Identification of the ilioinguinal and iliohypogastric nerves during open inguinal hernia repair: a nationwide register-based study.

BACKGROUND: Chronic pain remains prevalent after open inguinal hernia repair and nerve-handling strategies are debated. Some guidelines suggest sparing nerves that are encountered; however, the nerve identification rates are unclear. This study aimed to investigate the nerve identification rates in a register-based nationwide cohort. METHODS: This study was reported according to the RECORD guideline and used prospective, routinely collected data from the Danish Hernia Database, which was linked with the National Patient Registry. We included patients ≥ 18 years old, undergoing Lichtenstein hernia repair with information on nerve handling of the iliohypogastric and ilioinguinal nerves. RESULTS: We included 30,911 open hernia repairs performed between 2012 and 2022. The ilioinguinal nerve was identified in 73% of the repairs and the iliohypogastric nerve in 66% of repairs. Both nerves were spared in more than 94% of cases where they were identified. Female patient sex, emergency and recurrence surgery, general anesthesia, medial and saddle hernias, and large defect size all result in lower nerve identification rates for both nerves. CONCLUSION: The Ilioinguinal nerve was recognized in 73% of cases, while the iliohypogastric nerve was recognized in 66% with almost all identified nerves being spared during surgery. Several pre- and intraoperative factors influenced identification rates of the ilioinguinal and iliohypogastric nerve.

Epidemiology and surgical management of 184 obturator hernias: a nationwide registry-based cohort study.

PURPOSE: We aimed describe the patient characteristics, surgical details, postoperative outcomes, and prevalence and incidence of obturator hernias. Obturator hernias are rare with high mortality and no consensus on the best surgical approach. Given their rarity, substantial data is lacking, especially related to postoperative outcomes. METHODS: The study was based on data from the nationwide Danish Hernia Database. All adults who underwent obturator hernia surgery in Denmark during 1998-2023 were included. The primary outcomes were demographic characteristics, surgical details, postoperative outcomes, and the prevalence and incidence of obturator hernias. RESULTS: We included 184 obturator hernias in 167 patients (88% females) with a median age of 77 years. Emergency surgeries constituted 42% of repairs, and 72% were laparoscopic. Mesh was used in 77% of the repairs, with sutures exclusively used in emergency repairs. Concurrent groin hernias were found in 57% of cases. Emergency surgeries had a 30-day mortality of 14%, readmission rate of 21%, and median length of stay of 6 days. Elective surgeries had a 30-day mortality of 0%, readmission rate of 10%, and median length of stay of 0 days. The prevalence of obturator hernias in hernia surgery was 0.084% (95% CI: 0.071%-0.098%), with an incidence of one per 400,000 inhabitants annually. CONCLUSIONS: This was the largest cohort study to date on obturator hernias. They were rare, affected primarily elderly women. The method of repair depends on whether the presentation is acute, and emergency repair is associated with higher mortality.

The clinical task force: Improving quality of medical students' internship.

Background: Up to 40% of young medical doctors feel that the internships prepared them insufficiently for the clinical work. This study investigated whether a Clinical Task Force (CTF) could improve internship quality. Methods: The CTF visited internship departments with a triple-targeted approach: first, departments pre-filled a self-evaluating questionnaire; secondly, CTF visited departments to discuss the self-evaluation and previous student evaluations; and thirdly, CTF and departments agreed on several quality-improving focus points to work on after the meeting. Focus points were followed-up after three and 12 months. The impact on internship quality was assessed with departments' student evaluation scores, number of completed focus points, and the effect of completed focus points on a range of learning parameters. The CTF learned several things along the way, that potentially could affect the quality of internships. A shortlist of these was provided to illustrate unmeasurable benefits. Results: The CTF met with 53 out of 60 eligible departments. The CTF and departments agreed upon 197 focus points of which 64% were completed. The three most frequent categories of focus points were Introduction of the students, The departments' evaluation percentage, and The departments' function as an educational site. The mean student evaluation scores did not change significantly, but the individual evaluation parameters changed significantly in two categories. It decreased in the category regarding the students' satisfaction with the clinical lecturers and the scheduled teaching and increased in the category regarding the percentage of students evaluating the department. Conclusion: The CTF's triple-targeted approach did not increase the mean student evaluation score significantly. For departments that completed the agreed focus points, one category increased and another decreased. However, the unmeasurable benefits illustrated that CTF was a good viable linking element between the faculty, departments, and students with the potential of improving other aspects of the quality of internships.

Lower reoperation rates after open and laparoscopic groin hernia repair when performed by high-volume surgeons: a nationwide register-based study.

PURPOSE: Previous studies have shown a correlation between surgeons with high annual volume and better outcomes after various surgical procedures. However, the preexisting literature regarding groin hernia repair and annual surgeon volume is limited. The aim was to investigate how annual surgeon volume affected the reoperation rates for recurrence after primary groin hernia repair. METHODS: This nationwide cohort study was based on data from the Danish Hernia Database and the Danish Patient Safety Authority's Online Register. Patients ≥ 18 years undergoing laparoscopic or Lichtenstein primary groin hernia repair between November 2011 and January 2020 were included. Annual surgeon volume was divided into five categories: ≤ 10, 11-25, 26-50, 51-100, and > 100 cases/year. RESULTS: We included 25,262 groin hernia repairs performed in 23,088 patients. The risk of reoperation for recurrence after Lichtenstein repair was significantly higher for the volume categories of ≤ 10 (HR 4.02), 11-25 (HR 3.64), 26-50 (HR 3.93), or 51-100 (HR 4.30), compared with the > 100 category. The risk of reoperation for recurrence after laparoscopic repair was significantly increased for the volume categories of ≤ 10 (HR 1.89), 11-25 (HR 2.08), 26-50 (HR 1.80), and 51-100 (HR 1.58) compared with the > 100 category. CONCLUSION: The risk of reoperation for recurrence was significantly higher after Lichtenstein and laparoscopic repairs performed by surgeons with < 100 cases/year compared with > 100 cases/year. This indicates that higher surgeon volume minimizes the risk of reoperation for recurrence after groin hernia repair.

Dimeric boroles: effective sources of monomeric boroles for heterocycle synthesis.

Monomeric boroles have been gaining attention as reagents for the synthesis of heterocycles due to their ability to insert atoms into the BC4 ring in a single step. Although unique boron frameworks can be accessed via this methodology, the products feature aryl substitution on the carbon centers as steric bulk is required to preclude borole dimerization. This work demonstrates that insertion chemistry is possible with Diels-Alder dimeric boroles and that such reactivity is not exclusive to monomeric boroles with bulky groups. With 1-phenyl-2,3,4,5-tetramethylborole dimer, the formal 1,1-insertion of a nitrene and sulfur generate the six-membered aromatic 1,2-azaborine and 1,2-thiaborine, respectively. The isolation of the 1,2-thiaborine enabled the synthesis of an η6-chromium complex. Benzophenone and diphenylketene readily insert a CO unit to generate BOC5 seven-membered rings confirming dimeric boroles can serve as monomeric synthons in 1,2-insertion reactions. An epoxide did not furnish the anticipated eight-membered BOC6 ring, instead provided a bicyclic system with a BOC3 ring. The insertion chemistry was demonstrated with two other borole dimers featuring different substitution with diphenylketene as a substrate. This work elevates borole insertion chemistry to a new level to access products that do not require bulky substitution.

Diverse Reactivity of Dienes with Pentaphenylborole and 1-Phenyl-2,3,4,5-Tetramethylborole Dimer.

The reactions of a monomeric borole and a dimeric borole with 2,3-dimethyl-1,3-butadiene and 1,3-cyclohexadiene were investigated. The monomeric borole reacted at ambient temperature whereas heat was required to crack the dimer to form the monomer and induce reactivity. 2,3-Dimethyl-1,3-butadiene reacts to give diverse products resulting from a cycloaddition process with the B-C moiety of the boroles acting as a dienophile, followed by rearrangements to furnish bicyclic species. For 1,3-cyclohexadiene, a [4+2] process is observed in which 1,3-cyclohexadiene serves as the dienophile and the boroles as the diene partner. The experimental results are corroborated with mechanistic theoretical calculations that indicate boroles can serve as either a diene or dienophile in cycloaddition reactions with dienes.

Decreased re-operation rate for recurrence after defect closure in laparoscopic ventral hernia repair with a permanent tack fixated mesh: a nationwide cohort study.

PURPOSE: To investigate whether defect closure in laparoscopic ventral hernia repair reduces the re-operation rate for recurrence compared with no defect closure. METHODS: Data were extracted from the Danish Ventral Hernia Database. Adults with an elective laparoscopic ventral hernia repair with tacks used as mesh fixation were included, if their first repair was between the 1st of January 2007 and the 1st of January 2017. Patients with defect closure were compared with no defect closure. Re-operation rates are presented as crude rates and cumulated adjusted re-operation rates. Sub-analyses assessed the effect of the suture material used during defect closure and also whether defect closure affected both primary and incisional hernias equally. RESULTS: Among patients with absorbable tacks as mesh fixation, 443 received defect closure and 532 did not. For patients with permanent tacks, 393 had defect closure and 442 did not. For patients with permanent tacks as mesh fixation, the crude re-operation rates were 3.6% with defect closure and 7.2% without defect closure (p = 0.02). The adjusted cumulated re-operation rate was significantly reduced with defect closure and permanent tacks (hazard ratio = 0.53, 95% confidence interval = 0.28-0.999, p = 0.05). The sub-analysis suggested that defect closure was only beneficial for incisional hernias, and not primary hernias. We did not find any benefits of defect closure for patients with absorbable tacks as mesh fixation. CONCLUSION: This nationwide cohort study showed a reduced risk of re-operation for recurrence if defect closure was performed in addition to permanent tacks as mesh fixation during laparoscopic incisional hernia repair.

Systematic review and network meta-analysis of methods of mesh fixation during laparoscopic ventral hernia repair.

BACKGROUND: Ventral hernia repairs are common and have high recurrence rates. They are usually repaired laparoscopically with an intraperitoneal mesh, which can be fixed in various ways. The aim was to evaluate the recurrence rates for the different fixation techniques. METHODS: This systematic review included studies with human adults with a ventral hernia repaired with an intraperitoneal onlay mesh. The outcome was recurrence at least 6 months after operation. Cohort studies with 50 or more participants and all RCTs were included. PubMed, Embase and the Cochrane Library were searched on 22 September 2016. RCTs were assessed with the Cochrane risk-of-bias assessment tool and cohort studies with the Newcastle-Ottawa scale. Studies comparing fixation techniques were included in a network meta-analysis, which allowed comparison of more than two fixation techniques. RESULTS: Fifty-one studies with a total of 6553 participants were included. The overall crude recurrence rates with the various fixation techniques were: absorbable tacks, 17·5 per cent (2 treatment groups); absorbable tacks with sutures, 0·7 per cent (3); permanent tacks, 7·7 per cent (20); permanent tacks with sutures, 6·0 per cent (25); and sutures, 1·5 per cent (6). Six studies were included in a network meta-analysis, which favoured fixation with sutures. Although statistical significance was not achieved, there was a 93 per cent chance of sutures being better than one of the other methods. CONCLUSION: Both crude recurrence rates and the network meta-analysis favoured fixation with sutures during laparoscopic ventral hernia repair.

Using an integrated measurement system as a common language: lessons from the U.S. Army medical department.

The Process of developing an integrated measurement system for the U.S. Army Medical Department (AMEDD) is examined in this study. A fundamental issue is whether the measures of performance accumulated by any information system are the correct ones and whether these measures appropriately reflect managers' decision making. Measurement is proposed as a solution to performance barriers. The four steps involved in building the AMEDD integrated measurement system (IMS) model are set out. Strategy is explored as the key input to the IMS model. An activity-based management (ABM) model that can support the required IMS cost-based measures is also described and the interrelationship between the two models is illustrated. The key test for application of the IMS model will be whether linking strategy and measurement results in information that improves decision making.

Managing the cost of care: a predictive study to identify critical care patients at risk for nosocomial pneumonia.

Nosocomial infections represent a major health problem and can have a significant impact on the cost of treating a patient. Hospital-acquired pneumonia (HAP) is the second most common nosocomial infection in the United States and the leading cause of death due to a nosocomial infection. The high prevalence of HAP and its significant impact on increased length of stay and incremental treatment costs identify nosocomial pneumonia (NP) as a key component in managing the total cost of care. The study's objective was to develop a predictive tool for identifying those adult patients in critical care (CC) who are at greatest risk of developing NP to better manage the costs of care. The authors also expected to determine the expected probability of a patient developing NP in CC. A prospective study of longer stay critical care unit (CCU) patients was performed in nine U.S. CCUs. There were no interventions in the study. Development was based on variables common to CC and specific patient profile risk factors. Twelve statistically significant and clinically meaningful risk factors were identified and placed in a sequential cascade fashion. The positive predictive value of the sequential decision process and corresponding tool was 87.03 percent.

Identifying costs for capitation in psychiatric case management.

This article presents an example of how one hospital identified costs for capitation in psychiatric case management. An 18-month postacute case management pilot project collected data on a nurse-specific and patient-specific basis. Costs were identified using activity-based costing methodology.

Costs of interdisciplinary practice in a school-based health center.

In the context of market-driven health care reform, interest in cost and quality outcomes has increased. Quality, as defined by Donabedian, includes assessment of structure, process, and outcomes. However, the definition of quality in health care must be expanded to include the expectations and opinions of patients, their representatives, and society. The purpose of this article is to examine the outcome variable of costs in a specific nursing practice setting. Cost is frequently defined as the judicious use of resources consumed by structures and processes of care. This article presents activity-based costing methodology and results of a cost study of primary care and mental health services provided by advanced practice nurses (APNs) in a school-based health center. The application of the methods and outcomes of this pilot study has significant implications for the delivery of health care by APNs in a variety of settings, including community nursing centers, freestanding birthing centers, and rural and urban neighborhood centers. Because much of the health care delivered by APNs in these community-based settings includes health promotion, screening, counseling, and anticipatory guidance, it is important to explore methods such as activity-based costing to identify actual costs of care (versus charges) in emerging community-based practices where primary care is delivered by APNs.

Activity-based costing in the operating room at Valley View Hospital.

This article presents an example of how one hospital reports the results of activity-based costing (ABC). It examines the composition and supporting assumptions of an ABC report for a particular procedure in the operating room (OR). It describes management uses of the information generated. It comments upon how the continuous quality improvement (CQI) is synchronized with the ABC reporting.

They may want to take charge, but can physicians really organize?

Current managed care network models include physician organizations (POs) and fully integrated regional groups (FIRGs). Proper organization of such networks requires a sequence of essential organizational decisions. If physicians are to organize properly, they must avoid three major pitfalls. Of these, the loss of autonomy is the greatest threat. The proper fit of organizational structure with the founders can assist the entire process significantly.

Activity-based costing for integrated delivery systems.

The paradigm shift toward managed care is fueling new cost-finding demands. More sophisticated methods are emerging to meet these demands. Foremost among the new methods is activity-based costing (ABC). ABC is designed to eliminate cross-subsidies between products or services. Because costs are traced by activities across departments and cost centers, costs can also be traced by activities across integrated delivery systems (IDSs). The methodology makes ABC very applicable to combinations of providers including chains, affiliated groups, and IDS participants.

Lipoteichoic acid from Streptococcus sanguis is a natural glucosyl acceptor for glucosyltransferases.

The synthesis of methanol insoluble-[14C]labeled-polymers from [14C]sucrose by S. mutans glucosyltransferases was stimulated up to four-fold by the presence of highly purified, lipoteichoic acid (LTA) from S. sanguis. Gel filtration chromatography (Sepharose 4B) and ion exchange chromatography (DEAE-Bio-Gel A) of the [14C]labeled-polymers formed in the presence of [3H]glycerol-labeled-LTA showed that high molecular weight, negatively charged [14C]labeled-[3H]glycerol-labeled-LTA complexes were being formed. The [14C]component was identified as glucose by acid hydrolysis and paper chromatography. A similar high molecular weight, negatively charged [14C]glucosyl-[3H]glycerol-labeled-polymer was extracted from S. mutans cells grown in the presence of [3H]glycerol and [14C]sucrose, suggesting that LTA is a glucosyl-acceptor for glucosyltransferases in vivo as well as in vitro.

Biosynthesis and characterization of phosphatidylglycerophosphoglycerol, a possible intermediate in lipoteichoic acid biosynthesis in Streptococcus sanguis.

A membrane enzyme preparation from Streptococcus sanguis was shown to convert sn-[14C]glycerol 3-phosphate and CDP-diacylglycerol (or deoxyCDP-diacylglycerol) into a series of progressively higher-molecular-weight [14C]oligophosphoglycerophospholipids in vitro. The first oligophosphoglycerophospholipid to accumulate (termed lipid-1) was purified to homogeneity; chemical analysis, gas-liquid chromatography and chemical degradation studies indicated the most likely structure to be phosphatidylglycerophosphoglycerol (PGpG). PGpG is formed directly from two molecules of phosphatidylglycerol (PG), one molecule of PG serving as a sn-glycerol 1-phosphate (pG) donor and the second serving as the pG acceptor, with co-production of diacylglycerol. These oligophosphoglycerophospholipids may be intermediates in the biosynthesis of lipoteichoic acids.