Laparoscopic inguinal hernia repair: cost-effectiveness analysis of trend modifications of the technique.

The aim of this study is to evaluate the cost-effectiveness of different modifications of the trans-abdominal pre-peritoneal (TAPP) repair of groin hernia. Data were collected prospectively for all consecutive patients who underwent TAPP unilateral inguinal hernia repair between November 2017 and March 2019, and who completed a minimum of 1 year of follow-up. Costs and quality adjusted life year (QALY) gained were collected. Three TAPP variations were assessed: mesh fixation and peritoneal closure with staples (group 1); mesh fixation with fibrin glue and peritoneal closure with sutures (group 2); and mesh fixation and peritoneal closure with fibrin glue (group 3). A matched group of open repairs was established. The incremental cost-effectiveness ratio (ICER) and main intra-operative and post-operative outcomes were assessed. Overall 120 patients were included (group 1 n = 31; group 2 n = 27; group 3 n = 33; open group: 29). Operative time was shorter for groups 2 and 3, and the main post-operative outcomes were similar. The overall mean total cost of the open group (1185.95€) was lower compared with the laparoscopic group (group 1: 1682.39; group 2: 1538.54€; group 3: 1510.1€) (p = 0.026). However, the mean ICERs of groups 2 and 3 were significantly higher compared with group 1 (p = 0.021) and the open group (p = 0.032). At simulations analysis, the probability of cost-effectiveness was 33.32%, 36.26%, and 36.7% in TAPP groups 1, 2, and 3. In the long term, laparoscopic repair of groin hernia is cost-effective compared with open surgery. The use of fibrin glue for mesh fixation and/or for closing the peritoneum is the most cost-effective option and shortens operative times.

Indinavir-induced retinoid-like effects: incidence, clinical features and management.

Since 1998, many cases of antiretroviral therapy-related paronychia of the toes or fingers and ingrown toenails have been reported. Most of them were related to indinavir. Other indinavir-induced mucocutaneous disorders resembling the adverse effects of systemic retinoid therapy have also been reported. Although there is some uncertainty in the literature regarding a cause-effect relationship, results of several epidemiological and in vitro studies, together with cumulated clinical experience leave no doubt that indinavir causes a retinoid-like effect and nail alterations. Indeed, indinavir is the only antiretroviral drug that produces these disorders, although ritonavir may enhance indinavir-induced retinoid-like effects through pharmacokinetic interactions leading to increased plasma indinavir concentrations. Approximately 30% of patients receiving indinavir show two or more retinoid-like manifestations and 4-9% develop paronychia. These adverse effects are not related to other epidemiological variables such as the patient's sex, age or other risk factors or immune status. They seem to be exposure dependent and, therefore, largely dose-dependent. Chronic paronychia is considered generally to be caused by contact irritants and candidal infection. Nevertheless, indinavir is currently the most frequent cause of chronic or recurrent paronychia in HIV-infected patients. In addition, retinoid-like manifestations such as cutaneous xerosis and cheilitis are frequent mucocutaneous adverse effects related to indinavir. The exact mechanism of indinavir-induced retinoid-like effects is unclear. Hypotheses for pathogenesis include interference with retinoid metabolism by enhancing the retinoic acid signalling pathway, or by increasing retinoic acid synthesis, or by reducing cytochrome p450-mediated retinoic acid oxidative metabolism. Replacement of therapy by an antiretroviral regimen not containing indinavir, while retaining other protease inhibitors and lamivudine, resolves retinoid-like manifestations without recurrences.