Limited use of local anesthesia for open inguinal hernia repair: a qualitative study.

PURPOSE: Local anesthesia for open inguinal hernia repair is recommended by guidelines but is rarely used in clinical practice in several countries. This study aimed to explore physician's considerations in choosing type of anesthesia and barriers for implementing local anesthesia for open hernia repair in clinical practice. METHODS: We performed individual semi-structured interviews of surgeons and anesthesiologists. Transcribed data were condensed, coded, categorized, and formulated into themes in an inductive qualitative content analysis. RESULTS: Twenty two participants from seven public hospitals were included in the study. Participants described a standardized setup for general anesthesia with use of intravenous propofol/remifentanil and a laryngeal mask and were generally satisfied with this setup. Their considerations in choosing anesthesia could be described in four themes: (1) Intraoperative pain and quality of surgical technique, (2) Communication and teaching, (3) Logistics, and (4) Clinical routines. CONCLUSION: Participants considered intraoperative pain and quality of surgical technique, communication and teaching, logistics, and clinical routines as important factors when choosing anesthesia for open inguinal hernia repair and these factors acted as barriers for implementing of local anesthesia in Danish public hospitals. In this setting, implementation strategies should, therefore, be multimodal to address these barriers. The potential workload in such an effort should be justified by evidence supporting specific types of local anesthesia comapared with general anesthesia with use of propofol/remifentanil and a laryngeal mask.

Mortality and Urological Complications After Open Groin Hernia Repair in Local, General, and Regional Anesthesia: A Nationwide Linked Register Study.

BACKGROUND AND AIMS: The choice of anesthesia method may influence mortality and postoperative urological complications after open groin hernia repair. We aimed to investigate the association between type of anesthesia and incidence of urinary retention, urethral stricture, prostate surgery, and 1-year mortality after open groin hernia repair. MATERIALS AND METHODS: Data were linked from the Danish Hernia Database, the national patient register, and the register of causes of death. We investigated data on male adult patients receiving open groin hernia repair from 1999 to 2013 with either local anesthesia, regional anesthesia, or general anesthesia. In relation to the type of anesthesia, we compared mortality and urological complications up to 1 year postoperatively. We adjusted for covariates in a logistic regression assessing urological complications and with the Cox regression assessing mortality. RESULTS: We included 113,069 open groin hernia repairs in local anesthesia, regional anesthesia, or general anesthesia. The risk of urinary retention adjusted for covariates was higher after both general anesthesia (adjusted odds ratio = 1.64, 95% confidence interval = 1.05-2.57, p = 0.031) and regional anesthesia (odds ratio = 2.99, 95% confidence interval = 1.67-5.34, p < 0.0005) compared with local anesthesia. The adjusted risk of prostate surgery was also higher for both general anesthesia (odds ratio = 1.58, 95% confidence interval = 1.23-2.03, p < 0.0005) and regional anesthesia (odds ratio = 1.90, 95% confidence interval = 1.40-2.58, p < 0.0005) compared with local anesthesia. Type of anesthesia did not influence 1-year mortality or the risk for urethral stricture. CONCLUSION: Patients undergoing open groin hernia repair in local anesthesia experience the lowest rate of urological complications and have equally low mortality compared with patients undergoing repair in general anesthesia or regional anesthesia.

Marine resource abundance drove pre-agricultural population increase in Stone Age Scandinavia.

How climate and ecology affect key cultural transformations remains debated in the context of long-term socio-cultural development because of spatially and temporally disjunct climate and archaeological records. The introduction of agriculture triggered a major population increase across Europe. However, in Southern Scandinavia it was preceded by ~500 years of sustained population growth. Here we show that this growth was driven by long-term enhanced marine production conditioned by the Holocene Thermal Maximum, a time of elevated temperature, sea level and salinity across coastal waters. We identify two periods of increased marine production across trophic levels (P1 7600-7100 and P2 6400-5900 cal. yr BP) that coincide with markedly increased mollusc collection and accumulation of shell middens, indicating greater marine resource availability. Between ~7600-5900 BP, intense exploitation of a warmer, more productive marine environment by Mesolithic hunter-gatherers drove cultural development, including maritime technological innovation, and from ca. 6400-5900 BP, underpinned a ~four-fold human population growth.

Network meta-analysis of urinary retention and mortality after Lichtenstein repair of inguinal hernia under local, regional or general anaesthesia.

BACKGROUND: Urinary retention and mortality after open repair of inguinal hernia may depend on the type of anaesthesia. The aim of this study was to investigate possible differences in urinary retention and mortality in adults after Lichtenstein repair under different types of anaesthesia. METHODS: Systematic searches were conducted in the Cochrane, PubMed and Embase databases, with the last search on 1 August 2018. Eligible studies included adult patients having elective unilateral inguinal hernia repair by the Lichtenstein technique under local, regional or general anaesthesia. Outcomes were urinary retention and mortality, which were compared between the three types of anaesthesia using meta-analyses and a network meta-analysis. RESULTS: In total, 53 studies covering 11 683 patients were included. Crude rates of urinary retention were 0·1 (95 per cent c.i. 0 to 0·2) per cent for local anaesthesia, 8·6 (6·6 to 10·5) per cent for regional anaesthesia and 1·4 (0·6 to 2·2) per cent for general anaesthesia. No death related to the type of anaesthesia was reported. The network meta-analysis showed a higher risk of urinary retention after both regional (odds ratio (OR) 15·73, 95 per cent c.i. 5·85 to 42·32; P < 0·001) and general (OR 4·07, 1·07 to 15·48; P = 0·040) anaesthesia compared with local anaesthesia, and a higher risk after regional compared with general anaesthesia (OR 3·87, 1·10 to 13·60; P = 0·035). Meta-analyses showed a higher risk of urinary retention after regional compared with local anaesthesia (P < 0·001), but no difference between general and local anaesthesia (P = 0·08). CONCLUSION: Local or general anaesthesia had significantly lower risks of urinary retention than regional anaesthesia. Differences in mortality could not be assessed as there were no deaths after elective Lichtenstein repair. Registration number: CRD42018087115 ( https://www.crd.york.ac.uk/prospero).

ANTECEDENTES: La retención de orina y la mortalidad tras la reparación abierta de las hernias inguinales puede depender del tipo de anestesia. El objetivo de este estudio fue investigar posibles diferencias en la retención de orina y mortalidad en adultos tras reparación de Lichtenstein bajo diferentes métodos anestésicos. MÉTODOS: Se efectuaron búsquedas sistemáticas en las bases de datos Cochrane, PubMed y Embase con la última revisión el 1 de agosto de 2018. Los estudios elegibles incluyeron pacientes adultos sometidos a reparación electiva de hernia inguinal unilateral mediante la técnica de Lichtenstein bajo anestesia local, regional o general. Las variables de resultados fueron la retención de orina y la mortalidad, comparándose los tres tipos de anestesia con metaanálisis y un metaanálisis en red. RESULTADOS: En total se incluyeron 53 estudios con un total de 11.683 pacientes. Las tasas crudas de retención de orina fueron del 0,1% (i.c. del 95% 0,0-0,2%) para la anestesia local, del 8,6% (i.c. del 95% 6,6-10,5%) para la anestesia regional y del 1,4% (i.c. del 95% 0,6-2,2%) para la anestesia general. No se observó mortalidad relacionada con el tipo de anestesia. El metaanálisis en red mostró un riesgo más elevado de retención de orina tras la anestesia regional (razón de oportunidades, odds ratio, OR 15,73 (i.c. del 95% 5,85-42,32), P < 0,001) y anestesia general (OR 4,07 (i.c. del 95% 1,07-15,48), P = 0,040) en comparación con la anestesia local y un riesgo más alto tras la regional en comparación con la anestesia general (OR 3,87 (i.c. del 95% 1,10-13,60), P = 0,035). Los metaanálisis mostraron un riesgo más alto de retención de orina tras la anestesia regional en comparación con la anestesia local (P < 0,001), pero sin diferencias entre anestesia general y local (P = 0,08). CONCLUSIÓN: La anestesia local o general presentaba un riesgo significativo menor de retención urinaria en comparación con la anestesia regional. Las diferencias en mortalidad no pudieron ser evaluadas ya ningún paciente falleció tras la reparación electiva de Lichtenstein.

The earliest human occupation of the high-altitude Tibetan Plateau 40 thousand to 30 thousand years ago.

The Tibetan Plateau is the highest and one of the most demanding environments ever inhabited by humans. We investigated the timing and mechanisms of its initial colonization at the Nwya Devu site, located nearly 4600 meters above sea level. This site, dating from 40,000 to 30,000 years ago, is the highest Paleolithic archaeological site yet identified globally. Nwya Devu has yielded an abundant blade tool assemblage, indicating hitherto-unknown capacities for the survival of modern humans who camped in this environment. This site deepens the history of the peopling of the "roof of the world" and the antiquity of human high-altitude occupations more generally.

First trimester coffee and tea intake and risk of gestational diabetes mellitus: a study within a national birth cohort.

OBJECTIVE: Coffee and tea consumption is associated with a decreased type 2 diabetes risk in non-pregnant adults. We examined the relation between first trimester coffee and tea consumption and gestational diabetes mellitus (GDM) risk. DESIGN: Population-based cohort study. SETTING: Denmark 1996-2002. POPULATION: Non-diabetic women with singleton pregnancies in the Danish National Birth Cohort (n = 71,239). METHODS: Estimated adjusted relative risks (RR) and 95% confidence intervals (95%CI) for the association between first trimester coffee and tea or estimated total caffeine and GDM. MAIN OUTCOME MEASURES: GDM ascertained from the National Hospital Discharge Register or maternal interview. RESULTS: Coffee or tea intake was reported in 81.2% (n = 57,882) and 1.3% (n = 912) of pregnancies were complicated by GDM. Among non-consumers, 1.5% of pregnancies were complicated by GDM. Among coffee drinkers, GDM was highest among women who drank ≥8 cups/day (1.8%) with no significant difference across intake levels (P = 0.10). Among tea drinkers, there was no difference in GDM across intake levels (1.2%; P = 0.98). After adjustment for age, socio-occupational status, parity, pre-pregnancy body mass index, smoking, and cola, there was suggestion of a protective, but non-significant association with increasing coffee (RR ≥8 versus 0 cups/day = 0.89 [95%CI 0.64-1.25]) and tea (RR ≥8 versus 0 cups/day = 0.77 [95%CI 0.55-1.08]). Results were similar by smoking status, except a non-significant 1.45-fold increased risk with ≥8 coffee cups/day for non-smokers. There was a non-significant reduced GDM risk with increasing total caffeine. CONCLUSIONS: Our results suggest that moderate first trimester coffee and tea intake were not associated with GDM increased risk and possibly may have a protective effect.

Intimate associations between the endogenous opiate systems and the growth hormone-releasing hormone system in the human hypothalamus.

Although it is a general consensus that opioids modulate growth, the mechanism of this phenomenon is largely unknown. Since endogenous opiates use the same receptor family as morphine, these peptides may be one of the key regulators of growth in humans by impacting growth hormone (GH) secretion, either directly, or indirectly, via growth hormone-releasing hormone (GHRH) release. However, the exact mechanism of this regulation has not been elucidated yet. In the present study we identified close juxtapositions between the enkephalinergic/endorphinergic/dynorphinergic axonal varicosities and GHRH-immunoreactive (IR) perikarya in the human hypothalamus. Due to the long post mortem period electron microscopy could not be utilized to detect the presence of synapses between the enkephalinergic/endorphinergic/dynorphinergic and GHRH neurons. Therefore, we used light microscopic double-label immunocytochemistry to identify putative juxtapositions between these systems. Our findings revealed that the majority of the GHRH-IR perikarya formed intimate associations with enkephalinergic axonal varicosities in the infundibular nucleus/median eminence, while endorphinergic-GHRH juxtapositions were much less frequent. In contrast, no significant dynorphinergic-GHRH associations were detected. The density of the abutting enkephalinergic fibers on the surface of the GHRH perikarya suggests that these juxtapositions may be functional synapses and may represent the morphological substrate of the impact of enkephalin on growth. The small number of GHRH neurons innervated by the endorphin and dynorphin systems indicates significant differences between the regulatory roles of endogenous opiates on growth in humans.

Exposures that may affect sperm DNA integrity: two decades of follow-up in a pregnancy cohort.

Prenatal lifestyle exposures are linked to alterations in conventional semen characteristics. Sperm DNA integrity is another marker of semen quality shown to be altered in mice prenatally exposed to chemicals. From a Danish pregnancy cohort established in 1984-1987, sons were selected for a follow-up study in 2005-2006. We examined associations between prenatal and current lifestyle exposures and DNA fragmentation index (DFI) among 337 men. Sons of overweight mothers had 22% (95% CI: -3; 52) higher DFI than sons of normal weight mothers and sons of parents with a TTP >12 months had 14% (95% CI: -4; 34) higher DFI than sons of parents with a TTP of 0-6 months. Abstinence time was positively associated with DFI (p<0.005). Overweight men had higher DFI compared to normal weight men, however, statistically insignificantly. In conclusion, results indicate that DFI is affected by prenatal exposures, but confidence limits are wide and results statistically insignificant.

Semen quality according to prenatal coffee and present caffeine exposure: two decades of follow-up of a pregnancy cohort.

BACKGROUND: A few studies have investigated the association between male caffeine consumption in adult life and semen quality with conflicting results, but so far no studies have explored the effect of prenatal coffee exposure. We studied the association between prenatal coffee and current caffeine exposure and semen quality and levels of reproductive hormones. METHODS: From a Danish pregnancy cohort established in 1984-1987, 347 sons out of 5109 were selected for a follow-up study conducted 2005-2006. Semen and blood samples were analyzed for conventional semen characteristics and reproductive hormones and were related to information on maternal coffee consumption during pregnancy and present caffeine consumption. Data were available for 343 men. RESULTS: There was a tendency toward decreasing crude median semen volume (P = 0.06) and adjusted mean testosterone (P = 0.06) and inhibin B (P = 0.09) concentrations with increasing maternal coffee consumption during pregnancy. Sons of mothers drinking 4-7 cups/day had lower testosterone levels than sons of mothers drinking 0-3 cups/day (P = 0.04). Current male caffeine intake was associated with increasing testosterone levels (P = 0.007). Men with a high caffeine intake had approximately 14% higher concentration of testosterone than those with a low caffeine intake (P = 0.008). CONCLUSIONS: The results observed in this study are only tentative, but they do not exclude a small to moderate effect of prenatal coffee exposure on semen volume and levels of reproductive hormones. Present adult caffeine intake did not show any clear associations with semen quality, but high caffeine intake was associated with a higher testosterone concentration.

Antiepileptic drug use, folic acid supplementation, and congenital abnormalities: a population-based case-control study.

OBJECTIVE: To investigate whether folic acid supplementation in early pregnancy modifies the association between the prevalence of congenital abnormalities in the offspring and maternal use of carbamazepine (CBZ), phenobarbital (PB), phenytoin (PHT), and primidone (PRI). DESIGN: A population-based case-control study. SETTING: The Hungarian Case-Control Surveillance of Congenital Abnormalities (HCCSCA) (1980-1996) and its information on children from the Hungarian Congenital Abnormality Registry and the Hungarian National Birth Registry. POPULATION: Children with congenital abnormalities (cases; n= 20 792, of whom 148 had been exposed to antiepileptic drugs [AEDs]) and unaffected children (controls; n= 38 151, of whom 184 had been exposed to AEDs). METHODS: Information on drug exposure and background variables for the mothers were collected from antenatal logbooks, discharge summaries, and structured questionnaires completed by the mothers at the time of HCCSCA registration. MAIN OUTCOME MEASURES: Congenital abnormalities detected at termination of pregnancy, at birth or until 3 months of age according to CBZ, PB, PHT, or PRI exposure at 5-12 weeks from first day of the last menstrual period (LMP), stratified by folic acid supplementation. RESULTS: Compared with children unexposed to AEDs and folic acid, the odds ratio of congenital abnormalities was 1.47 (95% CI 1.13-1.90) in children exposed to AEDs without folic acid supplementation and 1.27 (95% CI 0.85-1.89) for children exposed to AEDs with folic acid supplementation. CONCLUSION: The results indicate that the risk of congenital abnormalities in children exposed in utero to CBZ, PB, PHT, and PRI is reduced but not eliminated by folic acid supplementation at 5-12 weeks from LMP. The statistical precision in our study is limited due to rarity of the exposures, and further studies are needed.

The threat to scientific integrity in environmental and occupational medicine.

Over the last century, environmental and occupational medicine has played a significant role in the protection and improvement of public health. However, scientific integrity in this field has been increasingly threatened by pressure from some industries and governments. For example, it has been reported that the tobacco industry manipulated eminent scientists to legitimise their industrial positions, irresponsibly distorted risk and deliberately subverted scientific processes, and influenced many organisations in receipt of tobacco funding. Many environmental whistleblowers were sued and encountered numerous personal attacks. In some countries, scientific findings have been suppressed and distorted, and scientific advisory committees manipulated for political purposes by government agencies. How to respond to these threats is an important challenge for environmental and occupational medicine professionals and their societies. The authors recommend that professional organisations adopt a code of ethics that requires openness from public health professionals; that they not undertake research or use data where they do not have freedom to publish their results if these data have public health implications; that they disclose all possible conflicts; that the veracity of their research results should not be compromised; and that their research independence be protected through professional and legal support. The authors furthermore recommend that research funding for public health not be directly from the industry to the researcher. An independent, intermediate funding scheme should be established to ensure that there is no pressure to analyse data and publish results in bad faith. Such a funding system should also provide equal competition for funds and selection of the best proposals according to standard scientific criteria.

Productivity of local chickens under village management conditions.

The productivity of local chickens under village management conditions was studied in six villages situated in three climatic zones within Morogoro District in Tanzania. Two villages were picked in each climatic zone (warm and wet, warm and dry, cool and wet) for the study. The data were obtained by actual measurement, qualitative observations and interview of members of the households directly responsible for the care of chickens. In addition, data sheets were given to selected farmers to record the performance of their chickens. The mean flock size for the three zones was 16.2, with a range of 2 to 58. The overall mean clutch size, egg weight and hatchability were 11.8, 44.1 g and 83.6%, respectively. The overall mean chick survival rate to 10 weeks of age was 59.7%. The mean live weights for cocks and hens were 1948 g and 1348 g, respectively. The mean growth rates to the age of 10 weeks were 4.6 g/day and 5.4 g/day, while those from 10 to 14 weeks of age were 8.4 g/day and 10.2 g/day for female and male birds, respectively. The age at first lay ranged between 6 and 8 months, and the average hen had three laying cycles per year. Most of the chickens were left to scavenge during the day and were provided with simple housing at night (95.2% of the owners). Only small amounts of supplementary feeds were occasionally given and minimal health care was provided. It was concluded that the low productivity of chickens was partly due to the prevailing poor management practices, in particular the lack of proper health care, poor nutrition and housing.

No strong long-term effect of vitamin A supplementation in infancy on CD4 and CD8 T-cell subsets. A community study from Guinea-Bissau, West Africa.

The World Health Organization recommends that 100,000 IU of vitamin A be given to infants between 6 and 12 months of age at the same time as measles vaccination in order to prevent vitamin A deficiency. In the present study, our aim was to assess the effect of vitamin A supplementation on T-cell subsets in a randomized factorial design, seeking a possible modifying effect of measles vaccination. Three hundred children were allocated either to two doses of measles vaccine at 6 and 9 months of age or to poliomyelitis vaccine at age 6 months and measles vaccine at age 9 months. Within each group, infants were to receive two doses of vitamin A or two doses of placebo at 6 and 9 months of age. We found no significant effect of vitamin A supplementation on CD4 and CD8 T-cell subsets at 3 and 9 months after supplementation. We found no effect of measles vaccine and no interaction between vitamin A supplementation and measles vaccine. Based on these observations, vitamin A supplementation does not seem to have a strong long-term effect on CD4 and CD8 T-cell subsets in infants without clinical vitamin A deficiency.

Malignant tumours and psoriasis: climatotherapy at the Dead Sea.

In this retrospective, nation-wide cohort study, the risk of cancer was assessed for 1738 Danish patients with psoriasis subjected to climatotherapy at the Dead Sea during 1972-93, by linkage to the Danish Cancer Registry. The overall risk of cancer in patients treated at the Dead Sea (standardized incidence ratio, SIR = 1.59) was higher than that expected in the general population, owing to an excess risk of non-melanoma skin cancer (NMSC) [SIR = 4.2 for basal cell carcinoma (BCC) and 10.7 for squamous cell carcinoma (SCC)]. In addition, the distribution of NMSC among body sites, age groups and sexes was unusual in those treated at the Dead Sea, favouring NMSC in young individuals and at multiple sites (SIR = 10.7 for BCC and 57.2 for SCC), multiple BCCs being particularly common among young women. Thus, people subjected to climatotherapy at the Dead Sea for psoriasis constitute a high-risk group for NMSC, SCC in particular, but not for malignant diseases in general. The study design precludes conclusions on whether climatotherapy plays a specific part in skin carcinogenesis which is different from other sources of ultraviolet (UV) radiation, as climatotherapy is inevitably confounded by excess UV exposure.

Phenotypic characterization and antibiotic resistance of Acinetobacter spp. isolated from aquatic sources.

A total of 99 Acinetobacter isolates from sewage, freshwater aquaculture habitats, trout intestinal contents and frozen shrimps was characterized phenotypically and antibiotic susceptibility patterns determined. One group of genomic species, including Ac. johnsonii, Ac. lwoffi and spp. 15TU, was detected in all sample types and represented the majority of the isolates (n = 54). Isolates belonging to the Acb complex (Ac. calcoaceticus, Ac. baumannii and genomic species 3) were detected in sewage (n = 6) and frozen shrimps (n = 1), Ac. haemolyticus in frozen shrimps (n = 6) and trout intestinal contents (n = 2) and genomic species 11 in freshwater aquaculture habitats (n = 6) and trout intestinal contents (n = 1). Acinetobacter junii (n = 5), genomic species 10 (n = 2), 14BJ (n = 8) and 16BJ (n = 4) were only isolated from sewage. Acinetobacter isolates from sewage were generally more biochemically reactive and resistant to antimicrobial agents compared with isolates from other sample types. Different strains, often belonging to different genomic species, were isolated from sites situated upstream and downstream of the discharge point of a pharmaceutical plant. This finding supported the hypothesis that the waste effluent from the pharmaceutical plant was likely to cause a change in the distribution of Acinetobacter spp. by selecting and/or introducing antibiotic-resistant strains into the recipient sewers.

Antibiotic resistance in Acinetobacter spp. isolated from sewers receiving waste effluent from a hospital and a pharmaceutical plant.

The possible increase of antibiotic-resistant bacteria in sewage associated with the discharge of wastewater from a hospital and a pharmaceutical plant was investigated by using Acinetobacter species as environmental bacterial indicators. The level of susceptibility to six antimicrobial agents was determined in 385 Acinetobacter strains isolated from samples collected upstream and downstream from the discharge points of the hospital and the pharmaceutical plant. Results indicated that while the hospital waste effluent affected only the prevalence of oxytetracycline resistance, the discharge of wastewater from the pharmaceutical plant was associated with an increase in the prevalence of both single- and multiple-antibiotic resistance among Acinetobacter species in the sewers.

Diet during pregnancy and the risk of cerebral palsy.

The role of maternal diet in the development of the fetal brain has not been adequately explored. Marine n-3 fatty acids have, however, been proposed to be important for brain development. The present case-control study aimed to investigate the relationship between dietary intake during pregnancy and the occurrence of cerebral palsy (CP) in the offspring. Children with CP (n 109), born between 1984 and 1988 to mothers residing in the Greater Athens area, were identified at any time in 1991 or 1992 through institutions delivering care and rehabilitation. Successful nutritional interviews were conducted with ninety-one of these children. Controls were chosen among the neighbours of the CP cases or were healthy siblings of children with neurological diseases other than CP, seen by the same neurologists as the children with CP. A total of 278 control children were chosen, and 246 of them were included in the nutritional study. Guardians of all children were interviewed in person on the basis of a questionnaire covering obstetric, perinatal socioeconomic and environmental variables. A validated semiquantitative food-frequency questionnaire of 111 food items was used to estimate maternal dietary intake during pregnancy. Statistical analysis was done by modelling the data through logistic regression. Food groups controlling for energy intake were alternatively and simultaneously introduced in a core model containing non-nutritional confounding variables. Consumption of cereals (mostly bread) and fish intake were inversely associated with CP (P < 0.05 and P < 0.09 respectively) whereas consumption of meat was associated with increased risk (P < 0.02). A protective effect of fish consumption and a detrimental effect of meat intake have been suggested on the basis of earlier work and appear to be biologically plausible. If corroborated by other studies, these results could contribute to our understanding of the nutritional influences on fetal brain development.