Laser-Induced Axotomy of Human iPSC-Derived and Murine Primary Neurons Decreases Somatic Tau and AT8 Tau Phosphorylation: A Single-Cell Approach to Study Effects of Acute Axonal Damage.

The microtubule-associated protein Tau is highly enriched in axons of brain neurons where it regulates axonal outgrowth, plasticity, and transport. Efficient axonal Tau sorting is critical since somatodendritic Tau missorting is a major hallmark of Alzheimer's disease and other tauopathies. However, the molecular mechanisms of axonal Tau sorting are still not fully understood. In this study, we aimed to unravel to which extent anterograde protein transport contributes to axonal Tau sorting. We developed a laser-based axotomy approach with single-cell resolution and combined it with spinning disk confocal microscopy enabling multi live-cell monitoring. We cultivated human iPSC-derived cortical neurons and mouse primary forebrain neurons in specialized chambers allowing reliable post-fixation identification and Tau analysis. Using this approach, we achieved high post-axotomy survival rates and observed axonal regrowth in a subset of neurons. When we assessed somatic missorting and phosphorylation levels of endogenous human or murine Tau at different time points after axotomy, we surprisingly did not observe somatic Tau accumulation or hyperphosphorylation, regardless of their regrowing activity, consistent for both models. These results indicate that impairment of anterograde transit of Tau protein and acute axonal damage may not play a role for the development of somatic Tau pathology. In sum, we developed a laser-based axotomy model suitable for studying the impact of different Tau sorting mechanisms in a highly controllable and reproducible setting, and we provide evidence that acute axon loss does not induce somatic Tau accumulation and AT8 Tau phosphorylation. UV laser-induced axotomy of human iPSC-derived and mouse primary neurons results in decreased somatic levels of endogenous Tau and AT8 Tau phosphorylation.

Stability of a Novel PEGylation Site on a Putative Haemoglobin-Based Oxygen Carrier.

PEGylation of protein sulfhydryl residues is a common method used to create a stable drug conjugate to enhance vascular retention times. We recently created a putative haemoglobin-based oxygen carrier using maleimide-PEG to selectively modify a single engineered cysteine residue in the α subunit (αAla19Cys). However, maleimide-PEG adducts are subject to deconjugation via retro-Michael reactions, with consequent cross-conjugation to endogenous plasma thiols such as those found on human serum albumin or glutathione. In previous studies mono-sulfone-PEG adducts have been shown to be less susceptible to deconjugation. We therefore compared the stability of our maleimide-PEG Hb adduct with one created using a mono-sulfone PEG. The corresponding mono-sulfone-PEG adduct was significantly more stable when incubated at 37 °C for 7 days in the presence of 1 mM reduced glutathione, 20 mg/mL human serum albumin, or human serum. In all cases haemoglobin treated with mono-sulfone-PEG retained >90% of its conjugation whereas maleimide-PEG showed significant deconjugation, especially in the presence of 1 mM reduced glutathione where <70% of the maleimide-PEG conjugate remained intact. Although maleimide-PEGylation of Hb seems adequate for an oxygen therapeutic intended for acute use, if longer vascular retention is required reagents such as mono-sulfone-PEG may be more appropriate.

Syndecan-2 selectively regulates VEGF-induced vascular permeability.

Vascular endothelial growth factor (VEGF)- driven increase in vascular permeability is a key feature of many disease states associated with inflammation and ischemic injury, contributing significantly to morbidity and mortality in these settings. Despite its importance, no specific regulators that preferentially control VEGF-dependent increase in permeability versus its other biological activities, have been identified. Here we report that a proteoglycan Syndecan-2 (Sdc2) regulates the interaction between a transmembrane phosphatase DEP1 and VEGFR2 by controlling cell surface levels of DEP1. In the absence of Sdc2 or the presence of an antibody that blocks Sdc2-DEP1 interaction, increased plasma membrane DEP1 levels promote selective dephosphorylation of the VEGFR2 Y951 site that is involved in permeability control. Either an endothelial-specific Sdc2 deletion or a treatment with an anti-Sdc2 antibody result in a highly significant reduction in stroke size due to a decrease in intracerebral edema.

Guidelines for Treatment of Umbilical and Epigastric Hernias From the European and Americas Hernia Societies-A Web-Based Survey on Surgeons' Opinion.

Background and aims: The European and Americas Hernia Society's (EHS and AHS) Guidelines on the treatment of primary midline ventral hernias were launched to guide surgeons. As a part of a dissemination plan of the guideline, this study aimed to evaluate the level of consensus between recommendations and the current surgical practices of EHS and AHS members before implementation. Material and methods: A questionnaire was constructed including questions on the current practice of the members and nine selected key recommendations from the guidelines. An on-stage consensus voting was performed at the EHS Congress in Hamburg 2019 followed by a SurveyMonkey sent to all EHS and AHS members. Consensus with a recommendation was defined as an agreement of ≥70%. Results: A total of 178 votes were collected in Hamburg. A further 499/1,754 (28.4%) of EHS and 150/1,100 (13.6%) of AHS members participated in the SurveyMonkey. A consensus was reached for 7/9 (78%) of the recommendations. The two recommendations that did not reach consensus were on indication and the technique used for laparoscopic repair. In current practice, more AHS participants used a preformed patch; 50.7% (76/150) compared with EHS participants 32.1% (160/499), p < 0.001. Conclusion: A consensus was achieved for most recommendations given by the new guideline for the treatment of umbilical and epigastric hernias. Recommendations that did not reach consensus were on indication and technique for laparoscopic repair, which may reflect the lack of evidence on these topics.

Reporting guideline for interventional trials of primary and incisional ventral hernia repair.

BACKGROUND: Primary and incisional ventral hernia trials collect unstandardized inconsistent data, limiting data interpretation and comparison. This study aimed to create two minimum data sets for primary and incisional ventral hernia interventional trials to standardize data collection and improve trial comparison. To support these data sets, standardized patient-reported outcome measures and trial methodology criteria were created. METHODS: To construct these data sets, nominal group technique methodology was employed, involving 15 internationally recognized abdominal wall surgeons and two patient representatives. Initially a maximum data set was created from previous systematic and panellist reviews. Thereafter, three stages of voting took place: stage 1, selection of the number of variables for data set inclusion; stage 2, selection of variables to be included; and stage 3, selection of variable definitions and detection methods. A steering committee interpreted and analysed the data. RESULTS: The maximum data set contained 245 variables. The three stages of voting commenced in October 2019 and had been completed by July 2020. The final primary ventral hernia data set included 32 variables, the incisional ventral hernia data set included 40 variables, the patient-reported outcome measures tool contained 25 questions, and 40 methodological criteria were chosen. The best known variable definitions were selected for accurate variable description. CT was selected as the optimal preoperative descriptor of hernia morphology. Standardized follow-up at 30 days, 1 year, and 5 years was selected. CONCLUSION: These minimum data sets, patient-reported outcome measures, and methodological criteria have allowed creation of a manual for investigators aiming to undertake primary ventral hernia or incisional ventral hernia interventional trials. Adopting these data sets will improve trial methods and comparisons.

Factors facilitating or hindering meaningful staff-client interactions in people with intellectual disabilities and challenging behaviour: A systematic mixed studies review using thematic synthesis.

BACKGROUND: Interactions with professional caregivers affect the quality of support and life of people with intellectual disabilities and contribute to the occurrence of challenging behaviour. The present literature review provides an overview of factors facilitating or hindering meaningful staff-client interactions in people with borderline to profound intellectual disabilities and challenging behaviour. METHOD: Database searches, reference list and citation screening, and expert consultations were undertaken. A thematic synthesis of 28 studies was performed. RESULTS: Factors were identified at the client (i.e. behaviour, emotions and (dis)abilities), staff (i.e. interactive principles, knowledge, psychological resources, attributions, attitudes and (coping with) emotions) and context levels (i.e. group size, team and organization). CONCLUSIONS: The present overview provides insights into factors that facilitate or hinder meaningful staff-client interactions with people with intellectual disabilities and challenging behaviour. The results support the need to combine client, staff and contextual factors when considering staff-client interactions in research and practice.

Evaluation of the immunogenicity and protective efficacy of a recombinant CS6-based ETEC vaccine in an Aotus nancymaae CS6 + ETEC challenge model.

Colonization factors or Coli surface antigens (CFs or CS) are important virulence factors of Enterotoxigenic E. coli (ETEC) that mediate intestinal colonization and accordingly are targets of vaccine development efforts. CS6 is a highly prevalent CF associated with symptomatic ETEC infection both in endemic populations and amongst travelers. In this study, we used an Aotus nancymaae non-human primate ETEC challenge model with a CS6 + ETEC strain, B7A, to test the immunogenicity and protective efficacy (PE) of a recombinant CS6-based subunit vaccine. Specifically, we determined the ability of dscCssBA, the donor strand complemented recombinant stabilized fusion of the two subunits of the CS6 fimbriae, CssA and CssB, to elicit protection against CS6 + ETEC mediated diarrhea when given intradermally (ID) with the genetically attenuated double mutant heat-labile enterotoxin LT(R192G/L211A) (dmLT). ID vaccination with dscCssBA + dmLT induced strong serum antibody responses against CS6 and LT. Importantly, vaccination with dscCssBA + dmLT resulted in no observed diarrheal disease (PE = 100%, p = 0.03) following B7A challenge as compared to PBS immunized animals, with an attack rate of 62.5%. These data demonstrate the potential role that CS6 may play in ETEC infection and that recombinant dscCssBA antigen can provide protection against challenge with the homologous CS6 + ETEC strain, B7A, in the Aotus nancymaae diarrheal challenge model. Combined, these data indicate that CS6, and more specifically, a recombinant engineered derivative should be considered for further clinical development.

Learning inguinal hernia repair? A survey of current practice and of preferred methods of surgical residents.

PURPOSE: During surgical residency, many learning methods are available to learn an inguinal hernia repair (IHR). This study aimed to investigate which learning methods are most commonly used and which are perceived as most important by surgical residents for open and endoscopic IHR. METHODS: European general surgery residents were invited to participate in a 9-item web-based survey that inquired which of the learning methods were used (checking one or more of 13 options) and what their perceived importance was on a 5-point Likert scale (1 = completely not important to 5 = very important). RESULTS: In total, 323 residents participated. The five most commonly used learning methods for open and endoscopic IHR were apprenticeship style learning in the operation room (OR) (98% and 96%, respectively), textbooks (67% and 49%, respectively), lectures (50% and 44%, respectively), video-demonstrations (53% and 66%, respectively) and journal articles (54% and 54%, respectively). The three most important learning methods for the open and endoscopic IHR were participation in the OR [5.00 (5.00-5.00) and 5.00 (5.00-5.00), respectively], video-demonstrations [4.00 (4.00-5.00) and 4.00 (4.00-5.00), respectively], and hands-on hernia courses [4.00 (4.00-5.00) and 4.00 (4.00-5.00), respectively]. CONCLUSION: This study demonstrated a discrepancy between learning methods that are currently used by surgical residents to learn the open and endoscopic IHR and preferred learning methods. There is a need for more emphasis on practising before entering the OR. This would support surgical residents' training by first observing, then practising and finally performing the surgery in the OR.

Accuracy and usefulness in assessing proficiency of the observational clinical human reliability assessment checklist of the open inguinal hernia repair procedure: A cross-sectional study.

BACKGROUND: The Observational Clinical Human Reliability Assessment (OCHRA) can be used to score errors during surgical procedures. To construct an OCHRA-checklist, steps, substeps, and hazards of a surgical procedure need to be defined. A step-by-step framework was developed to segment surgical procedures into steps, substeps, and hazards. The first aim of this study was to investigate if the step-by-step framework could be used to construct an accurate Lichtenstein open inguinal hernia repair (LOIHR) stepwise description. The second aim was to investigate if the OCHRA-checklist based on this stepwise description was accurate and useful for surgical training and assessment. MATERIALS AND METHODS: Ten expert surgeons rated statements regarding the accuracy of the LOIHR stepwise description, the accuracy, and the usefulness of the LOIHR OCHRA-checklist (eight, seven, and six statements, respectively) using a 5-point Likert scale. One-sample Wilcoxon signed-rank test was used to compare the outcomes to the neutral value of 3. RESULTS: The accuracy of the stepwise description and the accuracy and usefulness of the OCHRA-checklist were rated statistically significantly higher than the neutral value of 3 (median 4.75 [5.00-4.00] with p = .009, median 5.00 [5.00-4.00] with p = .012, median 4.00 [5.00-4.00] with p = .047, respectively). The experts rated the OCHRA-checklist to be useful for the training (5.00 [5.00-4.00], p = .009), and assessment (4.50 [5.00-4.00], p = .010) of surgical residents. CONCLUSION: This preliminary study showed that the stepwise LOIHR description constructed using the step-by-step framework was found to be accurate. The LOIHR OCHRA-checklist developed using the stepwise description was also accurate, and particularly useful for the training and assessment of proficiency of surgical residents.

Safety and feasibility of arterial wall targeting with robot-assisted high intensity focused ultrasound: a preclinical study.

PURPOSE: High-intensity focused ultrasound (HIFU) is a potential noninvasive thermal ablation method for the treatment of peripheral artery disease. Dual-mode ultrasound arrays (DMUA) offer the possibility of simultaneous imaging and treatment. In this study, safety and feasibility of femoral artery robot-assisted HIFU/DMUA therapy was assessed. METHODS: In 18 pigs (∼50kg), angiography and diagnostic ultrasound were used to visualize diameter and blood flow of the external femoral arteries (EFA). HIFU/DMUA-therapy was unilaterally applied to the EFA dorsal wall using a 3.5 MHz, 64-element transducer, closed-loop-control was used to automatically adjust energy delivery to control thermal lesion formation. A continuous lesion of at least 25 mm was created by delivering 6-8 HIFU shots per imaging plane perpendicular to the artery spaced 1 mm apart. Directly after HIFU/DMUA-therapy and after 0, 3 or 14 days follow up, diameter and blood flow were measured and the skin was macroscopically examined for thermal damage. The tissue was removed for histological analysis. RESULTS: No complications were observed. The most frequently observed treatment effect was formation of scar tissue, predominantly in the adventitia and the surrounding tissue. No damage to the endothelium or excessive damage of the surrounding tissue was observed. There was no significant decrease in the mean arterial diameter after HIFU/DMUA-therapy. CONCLUSION: HIFU/DMUA therapy successfully targeted the vessel walls of healthy porcine arteries, without causing endothelial damage or other vascular complications. Therefore, this therapy can be safely applied to healthy arterial walls in animals. Future studies should focus on safety and dose-finding in atherosclerotic diseased arteries.

Correction to: European Hernia Society (EHS) guidance for the management of adult patients with a hernia during the COVID­19 pandemic.

The originally published article: The surname and given name of authors, M. Pawlak and A.C. de Beaux has been incorrectly published.

EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances.

BACKGROUND: Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management. METHODS: The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full-text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed. RESULTS: Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence. CONCLUSION: This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.

ANTECEDENTES: Las hernias de localización rara, así como las hernias ventrales primarias en determinadas circunstancias (cirrosis, diálisis, diástasis de recto, tras un embarazo) pueden ser complejas desde el punto de vista técnico. El objetivo fue identificar situaciones en las que la estrategia de tratamiento pudiera ser diferente del tratamiento habitual. MÉTODOS: Esta guía fue elaborada por cirujanos de las sociedades europeas y americana de hernia (European Hernia Society, EHS y American Hernia Society, AHS). La búsqueda sistemática de la literatura se efectuó el 1 de mayo de 2018 y se actualizó el 1 de febrero de 2019. Para evaluar la calidad de los artículos completos seleccionados se utilizó la normativa SIGN (Scottish Intercollegiate Guidelines Network). Las recomendaciones formuladas siguieron la metodología GRADE (Grading of Recommendations Assessment, Development and Evaluation) y la redacción de la guía siguió las normas AGREE (Appraisal of Guidelines for Research & Evaluation). RESULTADOS: La literatura es limitada en cantidad y calidad. La mayoría de las recomendaciones se calificaron como débiles en función de la baja calidad de la evidencia. En pacientes con cirrosis o en diálisis, se sugiere una reparación con malla preperitoneal. Un embarazo tras la reparación de una hernia es un factor de riesgo de recidiva. La reparación debería posponerse hasta después del último embarazo. Debido a la falta de evidencia no se pudo hacer ninguna recomendación para la reparación de hernias en pacientes con diástasis de recto concomitante o con hernias de Spigel o lumbares. CONCLUSIÓN: Esta es la primera guía europea y americana del tratamiento de hernias umbilicales y epigástricas en pacientes con patologías especiales, incluyendo las hernias de Spigel y lumbares. Todas las recomendaciones fueron débiles debido a la falta de evidencia. Se necesitan más estudios en pacientes con diástasis de recto, hernias de Spigel y lumbares.

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society.

BACKGROUND: Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias. METHODS: The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019. RESULTS: Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity. CONCLUSION: This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

ANTECEDENTES: La reparación de las hernias umbilicales y epigástricas es un procedimiento quirúrgico frecuente con una tasa esperada de complicaciones baja. Sin embargo, sigue en discusión cuál es el mejor método de reparación óptimo para obtener los mejores resultados a corto y a largo plazo. El objetivo del estudio fue desarrollar una guía para el tratamiento de las hernias umbilicales y epigástricas. MÉTODOS: El grupo para la elaboración de la guía estuvo formado por cirujanos europeos y norteamericanos junto con miembros de la European Hernia Society (EHS) y de la America's Hernia Society (AHS). Para elaborar la guía, se siguieron las recomendaciones GRADE (Grading of Recommendations Assessment, Development and Evaluation), SIGN (Scottish Intercollegiate Guidelines Network) y AGREE (Appraisal of Guidelines for Research & Evaluation). Se realizó una búsqueda sistemática de la literatura el 1 de mayo de 2018, que luego se actualizó el 1 de febrero de 2019. RESULTADOS: Los trabajos dedicados de forma específica a las hernias umbilicales y epigástricas eran muy limitados en cantidad y calidad, por lo que la mayoría de las recomendaciones que se extrajeron fueron calificadas como débiles y basadas en una baja calidad de la evidencia. La recomendación principal era utilizar una malla en la reparación de las hernias umbilicales y epigástricas para reducir la tasa de recidiva. La mayoría de las hernias umbilicales y epigástricas pueden repararse mediante un abordaje abierto con una malla plana preperitoneal. Se puede considerar el abordaje laparoscópico si el defecto de la hernia es grande o si el paciente tiene un riesgo aumentado de morbilidad de la herida. CONCLUSIÓN: Esta es la primera guía europea y americana del tratamiento de las hernias umbilicales y epigástricas. Se sugiere reparar las hernias sintomáticas umbilicales y epigástricas mediante un abordaje abierto con una malla plana preperitoneal.

Abdominal wall hernia surgery in The Netherlands: a national survey.

PURPOSE: In The Netherlands, the quality of abdominal wall hernia surgery is largely unknown due to the lack of a hernia registry. This study was designed to assess the current state of abdominal wall hernia surgery in The Netherlands, to create a starting point for future evaluation of new quality measures. METHODS: Dutch hernia management indicators and recently proposed European Hernia Society (EHS) requirements for accredited/certified hernia centers were used. The number of Dutch hospitals that meet the four main EHS requirements (on volume, experience, use of a registry and quality control) was assessed by analyzing governmental information and the results of a survey amongst all 1.554 Dutch general surgeons. RESULTS: The survey was representative with 426 respondents (27%) from all 75 hospitals. Fifty-one percent of the hospitals had a median inguinal repair volume of more than 290 (14-1.238) per year. An open or laparo-endoscopic inguinal repair technique was not related to hospital volume. Experienced hernia surgeons, use of a registry and a structured quality control were reported to be present in, respectively, 97%, 39%, and 15% of the hospitals. Consensus in answers between the respondents per hospital was low (< 20%). Two hospitals (3%) met all four requirements for accreditation. CONCLUSION: This descriptive analysis demonstrates that hernia surgery in the Netherlands is performed in every hospital, by all types of surgeons, using many different techniques. If the suggested EHS requirements are used as a measuring rod, only 3% of the Dutch hospitals could be accredited as a hernia center.

Renal cell carcinoma in young FH mutation carriers: case series and review of the literature.

Hereditary Leiomyomatosis and Renal Cell Cancer (HLRCC) is an autosomal dominant syndrome caused by heterozygous pathogenic germline variants in the fumarate hydratase (FH) gene. It is characterized by cutaneous and uterine leiomyomas and an increased risk of developing renal cell carcinoma (RCC), which is usually adult-onset. HLRCC-related RCC tends to be aggressive and can metastasize even when the primary tumor is small. Data on children and adolescents are scarce. Herein, we report two patients from unrelated Dutch families, with HLRCC-related RCC at the ages of 15 and 18 years, and a third patient with an FH mutation and complex renal cysts at the age of 13. Both RCC's were localized and successfully resected, and careful MRI surveillance was initiated to monitor the renal cysts. One of the patients with RCC subsequently developed an ovarian Leydig cell tumor. A review of the literature identified 10 previously reported cases of HLRCC-related RCC in patients aged younger than 20 years, five of them presenting with metastatic disease. These data emphasize the importance of recognizing HLRCC in young patients to enable early detection of RCC, albeit rare. They support the recommendations from the 2014 consensus guideline, in which genetic testing for FH mutations, and renal MRI surveillance, is advised for HLRCC family members from the age of 8-10 years onwards.

Validity of a low-cost Lichtenstein open inguinal hernia repair simulation model for surgical training.

PURPOSE: Simulation training allows trainees to gain experience in a safe environment. Computer simulation and animal models to practice a Lichtenstein open inguinal hernia repair (LOIHR) are available; however, a low-cost model is not. We constructed an inexpensive model using fabric, felt, and yarn that simulates the anatomy and hazards of the LOIHR. This study examined the fidelity, and perceived usefulness of our developed simulation model by surgical residents and expert surgeons. METHODS: A total of 66 Dutch surgical residents and ten international expert surgeons were included. All participants viewed a video-demonstration of LOIHR on the simulation model and subsequently performed the surgery themselves on the model. Afterward, they assessed the model by rating 13 statements concerning its fidelity (six model, three equipment, and four psychological) and six usefulness statements on a five-point Likert scale. One-sample Wilcoxon signed-rank test was used to compare to the neutral value of 3. RESULTS: The fidelity was assessed as being high by residents [model 4.00 (3.00-4.00), equipment 4.00 (3.00-4.00), psychological 4.00 (3.00-4.00); all p's < 0.001] and by expert surgeons [model 4.00 (3.00-4.00), p = 0.025; equipment 4.00 (3.00-5.00), p < 0.001; psychological 4.00 (3.00-4.00), p = 0.053]. The usefulness was rated high by residents and experts, especially the usefulness for training of residents [residents 4.00 (4.00-5.00), p < 0.001; experts 4.50 (3.75-5.00), p = 0.015]. CONCLUSION: Our developed Lichtenstein open inguinal hernia repair simulation model was assessed by surgical residents and expert surgeons as a model with high fidelity and high potential usefulness, especially for the training of surgical residents.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery.

INTRODUCTION: The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature. METHODS: A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated. RESULTS: All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures. CONCLUSION: A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

The Brisbane Burn Scar Impact Profile (child and young person version) for measuring health-related quality of life in children with burn scars: A longitudinal cohort study of reliability, validity and responsiveness.

BACKGROUND: Clinical practice benefits from the measurement of health-related quality of life (HRQoL) to reflect the impact of the disease and treatments from the patient's lived experience. The Brisbane Burn Scar Impact Profile (child and young person version, BBSIP8-18), developed in 2013, is a self-report measure of burn scar-specific HRQoL. The purpose of the study was to test reliability, validity and responsiveness of this measure for an evaluative purpose. METHODS: Young people aged 8-18 years with burn scarring or at probable risk of burn scarring (defined as 14 days or longer to re-epithelialize) were included in a prospective, longitudinal cohort study. Data was collected at a paediatric burn centre at baseline (when ≥85% of the total body surface area re- epithelialized), then 1-2 weeks and 1-month post-baseline. Participants completed measures of HRQoL (BBSIP8-18, Pediatric Quality of Life Inventory) and scar characteristics (Patient Observer Scar Assessment Scale) at each time-point. RESULTS: Sixty-five participants completed the baseline testing. Forty-nine participants completed testing at 1-2 weeks post-baseline and thirty-two at 1-month post-baseline. Internal consistency of item groups ranged from Cronbach's α 0.60 (frequency of sensory symptoms) to 0.90 (emotional reactions). All item groups expected to be stable had acceptable test-retest reliability (ICC = 0.71-0.83), except 'mobility' and 'friendships and social interaction' (ICC = 0.52 and 0.45). Construct validity was supported with 10 of 13 (77%) hypothesised correlations of change in the BBSIP8-18 items corresponding with changes in external criterion measures. The responsiveness of 8 out of 10 item groups tested against an external criterion was supported (AUC = 0.71-0.92). CONCLUSION: The BBSIP8-18 has acceptable reliability, validity and responsiveness supporting its use as an evaluative self-report measure of burn scar-specific HRQoL in the early post-acute phase after burn injury.

The longitudinal validity, reproducibility and responsiveness of the Brisbane Burn Scar Impact Profile (caregiver report for young children version) for measuring health-related quality of life in children with burn scars.

BACKGROUND: The measurement of health-related quality of life (HRQoL) provides information about the perceived burden of the health condition and treatments from a lived experience. The Brisbane Burn Scar Impact Profile (caregiver report for young children, BBSIP0-8), developed in 2013, is a proxy-report measure of burn scar-specific HRQoL. The aim of this study was to report its psychometric properties in line with an evaluative purpose. METHODS: Caregivers of children up to 8 years of age at risk of burn scarring were recruited into a prospective, longitudinal cohort study. Caregivers completed the BBSIP0-8, Pediatric Quality of Life Inventory and Patient Observer Scar Assessment Scale at baseline (approximately ≥85% of the total body surface area re-epithelialised), 1-2 weeks after baseline and 1-month after baseline. Psychometric properties measured included internal consistency, test-retest reliability, validity and responsiveness. RESULTS: Eighty-six caregivers of mostly male children (55%), of a median age (IQR) of 1 year, 10 months (2 years, 1 month) and total body surface area burn of 1.5% (3.0%) were recruited. Over one third of participants were grafted and 15% had contractures or skin tightness at baseline. Internal consistency of ten item groups ranged from 0.73 to 0.96. Hypothesised correlations of changes in the BBSIP0-8 items with changes in criterion measures supported longitudinal validity (ρ ranging from -0.73 to 0.68). The majority of item groups had acceptable reproducibility (ICC = 0.65-0.83). The responsiveness of five item groups was supported (AUC = 0.71-0.90). CONCLUSION: The psychometric properties tested support the use of the BBSIP0-8 as an evaluative measure of burn scar-related health-related quality of life for children aged below eight years in the early post-acute period of rehabilitation. Further investigation at longer time period after burn injury is indicated.