Barriers and Facilitators to HIV Treatment Adherence in Indonesia: Perspectives of People Living with HIV and HIV Service Providers.

HIV treatment adherence in Indonesia is a major challenge. Although previous studies have demonstrated several barriers and facilitators to adherence, studies providing a comprehensive analysis from both PLHIV and HIV service providers' perspectives are limited, especially in Indonesia. In this qualitative study with 30 people living with HIV on treatment (PLHIV-OT) and 20 HIV service providers (HSPs), we explored, via online interviews, the barriers and facilitators to antiretroviral therapy (ART) adherence using a socioecological approach. Both PLHIV-OT and HSPs reported stigma as a major barrier at each socioecological level, including public stigma at the societal level, stigma in healthcare settings, and self-stigma at the intrapersonal level. Stigma reduction must therefore be prioritized. PLHIV-OT and HSPs also reported support from significant others and HSPs as the foremost facilitators to ART adherence. The enablement of support networks is thus an important key to improved ART adherence. Overall, the societal level and health system barriers to ART adherence should be addressed in order to remove barriers and enhance the facilitators at the subordinate socioecological levels.

Long-term sequelae after 1,311 primary inguinal hernia repairs.

BACKGROUND: Aim of this study was to analyze long-term sequelae, risk factors, and satisfaction after inguinal hernia primary repair. METHODS: A postal questionnaire was mailed to all patients operated between January 1997 and December 2004 for inguinal hernia repair. Patients who had a lump in the groin and patients who experienced chronic problems were invited for a physical examination. Patients who reported having chronic pain were asked to fill out the short-form McGill Pain Questionnaire (SF-MPQ). RESULTS: Chronic pain was present in 18.1% of cases. The strongest risk factors were presence of recurrence, use of heavyweight mesh, and age younger than 66 years. By means of the SF-MPQ, we found that the pain reported by most patients was sensory-discriminative in quality, with "tender" and "aching" being the most common descriptors used. About 71.3% of replies used descriptors typical of nociceptive pain, 8.9% of neuropathic pain, and 19.8% of nociceptive plus neuropathic. Chronic pain was severe in 2.1% of patients and interfered with normal activities, work, and exercise. The cumulative recurrence rate was 2.1%. There was a strong correlation between lump and recurrence. Patients declared themselves satisfied with the result of the operation in 93.1% of cases. Due to chronic pain, 6.5% of patients were unsatisfied. CONCLUSIONS: This study demonstrates that the main problem after inguinal hernia repair remains chronic pain, which was the primary reason of dissatisfaction. The SF-MPQ is feasible and easy to administer to all patients and provides important information about qualitative features of the pain.

Persistent dysphagia after laparoscopic fundoplication for gastro-esophageal reflux disease.

Persistent postoperative dysphagia is a potentially severe complication of fundoplication for gastroesophageal reflux disease (GERD). The aim of this retrospective study was to analyze our experience of laparoscopic fundoplication for GERD in 276 consecutive patients, to determine the frequency of postoperative dysphagia and assess treatments and outcomes. There was no relation between preoperative dysphagia, present in 24 patients (8.7%), and postoperative DeMeester grade 2 or 3 dysphagia, present in 25 patients (9.1%). Ten (3.6%) patients had clinically significant postoperative dysphagia, eight (2.9%) underwent esophageal dilation, with symptom improvement in five. Four (1.4%) of our patients (two with failed dilation) and 11 patients receiving antireflux surgery elsewhere, underwent re-operation for persistent dysphagia 12 months (median) after the first operation. DeMeester grade 0 or 1 dysphagia was obtained in 10/13 evaluable patients. Our experience is fully consistent with that of the recent literature. Redo surgery is necessary in only a small fraction of operated patients with GERD with good probability of resolving the dysphagia. Best outcomes are obtained when an anatomical cause of the dysphagia is documented preoperatively.

Transoral surgical removal of a giant fibrolipoma of the esophagus: case report.

An esophageal mass of more than 20 cm in length was diagnosed in a patient who presented with persistent dysphagia. Diagnosis of an endo-esophageal tumour was made by barium swallow; esophagoscopy confirmed the presence of a capsulated pink endo-esophageal mass. MRI confirmed the presence of a large capsulated mass within the esophagus, that appeared to be adipose tissue; a small stalk originating at the level of the upper esophageal sphincter was described and the polyp extended down to the gastroesophageal junction. Demonstration of the site and length of the stalk allowed a transoral removal of the mass, performed through a Weerda diverticuloscope (Karl Storz Endoskopie Gmbh, Tuttlingen Germany), a technique that has never been described before. Histology confirmed the mass as a fibrolipoma. The authors discuss both the role of MRI in diagnosis and treatment planning and the technique of transoral excision.

Analysis of post-surgical pain after inguinal hernia repair: a prospective study of 1,440 operations.

BACKGROUND: Pain remains a significant clinical problem after inguinal hernia repair. We prospectively assessed post-surgical pain following herniorrhaphy in 1,440 operations with the aim of describing the characteristics and identifying predisposing factors for pain. METHODS: Pain quality was assessed with the short-form McGill Pain Questionnaire (SF-MPQ); pain character was estimated as either nociceptive or neuropathic in nature. RESULTS: A total of 38.3% of replies reported pain (acute or chronic), and 18.7% reported chronic pain. Independent risk factors for pain were young age, BMI >25, day surgery, and use of Radomesh. In patients with chronic pain, independent risk factors were young age, BMI >25 and use of Radomesh. Analysis of the SF-MPQ revealed that the pain reported by most patients was sensory-discriminative in quality. The most common descriptors were tender and aching. Patients with chronic pain reported more intense pain and used sensory descriptors of greater mean intensity than patients with acute pain. A total of 73.9% of replies used descriptors typical of nociceptive pain, 6.5% used descriptors typical of neuropathic pain and 19.6% used nociceptive plus neuropathic descriptors. Patients considered to have nociceptive pain used significantly more sensory descriptors than those considered to have neuropathic pain. By contrast patients with neuropathic pain used more affective descriptors than those with nociceptive pain. Neuropathic pain was reported as more difficult to treat with analgesics than nociceptive pain and neuropathic plus nociceptive pain. CONCLUSIONS: Our study confirms that herniorrhaphy frequently produces chronic pain, which can reduce quality of life. The SF-MPQ is a useful instrument to administer to all patients and provides important information about qualitative properties of the pain.

Bioprofiling over grid for eHealthcare.

A trend in modern medicine is towards individualization of healthcare and, potentially, grid computing can play an important role in this by allowing sharing of resources and expertise to improve the quality of care. In this paper, we present a new test bed, the BIOPATTERN Grid, which aims to fulfil this role in the long term. The main objectives in this paper are 1) to report the development of the BIOPATTERN Grid, for biopattern analysis and bioprofiling in support of individualization of healthcare. The BIOPATTERN Grid is designed to facilitate secure and seamless sharing of geographically distributed bioprofile databases and to support the analysis of bioprofiles to combat major diseases such as brain diseases and cancer within a major EU project, BIOPATTERN (www.biopattern.org); 2) to illustrate how the BIOPATTERN Grid could be used for biopattern analysis and bioprofiling for early detection of dementia and for brain injury assessment on an individual basis. We highlight important issues that would arise from the mobility of citizens in the EU, such as those associated with access to medical data, ethical and security; and 3) to describe two grid services which aim to integrate BIOPATTERN Grid with existing grid projects on crawling service and remote data acquisition which is necessary to underpin the use of the test bed for biopattern analysis and bioprofiling.

Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athlete.

The nomenclature and the lack of consensus of clinical evaluation and imaging assessment in groin pain generate significant confusion in this field. The Groin Pain Syndrome Italian Consensus Conference has been organised in order to prepare a consensus document regarding taxonomy, clinical evaluation and imaging assessment for groin pain. A 1-day Consensus Conference was organised on 5 February 2016, in Milan (Italy). 41 Italian experts with different backgrounds participated in the discussion. A consensus document previously drafted was discussed, eventually modified, and finally approved by all members of the Consensus Conference. Unanimous consensus was reached concerning: (1) taxonomy (2) clinical evaluation and (3) imaging assessment. The synthesis of these 3 points is included in this paper. The Groin Pain Syndrome Italian Consensus Conference reached a consensus on three main points concerning the groin pain syndrome assessment, in an attempt to clarify this challenging medical problem.

A lower level of entropy in circadian rhythm of the sinus R-R intervals suggests a prevalence of the cardiac sympathetic regulation in early physiological pregnancy.

The study estimates the unpredictable disorder (chaos) within the 24 h pattern of sinus R-R intervals (SRRI) in clinically healthy pregnant women (CHPW) and clinically healthy non-pregnant women (CHNPW), in order to evaluate the early gestational changes in neurovegetative cardiac pacing. SRRI were provided by the 24-h Holter ECG of 10 CHPW and 10 CHNPW. SRRI were investigated by descriptive conventional statistics by means of the Time and Frequency Domain Analysis, and subsequently, in their chaotic component by means of entropy analysis. Both the SRRI and entropy were tested via the Cosinor method to better decipher whether or not the periodic disorder in heart rate variability is modified in pregnancy as a result of a gestational tonic resetting of the cardiac sympatho-vagal regulation. Cosinor analysis documented that the circadian rhythm of both the SRRI and entropy were preserved in CHNPW and CHPW. However, the circadian rhythm of SRRI and entropy in CHPW exhibited a significantly decreased 24 h mean. Via the analysis of the rhythmicity of entropy, this study has documented that the chaos in the 24 h pattern of SRRI is less prominent in CHPW than in CHNPW. Such a reduction of level in the deterministic periodic chaos of heart rate variability provides evidence that, in early pregnancy, a tonic elevation of the sympathetic activity regulates cardiac pacing.

Liver ischemia for hepatic resection: where is the limit?

BACKGROUND: A consecutive series of 50 patients who submitted to 53 hepatic resections with use of continuous normothermic liver ischemia is reported. METHODS: Portal triad clamping has been used in 28 cases, with associated inferior vena caval clamping above and below the liver (hepatic vascular exclusion) in 25 patients. The size of the tumor required major hepatic resection in 38 cases (71.7%). Malignant tumors (83%) were the most common indication for liver resection. Patients were placed in three groups according to the duration of liver ischemia: group A, less than 30 minutes (9 patients); group B, 30 to 60 minutes (29 patients); and group C, 60 or more (15 patients). RESULTS: No differences in mortality rates (5.7% in the entire series and 0% in group C) and morbidity rate could be shown. No significant difference was found in postoperative liver test results, and no persistent alteration remained thereafter. Liver biopsy at 6 and 12 months after operation did not reveal any chronic damage. Liver capability to regenerate was maintained as documented by postoperative computerized tomography scan or magnetic resonance imaging. CONCLUSIONS: Because interruption of hepatic blood flow in normothermia is safe for at least 60 minutes (up to 85 minutes in this study), vascular clamping is recommended for hazardous liver resections to minimize blood loss, which appears to be the main factor of death and morbidity.

Pancreatic polypeptide response to food and cerulein in patients with total gastrectomy.

In order to investigate the intestinal phase of pancreatic polypeptide (PP) release, the hormonal response to food and cerulein was measured in 19 patients with truncal vagotomy and total gastrectomy (10 with simple esophagojejunal anastomosis and 9 with an additional duodenojejunal anastomosis) and in 7 healthy subjects. After gastrectomy, the early peak of the physiologic biphasic PP response to food was lost but the late predominant phase was unchanged so that the overall postprandial release of the hormone was not significantly lowered. Gastrectomized patients with duodenal bypass had postprandial serum levels only slightly lower than those of patients with preserved duodenal transit of food. Serum PP response to cerulein stimulation was significantly lower in vagotomized patients than in healthy subjects. However, in operated patients as well as in controls, cerulein infusion did induce a rapid increase of plasma PP, followed by persistently elevated levels. The PP response to cerulein was abolished by atropine pretreatment. Our findings indicate that the intestinal phase of meal-stimulated PP response is not dependent on the integrity of vagal pancreatic innervation and that the preservation of the duodenal transit of food after total gastrectomy is not crucial for the maintenance of the enteroinsular axis.

Hepatic resection with ischemia of the liver exceeding one hour.

Twenty-six hepatic resections were performed using vascular clamping lasting more than one hour. The average duration of continuous normothermic ischemia was 67.0 +/- 7.5 minutes (plus or minus standard error of the mean) (range of 60 to 85 minutes). Vascular occlusion consisted of simple portal triad clamping in 14 patients and of hepatic vascular exclusion in 12. Extensive hepatectomy was performed upon more than 80 percent of the patients. One postoperative death was recorded. Extensive complications occurred in eight patients, including one case of hepatic failure. Postoperative changes in hepatic function tests were mild and transient. The rate of postoperative complications was higher in the group of patients with chronic hepatic disease (77.8 versus 11.8 percent, p < 0.005). Prolonged hepatic ischemia should not be considered a risk factor in patients with normal livers, whereas morbidity and mortality rates are seriously affected by the presence of chronic hepatic disease.

The role of abdominal drainage after major hepatic resection.

The authors reviewed their recent experience with major hepatic resection in order to evaluate the role of abdominal drainage in the development and treatment of postoperative complications. Fifty-one patients underwent major hepatectomy with abdominal drainage; 44 of these patients (86%) for malignancy (average age at operation: 59 years). Drains were removed after a median period of 4 days. Major complications occurred in 16 patients (31%), and 3 patients (6%) had a fatal outcome. Twenty patients (39%) experienced minor complications, including 6 cases (12%) of ascitic leak from the insertion site. Considering the type and extent of liver resections reported in this series, these results suggest that abdominal drainage, if technically adequate and maintained for a short period, is not responsible for a high rate of postoperative complications. Its use, although questionable after limited resections, is, therefore, still recommended after difficult and extended hepatectomies.

Laparoscopic approach to esophageal achalasia.

Certain technical details are considered important to ease the laparoscopic performance of a Heller myotomy combined with a Dor antireflux procedure for esophageal achalasia. A special emphasis is given to intraoperative esophagoscopy combined with a mild balloon distension of the esophagogastric junction. These maneuvers prove helpful in identifying the esophagogastric region, easing the myotomy, and controlling its completeness.

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study.

BACKGROUND: Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. METHODS: Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. RESULTS: Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). CONCLUSIONS: Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.

Bactericidal activity of Pistacia lentiscus mastic gum against Helicobacter pylori.

In this study we evaluated the antibacterial activity of mastic gum, a resin obtained from the Pistacia lentiscus tree, against clinical isolates of Helicobacter pylori. The minimal bactericidal concentrations (MBCs) were obtained by a microdilution assay. Mastic gum killed 50% of the strains tested at a concentration of 125 microg/ml and 90% at a concentration of 500 microg/ml. The influence of sub-MBCs of mastic gum on the morphologies of H. pylori was evaluated by transmission electron microscopy. The lentiscus resin induced blebbing, morphological abnormalities and cellular fragmentation in H. pylori cells.

Laparoscopic treatment of epiphrenic diverticula.

BACKGROUND AND PURPOSE: Epiphrenic diverticula are a rare disease probably caused by long-standing impairment of esophageal motor activity. Symptomatic disease, which may worsen clinically during follow-up even to severe symptoms, is usually considered an indication for surgical treatment. Surgery for epiphrenic diverticula consists of diverticulectomy, which traditionally is performed through a left thoracotomy; a myotomy and partial fundoplication are generally included in order to treat the underlying motor disorder and to prevent or correct reflux. The same principles of surgical treatment can be achieved through the laparoscopic transhiatal approach. The aim of this paper is to describe the technique and the results of laparoscopic diverticulectomy combined with esophageal myotomy and antireflux wrap to treat epiphrenic diverticula of the esophagus. PATIENTS AND METHODS: From January 1994 through May 2001, 11 patients underwent laparoscopic transhiatal diverticulectomy, esophageal myotomy, and partial fundoplication at our institution. RESULTS: In all patients, the operation was completed through the minimally invasive access. The postoperative course was complicated in one patient (9%), who had a leak from the staple line, which was repaired through a thoracotomy. At follow-up, this patient had persistence of a small pouch at the diverticuletomy site. However, he was asymptomatic. All other patients were free of symptoms and without recurrence. CONCLUSION: Laparoscopy offers good access to the distal esophagus and the inferior mediastinum. Removal of the diverticulum, treatment of the motor disorder, and prevention of postoperative reflux can all be obtained through this approach. The immediate postoperative and long-term results are satisfactory.

Thoracoscopic dissection of the esophagus for cancer.

Eighteen patients affected by a resectable intramural tumor of the esophagus have undergone esophagectomy with thoracoscopic dissection of the esophagus in the last 4 years. All patients had a relative contraindication to transthoracic esophagectomy with radical lymphadenectomy. All esophagectomies were completed thoracoscopically and reconstruction of the digestive tract was performed in 17 cases through cervical gastroplasty and in 1 case through cervical coloplasty. One cirrhotic patient died in the postoperative period due to cervical anastomotic leak. Six other patients experienced a postoperative complication (mortality rate 5.5%; morbidity rate 33.3%). After a median follow up of 17 months, 14 patients are alive without evidence of disease. One patient, who had excision of a cutaneous metastasis at a trocar insertion site 6 months postoperatively, eventually died with locoregional recurrence 14 months postoperatively. Another patient died 20 months after surgery with mediastinal recurrence. One patient died 28 months postoperatively after massive hematemesis with a suspect abdominal recurrence. The results of the present series and those reported by other authors do not seem to indicate presently evident advantages from the minimally invasive procedure during resection of the esophagus for cancer. At the present time, no indication to this procedure exists for standard clinical use; wider randomized trials and longer follow-up to be performed only in selected centers are needed to further evaluate the procedure.

Laparoscopic treatment of functional diseases of the esophagus.

The possibilities of laparoscopic surgery in the treatment of functional esophageal diseases (gastroesophageal reflux, achalasia and epiphrenic diverticula) are illustrated with special emphasis on the technical aspects, including intraoperative complications and postoperative care. Results are discussed on the ground of the following experience. Thirty-seven laparoscopic fundoplications were performed with 13% conversion rate, 2.7% postoperative morbidity (1 slipped Nissen requiring redo laparoscopic surgery). Median operative time was 140 min. One patient complained of dysphagia relieved by endoscopic dilation (2.7%). All patients are not asymptomatic after a median follow-up of 16 months although one has gastroesophageal reflux (GER) at 24-hrs pH monitoring. forty laparoscopic Heller-Dor procedures: 7% conversions, 5% postoperative morbidity. Median duration 120 min. One patient complained of persistent dysphagia requiring endoscopic dilation (2.5%) and asymptomatic GER was detected in 8% of patients. Finally, 2 patients underwent laparoscopic diverticulectomy, esophagomyotomy and Dor fundoplication without morbidity and excellent postoperative result. Laparoscopic treatment of functional diseases of the esophagus is safe and effective, provided it is performed by an experienced surgeon with respect for some important technical details. Further follow-up is needed to evaluate long-term results.

Anastomotic healing in dogs under cortisone treatment. A pilot study comparing compression and stapled anastomosis.

Colonic anastomoses made both by a new Compression Anastomotic Device (CAD) and by a traditional stapler (Autosuture CDEEA) were evaluated in impaired anastomotic healing induced by systemic cortisone in the dog. Twenty dogs were given daily i.m. hydrocortisone (25 mg/kg) starting one month before surgery and then until sacrifice. Eight untreated dogs served as controls. Surgery consisted of colonic transection and anastomosis done with CAD-25 in half the cases and with CDEEA-25 in the remaining half. The dogs were sacrificed six and 13 days after surgery. Macroscopic assessment, bursting pressure test, and histology were performed on the anastomosis. One dog died from peritonitis due to anastomotic dehiscence. No other clinical complications were observed. Although the number of observations was too small to attain statistical significance, CAD anastomoses appeared better than stapled ones as regards peri-anastomotic adhesions, anastomotic index, and histology. This preliminary study suggests that compression is as reliable as the stapler in the construction of colon anastomosis even in such situations of delayed anastomotic healing. Further experience is required to substantiate this conclusion.

[Right adrenal adenoma: laparoscopic exeresis]. / Adenoma surrenalico destro: exeresi per via laparoscopica.

The authors report the case of a non functioning adrenal adenoma, incidentally diagnosed and excised through a laparoscopic approach. Indications to adrenalectomy for such a pathological condition and surgical technique are reviewed and discussed. In consideration of the relatively rare disease and of the scant literature on minimally-invasive approach to right adrenalectomy, it seemed worth reporting this case and the technical skills performed to ease this operation through laparoscopy.