Randomized control trial evaluating the use of a shared decision-making aid for older ventral hernia patients in the Geriatric Assessment and Medical Preoperative Screening (GrAMPS) Program.

PURPOSE: Shared decision making (SDM) is ideally suited to abdominal wall surgery in older adults given the breadth of decision making required by the hernia surgeon and the impact on quality of life (QOL) by various treatment options. Given the paucity of literature surrounding SDM in hernia patients, the feasibility of a novel, formalized SDM aid/tool was evaluated in a pilot randomized trial. METHODS: Patients 60 years or older with a diagnosed ventral hernia were prospectively randomized at an academic hernia center. In the experimental arm, a novel SDM tool, based on the SHARE Approach, guided the consultation. Previously validated SDM assessments and patient's hernia knowledge retention was measured. RESULTS: Eighteen (18) patients were randomized (9 control and 9 experimental). Cohorts were well matched in age (p = 0.51), comorbidities (Charlson Comorbidity Score: p = 0.43) and frailty (mFI-11: p = 0.19; Risk Analysis Index: p = 0.33). Consultation time was 11 min longer in the experimental cohort (p < 0.01). There was a trend towards better Decisional Conflict Scores in the experimental group (p = 0.25) and the experimental cohort had improved post-visit retained hernia knowledge (p < 0.01). All patients in the experimental arm (100%) enjoyed working through the SDM aid/tool and felt it was a worthwhile exercise. CONCLUSION: Incorporating a formalized SDM tool into a busy hernia surgical practice is feasible and well received by patients. In addition, early results suggest it improves retention of basic hernia knowledge and may reduce patient's decisional conflict. Next steps include condensing the SDM tool to enhance efficiency within the clinic and beginning a large, randomized control trial.

Assessment of myofascial medialization following posterior component separation via transversus abdominis muscle release in a cadaveric model.

PURPOSE: Posterior component separation (PCS) via the transversus abdominis release (TAR) procedure continues to gain popularity. However, neither the physiologic basis nor the extent of myofascial medialization after TAR is established. We aimed to assess both anterior and posterior rectus fascia (AF and PF) medialization following each step of the TAR procedure. METHODS: Ten fresh cadavers underwent PCS via TAR. Steps included midline laparotomy (MLL), retrorectus dissection (RRD), incision of the posterior rectus sheath (IPL), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Medial advancement of AF and PF was measured following application of 2.5, 5.0 lb, and maximal tension to the fascial edge. Values are represented as mean advancement past midline in centimeters. RESULTS: MLL allowed advancement of 2.5, 3.7, and 4.9 cm. RRD provided advancement of 4.1, 5.9, and 7.6 cm for AF and 4.4, 6.2, and 7.5 cm for PF. IPL provided advancement of 4.2, 6.1, and 8.0 cm for AF and 4.6, 6.6, and 8.3 cm for PF. TAD provided advancement of 4.5, 6.6, and 8.6 cm for AF and 5.3, 7.5, and 9.5 cm for PF. RMD provided advancement of 5.5, 7.9, and 9.9 cm for AF and 6.9, 9.6, and 11.2 cm for PF. Overall, the complete TAR procedure provided AF advancement of 102% and PF advancement of 129%, over baseline. CONCLUSIONS: The TAR procedure provides for substantial medial advancement of both anterior and posterior myofascial components of the abdominal wall. Retromuscular dissection deep to the divided transversus abdominis muscle appears to be the key step of the procedure, allowing for effective reconstruction of very wide (≈ 20 cm) defects.

Infant and child mortality determinants in Bangladesh: are they changing?

From the data of the 1989 Bangladesh Fertility Survey, aggregate deaths reported at ages 0-12 and 13-60 months are used to estimate infant and child mortality. Multivariate analysis shows that preceding birth interval length, followed by survival status of the immediately preceding child, are the most important factors associated with differential infant and child mortality risks; sex of the index child and mother's and father's education are also significant. Demographic factors are influential during infancy as well as childhood, but social factors, particularly mother's and father's education, now emerge as significant predictors of infant mortality risks. This indicates a change in the role of socioeconomic factors, since the earlier Bangladesh Fertility Survey in 1975.

PIP: This study identifies the risk factors associated with infant and child mortality in Bangladesh. The data are obtained from the 1989 Bangladesh Fertility Survey. Since 1975, infant and child mortality declined. In 1975, the determinants of child survival were sex of the child, maternal age at birth, birth order, preceding birth interval, and survival of preceding sibling: all demographic factors. This study finds that both mothers' and fathers' educational status were negatively related to mortality. The lowest rates of mortality occurred among births to either parent who had a secondary level of education. Mothers' education had a greater impact than fathers' education. Infant mortality was higher among births to teenage mothers and to mothers older than 35. Infants with parents living in rural areas had higher rates. Child mortality showed similar relationships, with the exception that females had higher child mortality rates and children following a sibling death had lower child mortality rates. Multivariate analyses indicate that child survival was highly significantly affected by both demographic and socioeconomic factors. The effects of birth interval and survival of the preceding child were stronger than the effects of fathers' or mothers' education. The determinants of infant and child mortality in 1989 differed from the determinants in 1975. The influence of educational status increased to include fathers' educational status. Both parents' educational status in 1989 influenced infant mortality. Findings suggest the greater influence of social factors in explaining differential mortality risks. The influence could be due to reduced mortality levels or changes in educational status or both. Policy should be directed to spacing births, special care to women with a previous history of pregnancy loss, and increased educational status.

Measuring child cost--an intermediate situation between the Engel and Rothbarth measures.

"This paper examines the structure of cost functions underlying the Engel and Rothbarth measures [of measuring child costs]. A generalised cost function, based on these cost functions, is proposed here. The cost of [a] child, according to this cost function, lies between the Engel and Rothbarth measures."

Socioeconomic and environmental determinants of child survival in Bangladesh.

Differentials in child survival in Bangladesh have been examined using a number of socioeconomic and environmental factors on data from the 1989 Bangladesh Fertility Survey. Multivariate analysis reveals that both wife's and husband's education and household electricity show a significant positive association with child survival. The respondent's working status exerts a significant negative influence. Wife's education has a greater influence on child survival in Bangladesh than that of husband's education.

PIP: Statisticians used number of living children and total number of children ever born for each respondent of the 1989 Bangladesh Fertility Survey who had at least one live birth to determine the child survival index. They then controlled for the age of the mother to examine the differentials in child survival by using socioeconomic and environmental factors. The child survival index increased with parents' education. Mother's education had a greater positive effect than did father's education (among 20- 29 year old mothers, 79.9% for no education, 85.2% for primary education, and 90.4% for at least secondary education vs. 79.5%, 81.3%, and 87.8%, respectively, among same age fathers). Multivariate analysis showed that mother's and father's education and the presence of household electricity had a significant positive effect on child survival (T .0001). Enhanced knowledge about prevention, recognition, and treatment of childhood diseases probably explained the positive effect of mother's education. The positive effect of father's education and household electricity was mainly through higher socioeconomic status, indicating perhaps the ability to obtain child health care. On the other hand, mother's paid work had a significant negative effect on child survival (T .0001). Just 11% of all mothers worked. Working mothers tended to be from the lowest socioeconomic group. The multivariate analysis also indicated that the child survival index increased more between educational status levels for the mother than for the father (2.9 vs 1.6%). All the variables in the analysis accounted for only 5.6% of the total variation in the child survival index. These results indicated that an increase in male and female education, which should in turn increase socioeconomic status, and electrification, especially in rural areas, would improve child survival in Bangladesh.

Socioeconomic, demographic and environmental determinants of infant mortality in Nepal.

The Nepal Fertility and Family Planning Survey of 1986 demonstrated that demographic variables, previous birth interval and survival of preceding child, still predominated as determinants of infant mortality, particularly in rural areas of Nepal. However, in urban Nepal, where the level of socioeconomic development is higher, an environmental variable, along with previous birth interval and survival of preceding child emerges as important in determining infant mortality. Separate policy measures for child survival prospects in rural and urban Nepal are suggested.

PIP: The analysis of the 1986 Nepal Fertility and Family Planning Survey, based on a representative sample of 5-29 married women 15-50 years, was consistent with the hypothesis that demographic factors are more important in early stages of development, with socioeconomic and environmental factors gaining importance as development proceeds. The 1976 Nepal Fertility Survey also reveals the pattern of high infant mortality rates as a reflection of maternal age, parity, previous birth interval, and survival of preceding child. The infant mortality rates fell between 1976-86 from 150 to 100/1000. Urban areas are beginning to show environmental variables as determinants of infant mortality. In urban Nepal, the logit linear model of the effect of socioeconomic, environmental, and demographic factors show maternal age and birth order as significant determinants of infant mortality, regardless of whether demographic or socioeconomic variables are controlled. Mothers 20 years experience a risk of infant death 51% greater than mothers 20-29 years, and 50% higher than mothers 30 years. 1st born children have the lowest risk of dying during infancy and risk increases with birth order. Drinking water and toilet facilities were also significant factors. The probability of dying is 44% higher for those drinking lake or river water than those using piped or tube well water. Those without a toilet have a 64% higher probability of dying than those with their own toilet facility. These 2 variables are significant and enhanced even after controlling for maternal age and birth order. When a logit linear model is run with only 2 nd and higher order birth with birth interval and preceding child as control variables, only toilet facility has a significant effect. Birth interval and survival of preceding child become the significant demographic variables. The joint model of birth interval, survival of preceding child, and toilet facility has significant effects on infant mortality. Children born after a short interval (19 months) with the preceding child dead have a lower mortality due to lack of competition. The policy implications are to increase the use of contraception, to reduce births of young mothers, and insure adequate birth intervals. High risk households need special attention from family planning and health services.

Maternal factors and infant and child mortality in Bangladesh.

PIP: Using data from The World Fertility Survey, this study shows that the length of the preceding birth interval was the most important maternal factor influencing infant and child mortality risks in Bangladesh. This was such a crucial factor that its effects remain unaltered whether or not the influences of mother's age at birth and birth order are controlled. Infant and child mortality in Bangladesh can be expected to decline considerably if successive births can be spaced by an interval of at least 1.5 years. Child spacing seems to be the major factor requiring program attention. The effects of mother's education and place of residence on infant and child mortality are independent of the effects of maternal age at birth, birth order, and the preceding birth interval. The higher survival chances of children of educated mothers resulted neither through the age at which childbearing started nor through birth spacing but are likely to be related to their smaller family size and to other non-maternal proximate determinants of early mortality.^ieng