Asymptomatic contralateral inguinal and ventral hernias among people with a workers' compensation claim for hernia.

STUDY AIM: There is a gap in evidence that demonstrates an increased risk of hernia formation in laborers. A notable incidence of a second asymptomatic hernia among people making a workers' compensation claim for a hernia would suggest that the pathology is not acute and probably not related to work, or the performance of a single strenuous event. PATIENTS AND METHODS: We performed a retrospective database study of a consecutive sample of 106 adults who claimed a work-related abdominal hernia between September 2016 and December 2018 and had a Computed Tomography (CT) scan as part of a diagnostic workup. Hernias were classified as incidental if patients had a contralateral inguinal hernia with unilateral groin symptoms, or if patients had a ventral hernia with only groin symptoms or vice versa. RESULTS: Thirty-three percent of patients had an incidental hernia. No patient factors were associated with having an incidental hernia. Higher BMI and having a concurrent incidental hernia were associated with lower odds of surgical treatment under the injury claim. CONCLUSION: Abdominal symptoms after a work event might lead to a diagnosis of hernia, and there is a notable likelihood that the hernia is incidental and unrelated to work. New symptoms at or near the site of an abdominal hernia may or may not be from the hernia, and very often are more consistent with an abdominal muscle strain. The clinical or imaging finding of an abdominal wall defect or the presence of a hernia may be incidental, unrelated to the physical activity.

The association between gut microbiome affecting concomitant medication and the effectiveness of immunotherapy in patients with stage IV NSCLC.

Several observational studies suggested that gut microbiome-affecting-medication impairs the effectiveness of immunotherapy in patients with metastatic non-small-cell lung cancer (NSCLC). We postulated that if the effectiveness of immunotherapy is affected by drug-related changes of the microbiome, a stronger association between the use of co-medication and overall survival (OS) will be observed in patients treated with immunotherapy as compared to patients treated with chemotherapy. In a retrospective matched cohort study, immunotherapy patients were matched (1:1) to patients treated with chemotherapy in the pre immunotherapy era. The association between the use of antibiotics, opioids, proton pump inhibitors, metformin and other antidiabetics on OS was assessed with multivariable cox-regression analyses. Interaction tests were applied to investigate whether the association differs between patients treated with immuno- or chemotherapy. A total of 442 patients were studied. The use of antibiotics was associated with worse OS (adjusted Hazard Ratio (aHR) 1.39, p = 0.02) independent of the type of therapy (chemotherapy or immunotherapy). The use of opioids was also associated with worse OS (aHR 1.33, p = 0.01). The other drugs studied showed no association with OS. Interaction term testing showed no effect modification by immuno- or chemotherapy for the association of antibiotics and opioids with OS. The use of antibiotics and opioids is similarly associated with worse outcomes in both chemotherapy and immunotherapy treated NSCLC patients. This suggests that the association is likely to be a consequence of confounding rather than disturbing the composition of the microbiome.

A novel computational biostatistics approach implies impaired dephosphorylation of growth factor receptors as associated with severity of autism.

The prevalence of autism spectrum disorders (ASDs) has increased 20-fold over the past 50 years to >1% of US children. Although twin studies attest to a high degree of heritability, the genetic risk factors are still poorly understood. We analyzed data from two independent populations using u-statistics for genetically structured wide-locus data and added data from unrelated controls to explore epistasis. To account for systematic, but disease-unrelated differences in (non-randomized) genome-wide association studies (GWAS), a correlation between P-values and minor allele frequency with low granularity data and for conducting multiple tests in overlapping genetic regions, we present a novel study-specific criterion for 'genome-wide significance'. From recent results in a comorbid disease, childhood absence epilepsy, we had hypothesized that axonal guidance and calcium signaling are involved in autism as well. Enrichment of the results in both studies with related genes confirms this hypothesis. Additional ASD-specific variations identified in this study suggest protracted growth factor signaling as causing more severe forms of ASD. Another cluster of related genes suggests chloride and potassium ion channels as additional ASD-specific drug targets. The involvement of growth factors suggests the time of accelerated neuronal growth and pruning at 9-24 months of age as the period during which treatment with ion channel modulators would be most effective in preventing progression to more severe forms of autism. By extension, the same computational biostatistics approach could yield profound insights into the etiology of many common diseases from the genetic data collected over the last decade.

A prospective, randomized trial to assess the cost impact of pharmacist-initiated interventions.

BACKGROUND: Hospital pharmacists make many recommendations that improve patients' quality of care and/or reduce drug costs. While the impact of quality-of-care interventions is difficult to quantify, those limited to cost savings could be assessed in a prospective, randomized fashion. OBJECTIVE: To assess the impact of pharmacist-initiated interventions on cost savings. METHODS: Six pharmacists at a large university hospital recorded patient-specific recommendations for 30 days. All quality-of-care interventions were completed by the pharmacists, but those strictly aimed at reducing costs were stratified by drug class and randomized to an intervention or control group. Pharmacists contacted physicians with cost-saving recommendations in the intervention group, while control group patients were simply observed. MAIN OUTCOME MEASURE: Drug costs after randomization. RESULTS: Most (n=967 [79%]) of the 1226 interventions recorded were aimed at improving quality of care. The remaining 259 (21%) provided equivalent quality of care, but at less expense. These cost-saving interventions typically involved streamlining therapy to less expensive agents (39%), discontinuing an unnecessary medication (25%), or modifying the route of administration (24%). The group randomized to receive a pharmacist's intervention had drug costs that were 41% lower than those in the control group (mean, $73.75 vs $43.40; P<.001). Interventions involving anti-infective agents had the greatest cost savings (mean, $104.08 vs $58.45; P<.001). For our institution, this extrapolates to an annual savings of approximately $394,000 (95% confidence interval, $46,000-$742,000). As expected, these interventions had no impact on length of hospital stay, in-hospital mortality, 30-day readmissions, or the need to readminister the targeted medication or restart intravenous therapy. CONCLUSIONS: While interventions solely aimed at reducing costs represent a small portion of a pharmacist's activities, they can result in significant savings for an institution.

Enoxaparin-associated dermal necrosis: a consequence of cross-reactivity with heparin-mediated antibodies.

OBJECTIVE: To describe a patient with enoxaparin-induced dermal necrosis and to review previously reported cases of skin manifestations associated with low-molecular-weight heparins. CASE SUMMARY: A 43-year-old white woman with adult respiratory distress syndrome developed localized dermal necrosis and thrombocytopenia secondary to subcutaneous administration of unfractionated heparin. Upper extremity thrombi that had developed after administration of subcutaneous heparin at an outside hospital were treated with subcutaneous enoxaparin. Although platelet counts remained stable during enoxaparin therapy, dermal necrosis developed at the injection site. Parenteral anticoagulant therapy was discontinued and the necrotic lesions secondary to enoxaparin resolved with minimal local care. DISCUSSION: Numerous cases of dermal necrosis secondary to heparin administration have been reported while this reaction secondary to enoxaparin use has been reported only briefly. It has been postulated that dermal necrosis secondary to heparin is associated with heparin-induced thrombocytopenia and is a result of heparin-mediated thrombosis in the microvasculature. Antibodies to heparin have cross-reactivity with enoxaparin; therefore, dermal necrosis secondary to enoxaparin may occur by a similar mechanism. CONCLUSIONS: Although enoxaparin-associated dermal necrosis appears to be a rare occurrence, we advise against the use of enoxaparin or other low-molecular-weight heparins in patients with a previous history of heparin-associated thrombocytopenia or heparin-induced dermal necrosis.

[Studies on wound healing and secondary and tertiary wounds]. / Untersuchungen zur Wundheilung von Sekundär- und Tertiärwunden.

From animal experiments, the authors draw the following conclusions: 1. Compared with primary wounds, the tensile strength of secondary and tertiary wounds is significantly elevated. 2. Aside from a slight elevation on the third day, there is no difference of tensile strength between secondary and tertiary wounds. 3. Collagenous fibers are earlier formed in secondary and tertiary wounds because the initial phase of fibrillogenesis is shortened due to more developed granular tissue with increased vascularization as compared with primary wounds. Whether local factors influence the accelerated healing and the tensile strength of the wounds requires further investigation.