Importance of experience in transoesophageal echocardiographic evaluation of vegetation size in patients with infective endocarditis: a reliability study.

Aims: Vegetation size assessed by transoesophageal echocardiography (TOE) is a decisive metric in guiding surgical intervention and prognosis in patients with definite infective endocarditis (IE). The aim of this study was to assess the impact of echocardiographic experience on the reliability and reproducibility of TOE measurements of vegetations in patients with IE. Methods and results: Twenty-nine raters from a cardiac department at a tertiary centre were divided into three groups according to echocardiographic experience: experts, cardiologists, and novices. All raters were instructed to measure the maximum length of vegetations in 20 different TOE exams. Interrater agreement was evaluated using intraclass correlation coefficient (ICC), one-way analysis of variance, Kruskal-Wallis test, and Bland-Altmann plots. Reliability was assessed by minimal detectable change (MDC). All measurements were compared with the measured size agreed on by the multi-disciplinary IE team.There was an overall significant interrater variance between the three groups (P < 0.001). The variance was 10.1, 14.8, and 21.7 for the experts, cardiologists, and novices, respectively. ICC was excellent for experts (96.3%) and cardiologists (93.7%) and good for novices (84.6%). The three groups tended to measure smaller than the endocarditis team. MDC was 2.6 mm for experts, 3.3 mm for cardiologists, and 3.6 mm for novices. Conclusion: The study showed good to excellent intraclass correlation but high dispersion in all groups. Variance decreased with higher experience. Our findings support current recommendations that complicated cases should be cared for by the multi-disciplinary endocarditis team and underline the importance of echocardiographic expertise when evaluating and measuring vegetations in patients with IE.

Diarrhoea-causing microorganisms are rare in adult patients undergoing diagnostic laparoscopy for suspected appendicitis: a prospective observational cohort study.

We investigated if diarrhoea-causing bacteria, including Yersinia species, could mimic the symptoms of appendicitis and lead to surgery. This prospective observational cohort study (NCT03349814) included adult patients undergoing surgery for suspected appendicitis. Rectal swabs were analysed with polymerase chain reaction (PCR) for Yersinia, Campylobacter, Salmonella, Shigella and Aeromonas spp. Blood samples were analysed routinely and with an in-house ELISA serological test for Yersinia enterocolitica antibodies. We compared patients without appendicitis and patients with appendicitis confirmed by histopathology. The outcomes included PCR-confirmed infection with Yersinia spp., serologic-confirmed infection with Y. enterocolitica, PCR-confirmed infection with other diarrhoea-causing bacteria and Enterobius vermicularis confirmed by histopathology. A total of 224 patients were included, 51 without and 173 with appendicitis, and followed for 10 days. PCR-confirmed infection with Yersinia spp. was found in one patient (2%) without appendicitis and no patients (0%) with appendicitis (p = 0.23). Serology was positive for Y. enterocolitica for the same patient without appendicitis and two patients with appendicitis (p = 0.54). Campylobacter spp. were detected in 4% vs 1% (p = 0.13) of patients without and with appendicitis, respectively. Infection with Yersinia spp. and other diarrhoea-causing microorganisms in adult patients undergoing surgery for suspected appendicitis was rare.

Shorter Total Length of Stay After Intraperitoneal Fosfomycin, Metronidazole, and Molgramostim for Complicated Appendicitis: A Pivotal Quasi-Randomized Controlled Trial.

Background: We aimed to investigate the difference in the total length of hospital stay (LOS) after intraperitoneal vs. intravenous antibiotic treatment in patients with complicated appendicitis. Methods: We conducted a quasi-randomized prospective clinical trial. The intervention group received 4 g fosfomycin, 1 g metronidazole, and 50 µg recombinant human granulocyte-macrophage colony-stimulating factor intraperitoneally, which was left in the abdominal cavity, immediately after laparoscopic appendectomy. Postoperatively, this group received antibiotics orally. The control group received intravenous antibiotics both during surgery and postoperatively. We primarily evaluated total LOS within 30 days. Furthermore, we evaluated harms and adverse events, Gastrointestinal Quality of Life Index, postoperative complications, and convalescence. Participants were followed for 30 days postoperatively. Results: A total of 12 participants concluded the trial. The total LOS was significantly shorter in the intervention group (six participants, median 13 h; range 2-21 h) than in the control group (six participants, median 84 h; range 67-169 h), p = 0.017. Comparable harms and Gastrointestinal Quality of Life Index scores were found in the two groups. The time to return to normal activities was median 6 and 10 days for the intervention and the control group, respectively. There were no serious adverse events related to the trial nor any complications in the intervention group. In the control group, two patients developed intraabdominal abscesses. Conclusions: The intervention group had a significantly shorter total LOS. The study was not powered to assess differences in complications, but the results indicate that the intervention seems to be a safe regimen, which can be investigated further to treat patients with complicated appendicitis. Identifiers: EudraCT no. 2017-004753-16. ClinicalTrials: https://clinicaltrials.gov/ct2/show/NCT03435900?term=NCT03435900&draw=2&rank=1">draw=2&rank=1.

No difference in genitourinary complications after laparoscopic vs. open groin hernia repair in women: a nationwide linked register-based cohort study.

BACKGROUND: During laparoscopic groin hernia repair, the surgeon may transect the round ligament of uterus to facilitate mesh placement. Transection during open repair is rarer and anatomically further from the uterus. Our aim was to compare long-term genitourinary outcomes, particularly genital prolapse, between open and laparoscopic repair in women with a primary groin hernia. METHODS: The study was reported according to RECORD guidelines. All women having received a primary anterior open or laparoscopic groin hernia repair from 1998 to 2014 were identified through The Danish Hernia Database and linked with data from The Danish National Patient Registry and the Danish Register of Causes of Death. Our outcome was postoperative genital prolapse and other long-term complications related to gynecology, urology, and infertility. RESULTS: We included 10,867 women having received a primary groin hernia repair, 7732 (71%) had an open anterior repair and 3135 (29%) a laparoscopic repair. The median (range) age was 59 (19-102) and 64 (18-105), respectively (p < 0.001). Median follow-up was 65 (range 0-203) months. After open repair, 313/7340 (4.2%) had a postoperative genital prolapse, and 46/2,934 (1.5%) after laparoscopic repair (p < 0.001). In multivariate Cox Regression analyses adjusting for age and hernia type, there were no difference between the two methods (p = 0.474). Women with an inguinal hernia had a higher risk of genital prolapse than women with a femoral hernia, independent of repair method [HR = 1.455 (1.143-1.853), p = 0.002]. We found no significant differences between open and laparoscopic methods in multivariate analyses assessing other long-term postoperative genitourinary and/or infertility outcomes. CONCLUSION: We found no differences in postoperative genital prolapse or other complications related to gynecology, urology, and/or infertility between open anterior and laparoscopic groin hernia repair in women. Assuming the round ligament of uterus is being transected more often in laparoscopic repair than in open, the urogenital consequences of transection seem to be minimal.

Surgical techniques and convalescence recommendations vary greatly in laparoscopic groin hernia repair: a nationwide survey among experienced hernia surgeons.

BACKGROUND: Laparoscopic groin hernia repair has become increasingly popular. In Denmark, all groin hernia repairs are registered in the Danish Hernia Database. However, many surgical technical parameters are not registered in neither the hernia database nor in other national registries or the patient files. Our aim was to characterize differences in surgical techniques and variations in convalescence recommendations in laparoscopic groin hernia repair that are not available elsewhere. METHODS: A questionnaire was sent to all surgeons in Denmark regularly performing unsupervised laparoscopic groin hernia repair. The questionnaire was developed in collaboration with an experienced chief surgeon and face-validated on the target group. It contained demographic details and items on surgical parameters such as the creation of pneumoperitoneum, size of the optic, choice of closure methods, preoperative information, and postoperative recommendation of convalescence. RESULTS: A total of 71 surgeons were eligible for inclusion, and 61 (86%) responded. We found large variations in almost all surgical parameters, i.e. there was no uniform way of performing laparoscopic groin hernia repair. The variation was not due to the level of experience. The median recommended convalescence period was 1.5 (range 0-28) days for activities of daily living, 4.5 (range 0-28) days for light physical activity, and 14 (range 0-35) days for hard physical activity. Three percent of surgeons routinely informed patients about the risk of sexual dysfunction prior to operation, and 98% informed about the risk of chronic pain. CONCLUSIONS: Surgical technical parameters and convalescence recommendations in laparoscopic groin hernia surgery vary widely in a national cohort of experienced hernia surgeons.

Laparoscopic repair is superior to open techniques when treating primary groin hernias in women: a nationwide register-based cohort study.

BACKGROUND: Few studies have described recurrence rates after groin hernia repair in women. Our aim was to investigate if laparoscopic repair of primary groin hernias in women results in a lower reoperation rate for recurrence compared with open repairs. Furthermore, we wished to compare hernia subtypes at primary repair and reoperation. METHODS: This nationwide cohort study was reported according to the RECORD statement. We used prospectively collected data from the Danish Hernia Database to generate a cohort of females operated for a primary groin hernia from 1998 to 2017. Our primary outcome was reoperation for recurrence. The secondary outcome was subtype of hernia at primary repair and reoperation. All females had at least 6-month follow-up. RESULTS: We included 13,945 primary groin hernia operations in women, of whom 649 had undergone a reoperation for recurrence. Median follow-up time was 8.8 years. The cumulative reoperation rates were lower after laparoscopic repair compared with the open techniques, for both inguinal hernias (1.8 vs. 6.3%, p < 0.001) and femoral hernias (2.2 vs. 5.5%, p = 0.005). After laparoscopic repair, 25% of inguinal hernias recurred as femoral, compared with 47% after Lichtenstein (p < 0.001). Direct inguinal hernias and femoral hernias had higher risk of reoperation for recurrence after open repair compared with indirect inguinal hernias. For laparoscopic procedures, hernia subtypes at the primary groin hernia repair had similar reoperation rates. CONCLUSION: Laparoscopic repair of primary groin hernia in women had lower reoperation rates and fewer femoral recurrences than open repair techniques.

[Women with groin hernias should be referred to surgery].

In females, approximately 75% of groin hernias are inguinal hernias, and 25% are femoral. However, all groin hernias in women should be considered potential femoral hernias due to the difficult preoperative diagnosis of hernia type and the high incidence of femoral hernias. Complications following an untreated femoral hernia are unacceptable, which is why, watchful waiting is not recommended in women. Timely repair is desirable, and the laparoscopic approach is recommended due to lower recurrence rates and fewer femoral recurrences than in open repair methods.

Recurrence Rates After Repair of Inguinal Hernia in Women: A Systematic Review.

Importance: To our knowledge, a systematic review has not yet been performed that specifically addresses the management of inguinal hernia in women. Recurrence after repair of inguinal hernia is not unusual in women and may be a previously undiagnosed femoral hernia, which is rarely seen in men. Objective: To investigate rates and types of recurrences in women who had undergone repair of primary inguinal hernia. Evidence Review: PubMed, Embase, and the Cochrane databases were searched in September 2017 for studies reporting recurrences after repair of primary inguinal hernia in women. Crude rates of recurrence (number of recurrences/number of women) were calculated after open and laparoscopic repairs, and the type of recurrent hernia was registered, if noted in the studies. This review is reported according to the PRISMA guideline. Findings: A total of 55 studies were included, comprising 43 870 women (mean age, 42-69 years; median age, 57 years). Five studies were randomized clinical trials, 14 were prospective cohort studies, 7 were prospective database studies, and 29 were retrospective cohort studies. Twenty studies reported recurrence after laparoscopic repair, with a crude recurrence rate of 1.2% (27 of 2257) (range, 0%-5%) and a median follow-up of 24 months. Thirty-seven studies reported open repair, with a crude recurrence rate of 2.4% (818 of 33 971) (range, 0%-12.5%) and a median follow-up of 36 months. The crude recurrence rate in randomized clinical trials and prospective studies was 1.2% (18 of 1525) after laparoscopic repair compared with 4.9% (490 of 10 058) after open repair. The recurrent inguinal hernia was a femoral hernia in 203 of 496 patients (40.9%) after open repair, compared with 0% of patients after laparoscopic repair. Recurrence rates were similar when open mesh vs nonmesh techniques were used. Conclusions and Relevance: Recurrence rates after repair of primary inguinal hernia in women are lower after laparoscopic repair compared with open repair. Intraoperative findings during repair of recurrent inguinal hernia are often femoral hernias in women.

A combined metabolomic and phylogenetic study reveals putatively prebiotic effects of high molecular weight arabino-oligosaccharides when assessed by in vitro fermentation in bacterial communities derived from humans.

Prebiotic oligosaccharides are defined by their selective stimulation of growth and/or activity of bacteria in the digestive system in ways claimed to be beneficial for health. However, apart from the short chain fatty acids, little is known about bacterial metabolites created by fermentation of prebiotics, and the significance of the size of the oligosaccharides remains largely unstudied. By in vitro fermentations in human fecal microbial communities (derived from six different individuals), we studied the effects of high-mass (HA, >1 kDa), low-mass (LA, <1 kDa) and mixed (BA) sugar beet arabino-oligosaccharides (AOS) as carbohydrate sources. Fructo-oligosaccharides (FOS) were included as reference. The changes in bacterial communities and the metabolites produced in response to incubation with the different carbohydrates were analyzed by quantitative PCR (qPCR) and Liquid Chromatography-Mass Spectrometry (LC-MS), respectively. All tested carbohydrate sources resulted in a significant increase of Bifidobacterium spp. between 1.79 fold (HA) and 1.64 fold (FOS) in the microbial populations after fermentation, and LC-MS analysis suggested that the bifidobacteria contributed to decomposition of the arabino-oligosaccharide structures, most pronounced in the HA fraction, resulting in release of the essential amino acid phenylalanine. Abundance of Lactobacillus spp. correlated with the presence of a compound, most likely a flavonoid, indicating that lactobacilli contribute to release of such health-promoting substances from plant structures. Additionally, the combination of qPCR and LC-MS revealed a number of other putative interactions between intestinal microbes and the oligosaccharides, which contributes to the understanding of the mechanisms behind prebiotic impact on human health.

Introducing GUt low-density array (GULDA): a validated approach for qPCR-based intestinal microbial community analysis.

Alterations in the human gut microbiota caused, for example, by diet, functional foods, antibiotics, or occurring as a function of age are now known to be of relevance for host health. Therefore, there is a strong need for methods to detect such alterations in a rapid and comprehensive manner. In the present study, we developed and validated a high-throughput real-time quantitative PCR-based analysis platform, termed 'GUt Low-Density Array' (GULDA). The platform was designed for simultaneous analysis of the change in the abundance of 31 different microbial 16S rRNA gene targets in fecal samples obtained from individuals at various points in time. The target genes represent important phyla, genera, species, or other taxonomic groups within the five predominant bacterial phyla of the gut, Firmicutes, Bacteroidetes, Actinobacteria, Proteobacteria, and Verrucomicrobia and also Euryarchaeota. To demonstrate the applicability of GULDA, analysis of fecal samples obtained from six healthy infants at both 9 and 18 months of age was performed and showed a significant increase over time of the relative abundance of bacteria belonging to Clostridial cluster IV (Clostridia leptum group) and Bifidobacterium bifidum and concurrent decrease in the abundance of Clostridium butyricum and a tendency for decrease in Enterobacteriaceae over the 9-month period.

[Metastatic spinal cord compression syndrome. A retrospective analysis of 297 patients]. / Metastatisk medullaert tvaersnitssyndrom. Retrospektiv opgørelse af 297 patienter.

INTRODUCTION: The purpose of this study was to look at the prognostic factors and the effects (regression of symptoms and survival rate) of the treatment given to patients with metastatic spinal cord compression syndrome (MSCCS). MATERIALS AND METHODS: Data from 297 patients who were treated at Odense University Hospital from 1989 to 2003 were collected through a retrospective evaluation of medical records. RESULTS: The patients' median age was 67 years. The most common primary diagnoses were prostate cancer, breast cancer and lung cancer. The patients' motor function at the time of diagnosis, the primary cancer diagnosis, the time from primary diagnosis to development of MSCCS and the treatment given were all significant prognostic factors. The patients receiving surgery (whether or not also receiving radiotherapy) had a significantly higher survival rate (4.8 months) than those who received only radiotherapy (3.3 months). CONCLUSION: Primary diagnosis, the degree of symptoms and the time from primary diagnosis to development of MSCCS are important prognostic factors that should be considered when choosing the treatment for a given patient. With an active attitude, it is possible to retain walking skills during the remaining and often short lifetime. Patients whose general condition allows for it should receive acute surgery followed by radiotherapy.