined as the heart-rate response to acute blood pressure changes caused by nitroprusside (0.5-18 micrograms) or phenylephrine (0.2-3 micrograms). To determine the role of vagal stimulation specifically, each animal was randomized to receive atropine sulfate (1 mg/kg) or vehicle (normal saline) before administration of phenylephrine. Mean arterial pressure and fasting insulin concentrations were increased in the insulin-resistant group, whereas there were no differences in body weight, fasting glucose concentrations, or resting heart rate. Phenylephrine increased arterial blood pressure to a maximum of 54 +/- 2 mm Hg for control and 45 +/- 6 mm Hg for IR, p = 0.7. The maximal heart-rate change response to the increased blood pressure was markedly blunted in IR as compared with control (-88 +/- 12 beats/min for IR vs. -238 +/- 18 beats/min for control; p < 0.001). Thus the baroreflex sensitivity (BRS) was threefold less in IR versus the control group (-1.8 +/- 0.2 vs. -4.6 +/- 0.7 beats/min/mm Hg; p = 0.001). Pretreatment with atropine sulfate decreased the BRS in both groups, eliminating the difference between groups (-0.96 +/- 0.5 beats/min/mm Hg for control and -0.56 +/- 0.3 beats/min/mm Hg for IR; p = 0.2). Thus atropine sulfate caused the phenylephrine-induced heart rate and arterial blood pressure response to be equal between groups. On the other hand, BRS to nitroprusside-induced blood pressure changes were similar between groups. Insulin resistance, without the confounding factors of obesity, diabetes, and significant hypertension, is associated with a large reduction in vagal activity, which occurs via attenuation in reflex activity. In contrast, the insulin-resistant syndrome does not affect baroreflex sensitivity via sympathetic reflex.

A mental route to motor learning: improving trajectorial kinematics through imagery training.

There are contrasting reports upon the level of effectiveness of motor imagery in learning new motor skills, but there is general consensus that motor imagery can lead to improvements in performance, especially in combination with physical practice. In the present study we examined the effectiveness of motor imagery in the acquisition of movement invariants in two grapho-motor trajectorial learning tasks with differing visuospatial components: 'Ideogram drawing' and 'connecting circles'. Two subject groups were studied: An imagery group, which underwent 10 min of motor imagery training and a control group, which practised a control visuomotor task over the same period of time. The results showed that imagery training alone enabled the subjects to achieve a significant approach to movement isochrony as well as a significant shifting of peak velocity toward the target. After a practice phase, both groups improved their performance, but the imagery group was still significantly faster than the control group. Furthermore, a series of tests measuring visual imagery abilities was administered to the subjects. There were however no significant relationships between the motor performance and the visual imagery ability levels of the subjects. It is concluded that motor imagery can improve the acquisition of the spatio-temporal patterns of grapho-motor trajectories and that there are different processes involved in visual and motor imagery.

A decade of caring for drug users entirely within general practice.

BACKGROUND: The government encourages general practitioners (GPs) to become involved in caring for drug users. However, in some areas of the country, including Bedford, secondary care support is inadequate. GPs in these areas have to decide how to cope with such patients entirely within general practice. AIM: To assess the characteristics and quality of care given without secondary care support to drug users by one practice in Bedford over a decade. METHOD: A search was made of the practice computer for all patients with a problem title of 'addiction drug' between 1986 and 1995. The age, sex, social characteristics, and drug history were recorded. RESULTS: One hundred and ninety-two patients were found, of which 155 took part in the practice programme; i.e. they consulted more than three times. Forty-three patients (37%) who took part and were prescribed Methadone were prescribed this drug as ampoules. Sixty-three patients (40.6%) who took part in the programme stopped using drugs. Thirty-two (33.6%) of the Methadone users became abstinent. A higher proportion of women (13-48%) than men (19-27.7%) stopped using Methadone (P = 0.019). Among patients who had a stable lifestyle, a higher proportion had been prescribed ampoules than mixture (22 out of 28: 78.6%; P = 0.001). Similarly, of those who had a job, eight out of 11 (72%; P = 0.037) had been prescribed methadone ampoules. Two-thirds of all patients prescribed amphetamines stopped using drugs. CONCLUSION: Long-term care of drug users entirely within general practice is feasible. Among those prescribed methadone ampoules, a higher than average proportion had stable lifestyles and had a stable job.

Representations of graphomotor trajectories in the human parietal cortex: evidence for controlled processing and automatic performance.

The aim of this study was to identify the cerebral areas activated during kinematic processing of movement trajectories. We measured regional cerebral blood flow (rCBF) during learning, performance and imagery of right-hand writing in eight right-handed volunteers. Compared with viewing the writing space, increases in rCBF were observed in the left motor, premotor and frontomesial cortex, and in the right anterior cerebellum in all movement conditions, and the increases were related to mean tangential writing velocity. No rCBF increases occurred in these areas during imagery. Early learning of new ideomotor trajectories and deliberately exact writing of letters both induced rCBF increases in the cortex lining the right intraparietal sulcus. In contrast, during fast writing of overlearned trajectories and in the later phase of learning new ideograms the rCBF increased bilaterally in the posterior parietal cortex. Imagery of ideograms that had not been practised previously activated the anterior and posterior parietal areas simultaneously. Our results provide evidence suggesting that the kinematic representations of graphomotor trajectories are multiply represented in the human parietal cortex. It is concluded that different parietal subsystems may subserve attentive sensory movement control and whole-field visuospatial processing during automatic performance.

Directional hyperattention in tactile neglect within grasping space.

This study was motivated by the fact that unilateral neglect, an impediment to progress in patient rehabilitation, is often reported to occur in a wider area of space than that usually assessed in clinical settings. Neglect within "grasping space" (Halligan & Marshall, 1991; Kolb & Whishaw, 1990) was assessed via two search tasks: one in which search was guided by visual information and the other in which search was guided by tactile information. The performance of 10 left brain-damaged patients (LBD) and 20 right brain-damaged patients, 10 of whom showed left visual neglect (RBD+) while 10 did not (RBD-), was compared with that of age-matched controls. The visual search task confirmed the clinical diagnoses of unilateral visual neglect. On the tactile test, both RBD groups showed reduced search within the left hemispace, although this was a particularly strong feature of the performance of the RBD+ patients. Furthermore, this reduced leftwards exploration in RBD+ patients was associated with an increased frequency of repetitions made within the right hemispace, as had also been noted in some of these patients on conventional visual star cancellation. Results are discussed in relation to hyperattentional theories of directional spatial neglect.

Sound localization in egocentric space following hemispheric lesions.

In this paper the performance of patients with unilateral hemispheric lesions (n = 10 with right brain damage; n = 10 with left brain damage) on a free-field sound localization task was contrasted with that of healthy controls (n = 10). Sound stimuli were presented binaurally in the horizontal plane from eight loudspeakers set at azimuths between -105 degrees and +105 degrees. Whereas performance of both patient groups was generally less accurate than controls, no evidence suggested that this was specific to the contralateral hemisphere. The results indicate that both hemispheres play a role in sound localization, with systematic directional errors made towards the ipsilateral hemifield following unilateral lesions. Furthermore, particular location difficulties at pericentral positions (+15 degrees and -15 degrees) following right hemisphere damage, may indicate a specific function for the right hemisphere in determining personal frames of spatial reference within pericentral space.

Frontal and parietal transcranial magnetic stimulation (TMS) disturbs programming of saccadic eye movements.

Transcranial magnetic stimulation (TMS) of human motor cortex typically evoked motor responses. TMS has failed to elicit eye movements in humans, whereas prolongations of saccadic latency have been reported with TMS. In previous studied we demonstrated that saccades can be abolished or saccadic trajectories can be changed through TMS in the 100 msec before saccade onset. This effect was especially marked when TMS was applied parietally. TMS never influenced a saccade in flight. Simulations of predictive experimental saccades that were impaired through TMS of the frontal or parietal cortex demonstrated especially that the dynamics of small saccades were markedly influenced, resulting in a significant decrease in acceleration and amplitude, or an almost complete inhibition. The impact of inhibition through TMS was critically dependent on timing: early TMS (-70 msec) had a much larger inhibitory effect than late TMS (-20 msec) on experimental saccades. Differential timing of TMS in influencing the cortical control signal is demonstrated through simulations of a reciprocally innervated eye movement model that paralleled empirically determined changes in eye movement dynamics after real TMS. There is a reasonable match between the model and the experimental data. We conclude that the inhibitory action of a presaccadic disturbance, such as a TMS pulse, on saccadic programming is inversely related to timing and amplitude of the predicted saccade.

Associative learning in degenerative neostriatal disorders: contrasts in explicit and implicit remembering between Parkinson's and Huntington's diseases.

The performances of 12 patients with Parkinson's disease (PD), 16 with Huntington's disease (HD), and young and old healthy controls were assessed on a number of tests of verbal and nonverbal declarative memory, on a test of nonmotor conditional associative learning (words and colors), and on a number of reaction time (RT) tasks. The RT tasks consisted of cued simple and choice reactions. The relationship between the precue and the imperative stimulus in the S1-S2 paradigm was nonarbitrary in the first series and arbitrary in the second series. The series with arbitrary S1-S2 associations was repeated across two successive blocks of trials. The rationale of the study was to investigate the function of the basal ganglia "complex loop," and it was postulated that HD patients would show greater deficits because of greater involvement of the caudate nucleus. The patients with HD had the slowest RTs. Across the two blocks with arbitrary S1-S2 associations, the patients with HD but not PD nevertheless showed evidence of learning in their precued RTs. In contrast, the patients with PD were better able to remember the associations in free recall than were the HD patients. It is concluded that patients with PD have relatively greater deficits in procedural learning, whereas those with HD have relatively more impairments in declarative memory, and the greater level of cognitive impairment in HD overall is interpreted as being due to more serious damage to the caudate loop.

Successive roles of the cerebellum and premotor cortices in trajectorial learning.

The structures of the human brain engaged during learning of unilateral trajectorial hand movements were mapped by measurements of regional cerebral blood flow. Trajectorial movement velocity accelerated moderately after short-term training p < 0.025 and increased further after long-term training p < 0.01. During the early phase of learning there was a significant activation p < 0.001 of the ipsilateral dentate nucleus. By contrast, after overlearning the premotor cortical areas in both cerebral hemispheres were maximally activated p < 0.001, while the dentate nucleus was no longer activated. It is suggested that learning of new movement trajectories involves the cerebellum, while overlearned trajectorial movements engage the premotor cortex.

Conditional associative learning is impaired in cerebellar disease in humans.

Eight patients with lesions restricted to the cerebellum were compared with a total of 25 age-matched controls on a reaction time (RT) task allowing the recording of simple and choice RTs as well as RTs to abstract visual patterns signifying the particular movement to be performed. In all conditions the actual movements required (either a left or a right button press) remained the same, but the cognitive requirements of the task varied. In the abstract patterns condition, the significance of the various patterns with regard to the required movement had to be learned by the subjects. The patients with cerebellar lesions were particularly impaired in this condition. It is concluded that the cerebellum is involved not just in the timing of movements but also in the decision process as to which movement should be performed under particular circumstances.

Quantitation and characterization of plasma HLA in neonates of different gestational ages.

The functional significance of plasma HLA class I antigens is unclear. They are thought to have an immunomodulatory role and be tolerogenic in transplant settings including the materno-fetal semi-allograft. There is, however, no available data on the concentrations of soluble HLA class I antigens in fetuses or newborns. We therefore determined plasma HLA class I antigen levels in 93 neonates born at different gestational ages and compared them to those in 66 healthy adults. The mean plasma HLA concentration in cord blood obtained from these neonates (0.30 +/- 0.15 microgram/ml, mean +/- SD) was significantly lower (p < 0.0001) than in the adults (0.77 +/- 0.44 microgram/ml). No correlation between the plasma HLA levels and the gestational ages of the neonates was detected. Characterizing the plasma HLA class I antigens by immunoprecipitation and immunoblotting, four different molecular weight forms, 44, 39, 36 and 34 kDa, were recognized. Their distribution in neonates was not different from that in adults. Since the circulating leukocytes are a probable source of plasma HLA class I antigens, we measured the surface HLA expression on leukocytes in 4 neonates and 4 adults by immunofluorescent flow cytometry. The fluorescence intensities on neonatal granulocytes and lymphocytes were 50% of those on corresponding adult cells. This finding suggests that the reduced HLA expression by neonatal leukocytes may be partially responsible for the lower concentration of HLA class I antigens in neonatal plasma.

Proximal and distal reaction times (RTs) are not differentially affected in Parkinson's disease.

The hypothesis was tested that proximal and distal reaction times (RTs) might be differentially affected in Parkinson's disease (PD). Twelve patients with PD were compared with 12 age-matched healthy controls on tests of finger-, hand-, leg-, and torso-RTs. Patients were significantly slower in initiating all movements and were slower in executing all movements except for the leg (stepping) task. Choice- versus simple-RTs were also not differentially affected in the PD group. In the healthy subjects, age was significantly positively correlated with response initiation times (RITs) but not with movement times (MTs).

Behavioural treatment of slow cortical potentials in intractable epilepsy: neuropsychological predictors of outcome.

The study aimed to explore the predictive value of neuropsychological tests within the context of acquisition of slow cortical potential (SCP) self-control, a technique which has beneficial effects on seizure frequency in epilepsy. Patients with epilepsy who successfully achieved SCP control had longer digit or block-tapping spans than less successful patients. Patients who showed a better learning rate across training also displayed better verbal memory and learning abilities. Seizure reduction was related to block-tapping spans only. The results indicate that measures of attention, as indicated by digit spans or block-tapping spans, offer some predictive value for acquisition of SCP control and treatment outcome, whilst measures of visuospatial or frontal lobe function are unrelated to SCP acquisition and seizure reduction.

Slow cortical potentials (SCPS) in schizophrenic patients during performance of the Wisconsin card-sorting test (WCST).

Fifteen schizophrenic patients (diagnosed according to DSM-III-R) and 15 age- and education-matched controls were tested on a computerized version of the Wisconsin card-sorting test (WCST). Slow Cortical Potentials (SCPs) were recorded throughout the performance from frontal, central and parietal electrode sites. As expected, the patients were impaired on the WCST, achieving fewer categories overall and incurring significantly more "unique" errors, although they were not significantly more perseverative than the controls. The patients did not display a generalized impairment in SCPs, differences between the groups emerging only before presentation of the key-cards and after presentation of the feedback regarding the correctness of the response. Neither the choice-card at the beginning of the trial, nor the presentation of the key-cards resulted in attenuated Evoked Potentials (EPs) in the patients. The lack of any abnormality in EPs suggests that the reason for the poor performances of schizophrenic patients on the WCST lies elsewhere than in perceptual stimulus processing. Contrary to expectations no specific impairment in frontal SCPs was detected.