Incisional hernias post renal transplant: a systematic review and meta-analysis.

PURPOSE: Incisional hernia (IH) post renal transplant (RT) is relatively uncommon and can be challenging to manage clinically due to the presence of the kidney graft and patient immunosuppression. This systematic review and meta-analysis synthesises the current literature in relation to IH rates, risk factors and outcomes post RT. METHODS: PubMed, EMBASE, and Cochrane Central Registry of Controlled Trials (CENTRAL) were searched up to July 2023. The most up to date Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines were followed. Pertinent clinical information was synthesised. A meta-analysis of the pooled proportions of IH rates, the rates of patients requiring surgical repair and the rates of recurrence post RT are reported. RESULTS: Twenty studies comprising 16,018 patients were included in this analysis. The pooled rate of IH occurrence post RT was 4% (CI 3-5%). The pooled rate of IH repair post RT was 61% (CI 14-100%). The pooled rate of IH recurrence after repair was 16% (CI 9-23%). Risk factors identified for IH development post RT are BMI, immunosuppression, age, smoking, incision type, reoperation, concurrent abdominal wall hernia, lymphocele formation and pulmonary disease. CONCLUSIONS: IH post RT is uncommon and the majority of IH post RT are repaired surgically on an elective basis.

Incisional hernias post cytoreductive surgery/peritonectomy and hyperthermic intraperitoneal chemotherapy: a systematic review and meta-analysis.

PURPOSE: Cytoreductive surgery (CRS) is often combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of peritoneal tumour deposits. Considering CRS, the evidence relating the large incisions, local chemotherapy and abdominal wall trauma to incisional hernias (IH) has not been synthesized. This systematic review and meta-analysis was conducted to examine the proportion of IH present in patients post CRS and the effect HIPEC had on these rates. METHODS: PubMed, EMBASE, and Cochrane Central Registry of Trials were searched up to June 2023 to examine studies relating IH and CRS plus or minus HIPEC. The most up to date PRISMA guidelines were followed. Pertinent clinical information was synthesized in tabular form. A meta-analysis reporting the pooled proportions of IH post CRS plus or minus HIPEC, the odds of IH in HIPEC versus non-HIPEC CRS and the difference in follow-up time between groups was conducted. RESULTS: Nine studies comprising 1416 patients were included. The pooled proportion of IH post CRS was 12% (95% confidence interval (CI) 8-16%) in HIPEC and 7% (95% CI 4-10%) in non-HIPEC patients and 11% (95% CI 7-14%) overall. Previously reported rates of IH in midline laparotomy range from 10 to 30%. The odds of IH in the HIPEC was 1.9 times higher compared to non-HIPEC cohorts however this was not statistically significant (odds ratio (OR) 1.9, 95% 0.7-5.2; p = 0.21). There was no significant difference in average follow-up times between HIPEC and non-HIPEC cohorts. CONCLUSIONS: IH post CRS plus or minus HIPEC were in the expected range for midline laparotomies. IH in patients receiving HIPEC may occur at a greater proportion than in non-HIPEC patients, however, there were too few studies in our meta-analysis to determine this with statistical significance.

Cochlear implants and deafness: a global case study to increase policy awareness and action on an under-resourced health issue.

There has been a major growth in global health networks in recent decades to address health issues including tobacco use, alcohol abuse, and maternal mortality. Most conditions that incur high costs have provoked networks of advocates working to mitigate the impact, increase investment in research, and establish campaigns. Global health networks often work simultaneously across policy, knowledge creation, and advocacy. Until recently there has been limited activity in global health networks and advocacy addressing hearing loss and deafness which has contributed to its relatively low visibility with policymakers compared to other health conditions. This discussion paper reports on a global consultation that explored the views of advocacy groups and individuals on advocacy for the management of hearing loss, and cochlear implantation (CI). It focussed on stakeholders' views of current advocacy endeavours, opportunities and barriers, and the possible development of a global advocacy network to improve access to cochlear implantation and the supporting services. The subsequent development of a global health network, the Cochlear Implant International Community of Action (CIICA) is discussed and the conditions necessary for the successful development of health networks are explored. This paper will be of interest to those wishing to understand the factors influencing the development of health networks and advocacy.

The Painful Anterior Apprehension Test - an Indication of Occult Shoulder Instability.

Introduction: To evaluate the clinical relevance of the painful anterior apprehension test in shoulder instability. Materials and methods: We performed a retrospective study of 155 patients that underwent arthroscopic anterior Bankart repair between 2014-2016. Exclusion criteria were previous ipsilateral shoulder surgery, bony Bankart lesions, glenohumeral osteoarthritis and concomitant surgery involving rotator cuff tears, biceps tendon pathology and superior labrum from anterior to posterior (SLAP) lesions. The study cohort was divided into three groups: apprehension test with apprehension only, apprehension test with pain only, and apprehension test with both apprehension and pain. Patient demographics, clinical characteristics, radiological imaging, arthroscopy findings and surgical outcomes (Constant, American Shoulder and Elbow Surgeons (ASES), SF-36 scores) were evaluated. Results: A total of 115 (74.2%) had apprehension only, 26 (16.8%) had pain only and 14 (9.0%) had pain and apprehension with the apprehension test. Univariate analysis showed significant differences between the groups in patients with traumatic shoulder dislocation (p=0.028), patients presenting with pain (p=0.014) and patients presenting with recurrent dislocations (p=0.046). Patients with a purely painful apprehension test were more likely to have a traumatic shoulder dislocation, more likely to present only with pain, and less likely to present with recurrent shoulder dislocations. Multivariate analysis showed that none of these factors alone were significant as single predictors for shoulder instability. All three groups were otherwise similar in patient profile, MRI and arthroscopic assessments, and clinical outcomes of surgery. Excellent clinical outcomes were achieved in all groups with no difference in pre-operative and post-operative scores across all groups at all time points. Conclusion: The painful apprehension test may suggest underlying shoulder instability.

Enterocutaneous fistula from migration of hepatic artery infusion catheter.

We present an 84-year-old man with erosion of the chemotherapy port on his chest wall. He had a history of colorectal cancer with liver metastases more than 20 years ago, when he underwent right hemicolectomy and liver resection. A hepatic artery infusion catheter was placed for targeted administration of chemotherapy for the liver metastases. Imaging showed the catheter had migrated into the small bowel lumen. We considered the best approach for removing the migrated catheter - either remove the catheter and accept the likelihood of a low-volume enterocutaneous fistula that may self-resolve, or explore the enterocutaneous tract with a view to small bowel resection. We discuss the advantages and disadvantages here.

Caecal Volvulus after a dental procedure - not just constipation!

Caecal volvulus has been reported to be associated with various abdominal and pelvic pathologies. Its signs and symptoms are usually non-specific and maybe overlooked in favour of benign causes, such as constipation. A high degree of suspicion is required for prompt diagnosis. Herein, we report on an unusual case of caecal volvulus after a dental procedure that was managed initially as constipation.

Appropriateness of deep vein thrombosis (DVT) prophylaxis use among medical inpatients: a DVT risk alert tool (DRAT) study.

INTRODUCTION: Increasing incidence of Venous Thromboembolism (VTE) has complicated treatment courses for hospitalised patients. Despite recommendation to support deep vein thrombosis (DVT) risk assessment and appropriate use of prophylaxis in medical inpatients, it is either neglected or prescribed unnecessarily by the clinicians. This study aimed to assess and compare the appropriateness of DVT prophylaxis prescribing between usual care versus a pharmacist-driven DVT Risk Alert Tool (DRAT) intervention among hospitalised medical patients. METHODS: A prospective pre- and post-intervention study was conducted among medical inpatients in a Malaysian secondary care hospital. DVT and bleeding risks were stratified using validated Padua Risk Assessment Model (RAM) and International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) Bleeding Risk Assessment Model. Pharmacist-driven DRAT was developed and implemented post-interventional phase. DVT prophylaxis use was determined and its appropriateness was compared between pre and post study using multivariate logistic regression with IBM SPSS software version 21.0. RESULTS: Overall, 286 patients (n=142 pre-intervention versus n=144 post-intervention) were conveniently recruited. The prevalence of DVT prophylaxis use was 10.8%. Appropriate thromboprophylaxis prescribing increased from 64.8% to 68.1% post-DRAT implementation. Of note, among high DVT risk patients, DRAT intervention was observed to be a significant predictor of appropriate thromboprophylaxis use (14.3% versus 31.3%; adjusted odds ratio=2.80; 95% CI 1.01 to 7.80; p<0.05). CONCLUSION: The appropriateness of DVT prophylaxis use was suboptimal but doubled after implementation of DRAT intervention. Thus, an integrated risk stratification checklist is an effective approach for the improvement of rational DVT prophylaxis use.

Management of the floating shoulder: Does the glenopolar angle influence outcomes? A systematic review.

INTRODUCTION: Currently there is no consensus on the optimal treatment of the "floating shoulder". We aim to perform a systematic review to determine outcomes in the management of this condition. MATERIALS AND METHODS: Studies related to the management of the "floating shoulder" were identified by a review of medline using platform Pubmed/Ovid, Scopus and Cochrane library data bases. Studies were included if they: (1) are published in the English language and (2) reported outcomes of at least 2 or more cases of floating shoulder injuries using at least one objective shoulder scoring system. Exclusion criteria were (1) non-human and biomechanical studies and (2) studies with a clear selection bias. Three treatment groups were identified. Group 1-non-operative, Group 2-fixation of clavicle only, and Group 3-fixation of clavicle and scapula neck. RESULTS: Thirteen studies gave a population of 244 subjects of which 104 had non-operative treatment, 98 had internal fixation of the clavicle only and 42 had fixation of both the clavicle and the scapula. There were no differences in the outcome scores among the 3 treatment arms as the patients with undisplaced or minimally displaced fractures had conservative treatment and those with displaced fractures were surgically stabilised. There was a positive correlation between the final glenopolar angle and the Constant score. CONCLUSIONS: The review was unable to show a difference in outcomes among the 3 treatment groups. Any treatment modality that restores the glenopolar angle is likely to result in a good outcome. LEVEL OF EVIDENCE: Therapeutic level IV.

Stapled Mesh stomA Reinforcement Technique (SMART) in the prevention of parastomal hernia: a single-centre experience.

PURPOSE: Parastomal hernia remains a frequent complication following creation of an abdominal stoma. Previous interests have centred around the exploration of methods to repair; however, prophylactic mesh placement has demonstrated its efficacy in reduction of parastomal hernia. The aim of this retrospective analysis was to evaluate the outcomes of Stapled Mesh stomA Reinforcement Technique (SMART) in terms of parastomal hernia occurrence rate and mesh-related complications. METHODS AND MATERIALS: All patients operated with an abdominal perineal resection or Hartmann's procedure with SMART from November 2013 to March 2016 were included. Patient demographics, operative details and stoma-related symptoms were collected. Patients were examined clinically by the medical team and also reviewed independently by a specialist stoma care nurse for signs of stoma-related complications. As part of oncological follow-up, CT scans were available for review for evidence of parastomal herniation. RESULTS: 14 patients (mean age 76 years) were included in the analysis. All the SMART cases were successfully completed with no intraoperative or immediate post-operative complications. No cases of mesh-related complications such as infection, immediate stomal prolapse, stenosis, retraction, stomal obstruction, mesh erosion or fistulation were observed. No mesh removal was required. There were two cases of parastomal hernia detected on CT scan. Both cases have remained asymptomatic no intervention was required at this stage. Median follow-up was 24 months. CONCLUSION: Our medium-term experience has demonstrated the efficacy of SMART in the reduction of parastomal hernia occurrence. With appropriate learning curve, parastomal hernia can be prevented.

Cerebellar strokes: a clinical outcome review of 79 cases.

INTRODUCTION: Cerebellar infarcts and haemorrhages are relatively uncommon, accounting for less than 10% of all strokes. The objective of the present study was to quantify and compare the outcomes of patients with cerebellar infarct and those of patients with cerebellar haemorrhage, as well as to identify the risk factors that predict poor outcome in patients with cerebellar stroke. METHODS: We retrospectively reviewed the medical records of consecutive patients admitted to National University Hospital, Singapore, between 2004 and 2006, within one week of cerebellar stroke onset. Baseline data included demographics, concomitant comorbidities, and the presence or absence of brainstem compression and hydrocephalus (on computed tomography or magnetic resonance imaging). The Glasgow Outcome Scale and modified Rankin Score were used to assess outcome at discharge and at six months after discharge. RESULTS: A total of 79 patients with cerebellar stroke were admitted during the study period. Of these 79 patients, 17.7% died and 31.6% had poor outcomes at six months after discharge. Patients with cerebellar haemorrhage were found to be more likely to have poor outcomes as compared to patients with cerebellar infarct, both at discharge (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.3-14.1) and at six months after discharge (OR 5.2, 95% CI 1.6-17.2). When compared to small lesions (< 5 cm(3)), lesions > 20 cm(3) were significantly associated with poorer outcomes and the development of hydrocephalus and brainstem compression. CONCLUSION: Cerebellar strokes are a significant cause of morbidity and mortality. The outcomes of patients with cerebellar haemorrhage are more likely to be worse than those of patients with cerebellar infarct.

Three-dimensional analysis of the palmar plate and collateral ligaments at the proximal interphalangeal joint.

The purpose of this study was to analyze the palmar plate complex at the proximal interphalangeal joint using a three-dimensional (3D) technique, which makes it easier to understand the dimensions of structures and their relationship to the adjacent components. This method allows individual elements to be removed virtually, facilitating clearer observation of each component. Sixteen cadaveric specimens were dissected and reconstructed in a 3D virtual environment. The palmar plate is made up of a distal, fibrous portion and a proximal, membranous portion, which anchors distally on the base of the middle phalanx and is continuous with the bilateral check-rein ligaments proximally. The accessory collateral ligaments and the A3 pulley suspend the palmar plate laterally.

Management of ruptured intracranial aneurysms in the post-ISAT era: outcome of surgical clipping versus endovascular coiling in a Singapore tertiary institution.

INTRODUCTION: The results of the International Subarachnoid Aneurysm Trial (ISAT) in 2002 have significantly influenced the management of ruptured intracranial aneurysms. There is now an established shift worldwide toward endovascular coiling as the initial treatment of choice. We assessed the outcomes of patients admitted to our institution for aneurysmal subarachnoid haemorrhage (SAH), comparing the outcomes of patients (World Federation of Neurosurgical Societies [WFNS] grades 1-3) who underwent surgical clipping versus those who underwent endovascular coiling. METHODS: We retrospectively reviewed patients admitted to the National University Hospital for SAH secondary to ruptured intracranial aneurysm in 2005-2009. Patients were divided into two groups - clipping and coiling. Data on individual demographics, comorbidities, Fisher grading and Glasgow Outcome Scale scores were collected for the two groups and subjected to relevant statistical analyses. RESULTS: Of the 133 patients admitted for nontraumatic SAH, 89 had ruptured aneurysms. Among the 56 patients classified as WFNS grades 1-3, 23 underwent coiling while the remaining 33 underwent clipping. A significant association was found between Fisher grade and the likelihood of developing hydrocephalus in these patients. CONCLUSION: Although we acknowledge the presence of management bias in our institution, our findings were similar to those of the ISAT trial. Upon correlation between our results and current evidence-based findings, our findings show that clipping provides similar long-term outcomes as endovascular coiling. In the event that an aneurysm is deemed unsuitable for coiling, clipping remains an effective option.

Lack of association between Gly82Ser, 1704G/T and 2184A/G of RAGE gene polymorphisms and retinopathy susceptibility in Malaysian diabetic patients.

Diabetic retinopathy is the most common diabetic eye disease, occurring in about 60% of type 2 diabetic patients. Other than known clinical risk factors, the influence of genes has been suggested as part of the development of diabetic retinopathy. We investigated the association of Gly82Ser, 1704G/T and 2184A/G polymorphisms in the RAGE gene with retinopathy in type 2 diabetic patients in Malaysia. Ninety-eight unrelated retinopathy patients and 185 unrelated healthy controls from all over Malaysia were recruited in this study. The allele and genotype frequencies of the three gene polymorphisms were investigated using PCR-RFLP. The allele frequency of the three polymorphisms did not differ significantly between the control and the retinopathy group (P > 0.05). Analysis of the frequency of GA+AA, GT+TT and AG+GG in the retinopathy group did not reveal significant differences (P > 0.05) compared to the control group. We conclude that RAGE gene Gly82Ser, 1704G/T and 2184A/G polymorphisms are not associated with retinopathy development in the Malaysian population.

Modified Brostrom-Evans-Gould technique for recurrent lateral ankle ligament instability.

PURPOSE: To review the outcome of the modified Brostrom-Evans-Gould technique in patients with chronic lateral ankle ligament instability. METHODS: Between August 2003 and June 2005, 20 men aged 19 to 35 (mean, 23) years with chronic lateral instability affecting 21 ankles, underwent the modified Brostrom-Evans-Gould technique by a single surgeon. The mean follow-up period was 12 (range, 6-20) months. Patients were assessed preoperatively and postoperatively using the Kaikkonen Ankle Scoring Scale. RESULTS: Preoperatively, all patients had poor scores (<50). Postoperatively, 17 (81%) of the ankles attained excellent scores (85-100) and 4 (19%) attained good scores (70-84). CONCLUSION: The modified Brostrom-Evans-Gould technique appears effective for chronic lateral ankle ligament instability, particularly in the Asian population with a higher prevalence of generalised joint hyperlaxity.