Where is the nerve? Review of operation note documentation practice for inguinal hernia repair.

INTRODUCTION: Careful identification and management of inguinal nerves during inguinal hernia repair is important to avoid iatrogenic injury. Documentation of this practice may inform postoperative clinical management. We set out to investigate how often surgeons identify inguinal nerves and document findings and management in their operation notes. METHODS: We carried out a retrospective review of operation notes at a single district general hospital. We analysed operation notes for documentation of identification and intraoperative management (preservation or sacrifice) of the inguinal nerves (iliohypogastric, ilioinguinal, genital branch of genitofemoral nerve). We collected data on the baseline characteristics of the patients, hernia characteristics and primary operating surgeons for subgroup analysis. RESULTS: A total of 100 patients were included in the analysis. Identification of any inguinal nerves (generic 'nerve') was documented in 17% of operation notes. Documentation in the operation notes of named individual nerves was limited. No documentation of intraoperative management of inguinal nerves was found in 83% of operation notes. Preservation of the inguinal nerves (generic 'nerve') was recorded in 8% and sacrifice recorded in 9% of cases. Subgroup analysis revealed similar incidence of documentation of identification and management of inguinal nerves across grades of primary surgeon, with overall incidence low for all grades. CONCLUSION: This study reveals a lack of appreciation of the importance of documenting identification and management of inguinal nerves in operation notes. Further consideration of the potential implications of poor documentation would be beneficial to improve standards.

Chronic groin pain following open inguinal hernia repair: has consenting practice improved?

INTRODUCTION: Chronic groin pain following inguinal hernia surgery is a common and potentially debilitating complication, and yet patients are infrequently informed of this risk. This leaves surgeons open to negligence claims, especially given recent changes to case law, which for the first time highlighted the need for a more patient-centred approach to risk disclosure. We investigated how these changes have influenced our consenting practice with respect to the disclosure of this risk. METHODS: We compared how often surgeons discussed the risk of chronic groin pain with adults undergoing elective open unilateral inguinal hernia mesh repairs in 2019 and 2009. The first 50 patients in each of these two years were retrospectively compared. Discussions during the initial consultation and on the day of surgery were assessed by reviewing clinic letters, medical notes and consent forms. FINDINGS: The risk of chronic pain was discussed with significantly more patients in 2019 than in 2009 (96% v 54%, p<0.0001). Most of these discussions occurred on the day of surgery (92% v 54%, p<0.0001). Only a few patients had these discussions during their initial consultation (18% v 4%, p<0.025). CONCLUSIONS: Discussing the risk of chronic groin pain has improved significantly over the past 10 years. However, these discussions occur mostly on the day of surgery, which gives patients very little time to weigh up the risk. This potentially invalidates the consent they give for surgery. Patients should be given an opportunity to discuss their operative risks in advance of their operation.

Anti-TNFα antibody-induced psoriasiform skin lesions in patients with inflammatory bowel disease: an Irish Cohort Study.

AIM: To determine the prevalence of psoriasis in an IBD cohort with reference to clinical characteristics and anti-TNFα use. METHODS: Patients with psoriasis and IBD were retrospectively identified from the IBD database at Tallaght Hospital from 2000 to 2015. Pertinent clinical data were obtained from patients notes including anti-TNFα exposure. Prevalence rates of genuine and reactive psoriasis were calculated and compared using Student's T -test. A P values of <0.05 was considered significant. RESULTS: In total, 1384 IBD patients were identified. The overall prevalence rate of IBD and psoriasis was 2.4% ( n = 33), with 1.8% ( n = 25) in the Crohn's disease group and 0.6% ( n = 8) in the ulcerative colitis group. Within the psoriasis group, 24% ( n = 8 of 33) had reactive psoriasis. The prevalence rates of psoriasis in the non-biological and biological cohorts were similar 2.5% (25 of 981) and 2% (8 of 403), respectively. There was no significant association with reactive psoriasis and disease type. There was a trend towards higher rates of reactive psoriasis Adalimumab users, 3.6% (6 of 166) vs. 0.8% (2 of 237), OR = 4.283, P = 0.077, 95% CI 0.854-21.483 in infliximab users. In addition, in our cohort, smoking was not associated with any form of psoriasis in IBD, OR = 1.377, 95% CI 0.061-3.087, P = 0.437. CONCLUSION: In our large study, the prevalence rate of reactive psoriasis was similar to the background rate of psoriasis in the overall IBD cohort (2.0 vs. 2.4%). A 2% prevalence rate represents a common adverse event that clinicians should be aware of.

A clinicopathological study of serotonin of sigmoid colon mucosa in association with chronic symptoms in uncomplicated diverticulosis.

INTRODUCTION: Neurotransmitter imbalance is hypothesised as a pathogenetic mechanism in several bowel conditions. We previously reported increased 5-HT in the sigmoid mucosa of colon resected for complicated diverticular disease (DD). We aimed to identify if abnormal 5-HT expression is associated with symptoms of uncomplicated DD. METHODS: This was a prospective, comparative study and follow-up survey of symptoms. We examined the differences in 5-HT between DD patients and controls, as well as the presence of bowel symptoms at time of endoscopy and also 2 years later. Sigmoid biopsies were collected at colonoscopy. Immunohistochemical staining for 5-HT cells was performed. RESULTS: Eighty-seven patients were recruited, 37 (42.5 %) DD and 50 (57.5 %) controls. No patients underwent surgery. There was no significant difference in total mean number of 5-HT-positive cells in DD compared to controls or between patients and controls with abdominal symptoms. Forty-one patients (47.1 %) responded to questionnaires at median 57.8 months from biopsy. Eighteen (43.9 %) were DD and 23(56.1 %) controls. 5-HT counts showed no significant association to symptom persistence. DISCUSSION: Although 5-HT expression has previously been found to be increased in complicated DD in whole bowel-resected specimens, the same is not confirmed on colonic mucosal biopsies. This raises the suggestion that 5-HT may be involved in the development of acute complications but may not be involved in the pathogenesis of chronic symptoms.

Review article: the pathogenesis of diverticular disease--current perspectives on motility and neurotransmitters.

BACKGROUND: Low-fibre diet, structural abnormalities and ageing are traditional aetiological factors implicated in the development of diverticular disease. More recently, motility disorders are implicated in its causation leading to speculation that neurotransmitters play a role in mediating these disturbances. AIMS: To draw together studies on the role of neurotransmitters in the development of diverticular disease and its symptoms. METHODS: Medline, GoogleScholar and Pubmed were searched for evidence on this subject using the terms neurotransmitters, motility, diverticular disease and pathogenesis. Articles relevant to the subject were cited and linked references were also reviewed. RESULTS: Serotonin, which has been found to be an excitatory colonic neurotransmitter, has been found in early studies to be increased in colonic enterochromaffin cells. Acetylcholine, which is thought to be an excitatory neurotransmitter and cholinergic activity, has also seen to be increased in diverticular disease. These findings may suggest that an increase in excitatory neurotransmitters may result in the hypersegmentation thought to cause pulsion diverticula. Similarly, a decrease in nitric oxide which is inhibitory is found. CONCLUSIONS: There is some evidence that neurotransmitters may play a role in the motility disturbances seen in diverticular disease; however, a clear role is yet to be ascertained.

Prospective evaluation of a colorectal cancer nurse follow-up clinic.

AIM: Colorectal Nurse Specialist (CNS) clinics for postoperative follow up of colorectal cancer aim to maintain clinical efficacy while reducing costs. We prospectively studied the efficacy and financial implications of such a clinic. METHOD: This was a prospective study of all patients attending CNS clinics over 3 years. A lower-risk protocol for patients with Dukes A was used over 3 years and a higher-risk protocol for patients with Dukes B, C or D was used over 5 years. Department of Health Pricing Charts were used to cost the follow-up protocols, and adjustment was performed to calculate the cost of each quality adjusted life year (QALY) gained. RESULTS: One hundred and ninety-three patients entered into this nurse-led follow-up protocol implemented by the CNS clinic between 2005 and 2007. The Dukes stages and proportions of patients in each stage were as follows: stage A, 13%; stage B, 8%; stage C, 36.3%; and stage D, 9.3%. Ninety-seven per cent underwent curative treatment and 2.6% had palliative treatment. Twenty-one per cent of patients developed recurrent disease. Overall actuarial 5-year survival was 80% and recurrences had a 30% 5-year actuarial survival. The total cost per patient for 3 years of follow up was £1506 and £1179 for lower-risk rectal and nonrectal cancers, respectively. The adjusted cost for each QALY gained for lower-risk tumours was £1914. The total cost per patient with higher-risk tumours was £1814 and £1487 for rectal and nonrectal tumours, respectively. The adjusted cost for each QALY gained was £2180 for higher-risk tumours. CONCLUSIONS: This clinic demonstrated cost-effective detection of recurrent disease. Computed tomography (CT) was the most sensitive alert test. As all recurrences were detected within 4 years, we suggest that this is the indicated time to follow up.

Diverticular disease hospital admissions are increasing, with poor outcomes in the elderly and emergency admissions.

BACKGROUND: Diverticular disease has a changing disease pattern with limited epidemiological data. AIM: To describe diverticular disease admission rates and associated outcomes through national population study. METHODS: Data were obtained from the English 'Hospital Episode Statistics' database between 1996 and 2006. Primary outcomes examined were 30-day overall and 1-year mortality, 28-day readmission rates and extended length of stay (LOS) beyond the 75th percentile (median inpatient LOS = 6 days). Multiple logistic regression analysis was used to determine independent predictors of these outcomes. RESULTS: Between the study dates 560 281 admissions with a primary diagnosis of diverticular disease were recorded in England. The national admission rate increased from 0.56 to 1.20 per 1000 population/year. 232 047 (41.4%) were inpatient admissions and, of these, 55 519 (23.9%) were elective and 176 528 (76.1%) emergency. Surgery was undertaken in 37 767 (16.3%). The 30-day mortality was 5.1% (n = 6735) and 1-year mortality was 14.5% (n = 11 567). The 28-day readmission rate was 9.6% (n = 21 160). Increasing age, comorbidity and emergency admission were independent predictors of all primary outcomes. CONCLUSIONS: Diverticular disease admissions increased over the course of the study. Patients of increasing age, admitted as emergency and significant comorbidity should be identified, allowing management modification to optimize outcomes.

Colo-anal pouches: lessons from a prospective audit.

OBJECTIVE: Colonic pouch formation with pouch-anal anastomosis is the treatment of choice following restorative anterior resection for low rectal cancers with a proximal loop ileostomy to defunction the anastomosis. Controversy exists as to whether anastomotic integrity needs to be checked prior to ileostomy reversal. The aim of this prospective study was to audit our current practice. METHOD: Data on all patients undergoing resectional surgery for rectal cancer in our unit are entered prospectively onto a database. Patients who underwent an anterior resection with pouch formation and defunctioning ileostomy were identified and a review of notes and radiological records was carried out. RESULTS: Forty-two patients with rectal adenocarcinoma underwent an anterior resection with colo-colonic pouch, colo-anal anastomosis and a covering loop ileostomy. Of these, 38(90.5%) had water-soluble contrast enemas (WSCE) 6-8 weeks postoperatively. Two studies (5.3%) confirmed the presence of normal colo-colonic pouch but 24(63.2%) normal reports made no mention of the presence of pouch. Three studies (7.9%) reported true leaks, one study (2.6%) an anastomotic stricture and eight studies (21.1%) anastomotic leaks. Review by radiologists and surgeons, and examination with flexible sigmoidoscopy of these final eight confirmed that these appearances were consistent with normal colo-colonic pouches and anastomosis with no leak. These patients went on to have uneventful stoma closure. CONCLUSION: Our study suggests that Colon pouches are difficult to clearly delineate on WSCE and appearances may be mistaken for leaks leading to questioning of the suitability of WSCE in assessing anastomotic integrity. A true positive leak rate of 7.9% would suggest that postoperative assessment prior to closure is still necessary in some patients.

Factors that influence the adequacy of total mesorectal excision for rectal cancer.

OBJECTIVE: In 1997 with the start of CRO7 trial it was agreed that adequacy of surgical resection of rectal cancer would be determined by a pathologically determined grading of the mesorectum the so called total mesorectal excision score (TME score). Scores ranged from 1-3 with 3 being a perfect specimen. The aim of this study was to investigate factors which may influence TME scores and establish if local recurrence is related to them. METHOD: Data on all patients undergoing resectional surgery for rectal cancer in our unit are entered prospectively onto a database. Pathology reports of those patients who underwent total mesorectal excision were examined and the TME scores added to the database. Categorical variables were analysed using the chi2 test, continuous variables using ANOVA. Statistical significance was taken as P < 0.05. RESULTS: Between January 2000 and June 2005, 518 patients underwent surgery for adenocarcinoma of the rectum, of these, 287 patients had a total mesorectal excision for mid or lower third tumours under the care of seven colorectal surgeons. All resected specimens were scored by a Consultant GI pathologist. Two hundred and fourteen patients underwent anterior resection and 73 underwent abdomino-perineal resection. The median age of the patients was 73 years (range 38-95 years). One hundred and ninety-four patients were male. Seventy-eight patients were treated with preoperative radiotherapy, 59 short course and 19 long course. TME scores were TME1 n = 30, TME2 n = 99, TME3 n = 158. Fifteen patients developed local pelvic recurrence at 2 years. Total mesorectal excision scores were not statistically influenced by Dukes' stage, width of tumour, preoperative radiotherapy or grade of surgeon. Male patients were statistically more likely to have a TME score of 2 or 3 compared with female P = 0.04. Patients undergoing an anterior resection were statistically more likely to have a TME score of 2 or 3 compared with abdomino-perineal resection P = 0.0001. Tumours with a circumferential resection margin (CRM) of more than 1 mm were more likely to have a TME score of 2 or 3 score (P = 0.0001). There was no relationship between TME and local recurrence (P = 0.966). CONCLUSION: There is no relationship between the TME score in patients undergoing resectional surgery for adenocarcinoma of the rectum and the development of local recurrence at 2 years. Other factors such as CRM involvement are more likely to have an impact on local recurrence. The factors that influence the quality of TME are the operative procedure of anterior resection, male gender and CRM positivity. There appear to be no deleterious effects on the TME score by Specialist Registrars performing the operation under Consultant supervision. While TME scores may be an index of a technical performance, they appear to have little role in predicting future outcomes.

Electrical stimulation of transforming growth factor-beta 1 secretion by human dermal fibroblasts and the U937 human monocytic cell line.

The in vitro effects on human dermal fibroblasts and the U937 human monocytic cell line of three phases of electrical microcurrents generated by the ACE Stimulator were investigated. The growth and viability of growing and confluent dermal fibroblasts were not directly influenced by the separate microcurrent phases. One form of microcurrent (designated phase 1) stimulated both dermal fibroblasts and U937 cells to secrete transforming growth factor-beta 1 (TGF-beta 1), which is an important regulator of cell-mediated inflammation and tissue regeneration, but none of the three phases stimulated secretion of the pro-inflammatory cytokine interleukin-6 by U937 cells. The stimulation of TGF-beta 1 secretion in these experiments was not dramatic (a median increase over control levels of 20-30%), although it could be biologically significant.

Site-specific phosphorylation of human p53 protein determined by mass spectrometry.

Human recombinant p53 (r-p53) protein was studied by mass spectrometry (MS) to determine site-specific posttranslational differences between basal and hyperphosphorylated r-p53. Wild-type p53 was basally expressed after baculovirus infection while a parallel preparation was treated with the phosphatase inhibitor okadaic acid during the terminal stages of expression to create a hyperphosphorylated form of p53 known for its higher DNA binding and transcriptional activation. After immunoaffinity and HPLC purification, MALDI/MS measured a higher molecular mass for r-p53 from okadaic acid treatment relative to control, suggesting a higher phosphorylation state. This was supported by an acidic shift of r-p53 isoforms separated by gel isoelectric focusing. Employing a variety of mass spectrometric analyses combined with separation and affinity techniques, six specific phosphorylation sites of p53 were identified. The MS data indicated that hyperphosphorylated p53 showed a higher degree of phosphorylation than basal p53 at specific amino- and carboxy-terminal sites. In particular, ESI-MS demonstrated that Ser(315) was entirely phosphorylated after okadaic acid treatment, as confirmed biochemically by CDK2 kinase assay and by isoelectric focusing. In summary, MS analysis uniquely revealed increased, site-specific phosphorylations on p53 after phosphatase inhibition, particularly at Ser(315), which may be critical molecular events in defining p53 activity.

Matrix-assisted laser desorption ionization/mass spectrometry mapping of human immunodeficiency virus-gp120 epitopes recognized by a limited polyclonal antibody.

In this study we have applied epitope excision and epitope extraction strategies, combined with matrix assisted laser desorption/ionization mass spectrometry, to determine the fine structure of epitopes recognized by a polyclonal antibody to human immunodeficiency virus envelope glycoprotein gp120. This is the first application of this approach to epitope mapping on a large, heavily glycosylated protein. In the epitope excision method, gp120 in the native form is first bound to the antibody immobilized on sepharose beads and cleaved with endoproteinase enzymes. In the epitope extraction method, the gp120 was first proteolytically cleaved and then allowed to react with the immobilized antibody. The fragments that remain bound to the antibody, after repeated washing to remove the unbound peptides, contain the antigenic region that is recognized by the antibody, and the bound peptides in both methods can be characterized by direct analysis of the immobilized antibody by matrix assisted laser desorption ionization/mass spectrometry. In this study we have carried out epitope excision and extraction experiments with three different enzymes and have identified residues 472-478 as a major epitope. In addition, antigenic regions containing minor epitopes have also been identified.

Prevalence of emotional and behavioural problems in Johor Bahru District school children--comparing three geographical areas.

This is a cross sectional community study in Johor Bahru District. The aim of this study is to estimate the overall prevalence of emotional and behavioural deviance among the school children in three different geographical areas, and to identify their correlates. This paper presents the findings of phase one of a two-stage procedure involving a total of 589 children aged 10-12 years. Using the cut-off point validated locally, the prevalence of deviance on the parental scale was 40% in the rural school, 30.2% in the agricultural resettlement (Felda) school and 32.3% in the urban school. On the teachers' assessment, the prevalence of deviance was 40.8% in the rural school, 10.8% in the Felda School and 8.9% in the urban school. There was significantly higher prevalence of deviance in the rural school on the teachers' scale. In the rural school, significantly higher prevalence of deviance was found among boys.

Audit of new long-stay patients in Permai Mental Hospital, Johor.

We report a cross-sectional descriptive study of 90 new long-stay patients (NLS) (i.e. those who had been resident for six months to three years in Permai Mental Hospital, Johor) and studied from April to June, 1995. The age of this sample ranged from 18 to 85 years. Two subgroups were observed (i.e. younger NLS patients aged 18 to 34 years and older NLS patients aged 35 to 85 years). Among the younger NLS patients, the commonest diagnosis was schizophrenia (51.2%), followed by mental retardation with related problems (24.4%). Sixty-one percent of these younger patients had a history of serious violence or dangerous behaviour. Older NLS patients were likely to have a diagnosis of schizophrenia (79.6%), followed by mood disorder (6.1%) and dementia (4.1%). Forty seven percent of these older group had history of danger to others and 57.1% were at moderate or severe risk of non-deliberate self-harm. Focusing on the schizophrenic patients, all of them had some form of psychopathology, either positive, negative or general symptoms and about one-fourth were assessed to pose a risk for aggression.

Factors affecting activation of the 'cloaked' Zea maize ribosome inactivating protein (RIP) zymogen. 1. 'LID' peptide hydrophobicities and oxidative structural changes.

We want to understand how environmental factors influence zymogen activation of the "cloaked' active site of the 'Ribosome Inactivating Protein' (RIP) from corn kernels. In this study, we focus on how likely chemical effectors in the immediate environment of the 'lid' conspire to unleash the active site upon encountering target membranes of invading pests. Octanol-H2O partitioning free energies of peptides which (i) straddle the proteolysis site, and (ii) form the 'side' and 'bottom' of the proposed 'lid' were found to only slightly favor H2O, suggesting that the peptide is poised to detach from the less polar surface surrounding the RIP active site. Circular dichroism results obtained upon catalase/H2O2 oxidation of the 'lid' peptide suggest that the structure shifts from primarily alpha-helical to primarily beta-like. These results suggest that the active site is more easily 'uncloaked' as a result of the lowered solvent polarity conditions and higher oxidant concentrations in the presence of pest membranes encountered during crucial stages of seed germination.

Low frequency vibrational modes of oxygenated myoglobin, hemoglobins, and modified derivatives.

The low frequency resonance Raman spectra of the dioxygen adducts of myoglobin, hemoglobin, its isolated subunits, mesoheme-substituted hemoglobin, and several deuteriated heme derivatives are reported. The observed oxygen isotopic shifts are used to assign the iron-oxygen stretching (approximately 570 cm-1) and the heretofore unobserved delta (Fe-O-O) bending (approximately 420 cm-1) modes. Although the delta (Fe-O-O) is not enhanced in the case of oxymyoglobin, it is observed for all the hemoglobin derivatives, its exact frequency being relatively invariable among the derivatives. The lack of sensitivity to H2O/D2O buffer exchange is consistent with our previous interpretation of H2O/D2O-induced shifts of v(O-O) in the resonance Raman spectra of dioxygen adducts of cobalt-substituted heme proteins; namely, that those shifts are associated with alterations in vibrational coupling of v(O-O) with internal modes of proximal histidyl imidazole rather than to steric or electronic effects of H/D exchange at the active site. No evidence is obtained for enhancement of the v(Fe-N) stretching frequency of the linkage between the heme iron and the imidazole group of the proximal histidine.

Characteristics of psychiatric admissions and aspects of overcrowding at the general Hospital, Kuala Lumpur.

This study examined admissions, final diagnoses and mean duration of stay of patients in the Psychiatric Wards at the General Hospital, Kuala Lumpur. The male ward was severely overcrowded by 125% over the maximum bed capacity. The majority were psychotic, mainly schizophrenic. The female ward had 76% occupancy, also mainly psychotic. Neurotics, alcohol dependents and personality disorders formed less than 5% of the admissions. There was no difference in the mean duration of stay of patients of both UKM and GHKL Units stratified for diagnosis and disposal except for newly diagnosed schizophrenics. There is an urgent need for more male psychiatric beds/wards.

Resonance Raman studies of hemoglobins reconstituted with mesoheme. Unperturbed iron-histidine stretching frequencies in a functionally altered hemoglobin.

Hybrid hemoglobins, containing mesoheme in one type of subunit and protoheme in the partner subunits, have been studied by resonance Raman spectroscopy. These hybrids have been studied in both the met hybrid and fully reduced, deoxy forms. Judicious choice of laser excitation frequency permits selective enhancement of modes associated with each type of subunit; i.e., either meso- or protoheme-containing subunit. The assignments of low-frequency modes of meso- and protoheme are briefly discussed with special reference to the iron-histidine linkage. Despite functional differences between the hybrids, no significant changes in the strength of the iron-histidine linkages are detected by resonance Raman spectroscopy. These results are discussed with reference to recent high-resolution NMR studies of these same hybrids.