Impact on quality of life following inguinal hernia repair under local anaesthetic in a primary care setting.

PURPOSE: Inguinal hernia repair remains one of the most common elective general surgical procedures. Previous studies have suggested high rates of chronic pain afterwards. The aim of this study was to evaluate changes in quality of life after local anaesthetic (LA) inguinal hernia surgery performed in a primary care setting. METHODS: Quality of life (QoL) was measured in all patients both pre-operatively and at 6-months post-operatively using the European Hernia Society Scoring tool. Data was analysed by tertile grouping according to initial symptom score. RESULTS: 497 patients filled out pre-operative QoL forms between June 2020 and May 2022. Post-operative QoL scores were received from 179 patients (164 male (91.6%)). Median pre-operative score was 33 (IQR 20-48). Median post-operative score was 4 (IQR 1-11). Mean improvement in QoL score was 27.8. Nine patients had a worse score at 6-months compared to pre-op (5%). When the data was analysed by pre-op QoL group as expected the low symptom group (score 0-10) had minimal improvement in QoL (0.23) and 5 out of 13 patients (38%) had a worse score. The medium group (score 11-40) had a mean improvement in QoL of 17.25 with 3 out of 92 (3.2%) experiencing a worse score. The high symptom group (score 41-90) had a mean improvement in QoL of 45.4 with only 1 of 76 (1.3%) experiencing a worse score. CONCLUSIONS: LA Inguinal hernia repair improves QoL substantially 6-months after surgery. However, in those patients with low pre-operative scores (< 11) the gain is minimal and rates of chronic symptoms following surgery are very high. We recommend avoiding surgery in this group and instead adopting a surveillance approach.

Vitiligo prevalence and quality of life among adults in Europe, Japan and the USA.

BACKGROUND: Vitiligo, an autoimmune disorder characterised by skin depigmentation, is associated with reduced quality of life (QoL). Vitiligo may be under-reported, in part because of misconceptions that it is a cosmetic disease. OBJECTIVES: This survey sought to characterise vitiligo prevalence and explore the relationship between sociodemographic and clinical characteristics with QoL in a population-based, multinational study. METHODS: Participants aged ≥18 years were recruited via an online panel in Europe, Japan and the USA to answer questions regarding skin disorders they may have experienced. Those reporting vitiligo (diagnosed or undiagnosed) or vitiligo signs (experiencing loss of skin colour but unaware of vitiligo and not diagnosed) were included in the analyses of vitiligo prevalence. Participants who self-reported physician-diagnosed vitiligo were given a broader survey to characterise disease progression, management and QoL (as measured with the Vitiligo-specific QoL [VitiQoL] instrument). RESULTS: The total estimated vitiligo prevalence among 35 694 survey participants (Europe, n = 18 785; USA, n = 8517; Japan, n = 8392) was 1.3% (diagnosed, 0.6%; undiagnosed, 0.4%; vitiligo signs, 0.3%). Among 219 patients formally diagnosed with vitiligo (Europe, n = 150; USA, n = 48; Japan, n = 21), total VitiQoL scores were associated with age (P = 0.00017), disease extent (P < 0.0001), disease progression (P < 0.0001), disease management (P < 0.0001) and time since diagnosis (P = 0.0015). Behaviour scores varied based on skin phototype (P = 0.024) and ethnicity (P = 0.048). Higher total VitiQoL scores were reported in patients with head lesions (P = 0.027) and those with head and hand and/or wrist lesions (P = 0.018). Substantial high concern (rated 8-10 on an 11-point Likert scale) for lesions was found across all body areas and varied with geographical region. CONCLUSIONS: The vitiligo prevalence rate may be higher than previously reported, with a substantial proportion attributed to people who have not received a formal diagnosis. Among formally diagnosed patients with vitiligo, QoL was most severely impacted by more progressive and higher extent of disease.

Optimizing Small, Low-Risk, Unruptured Intracranial Aneurysm Treatment Using Game Theory.

The incidental diagnosis of unruptured intracranial aneurysms has been increasing in the past several decades. A significant proportion represent small, low-risk, unruptured intracranial aneurysms for which there is equipoise on whether to offer treatment or conservative management. Given this uncertainty, patients may not always be comfortable with their physicians' recommendations. Herein, we use game theory to study the interactions between physicians and patients to determine how conflict and cooperation affect the management of small, low-risk, unruptured intracranial aneurysms. We constructed a game theory model of the interaction between physicians and patients with respect to decision-making for a small, low-risk, unruptured intracranial aneurysm in an asymptomatic patient when there is perceived equipoise between whether to treat or manage conservatively. Assuming that both the physician and patient are rational and eliciting individual patient preferences is not practical, the physician should play the game based on an ex ante probability of meeting a patient with a certain type of preference. This recommendation means that the expectations of the physician regarding the patient's preferences should guide the decision to offer treatment or conservative management as a first option for a small, asymptomatic, low-risk, unruptured intracranial aneurysm for which there is clinical equipoise.

Rescan Time Delays in Ischemic Stroke Imaging: A Retrospective Observation and Analysis of Causes and Clinical Impact.

BACKGROUND AND PURPOSE: Delays to reperfusion negatively impact outcomes of patients with ischemic stroke, yet current guidelines recommend selective sequential imaging for thrombectomy candidates. We aimed to quantify and analyze time delays associated with rescanning in sequential acute stroke imaging. MATERIALS AND METHODS: This was a retrospective cohort study of consecutive patients with acute ischemic stroke who underwent imaging for treatment decision-making from January 1, 2017, to June 30, 2020. Rescan time delay was defined as ≥10-minute difference between initial NCCT and CTA ± CTP. Mean rescan time delays in comprehensive and primary stroke centers were compared. Bivariate and multivariable regression analyses assessed clinical and imaging factors associated with rescanning time delays and early outcomes. RESULTS: A total of 588 patients with acute ischemic were included in statistical analyses. Rescanning occurred in 27.9% (164/588 patients), with a mean time delay of 53.7 (SD, 43.4) minutes. For patients presenting at primary compared with comprehensive stroke centers, rescan time delays were more common (59.6% versus 11.8%, P < .001), with longer delays (65.4 [SD, 45.4] minutes versus 23.6 [SD, 14.0] minutes, P < .001). Independent predictors of rescan time delays included primary stroke center presentation, intravenous thrombolysis administration, black race, admission NIHSS ≥10, baseline independent ambulation, and onset-to-comprehensive stroke center arrival in ≥6 hours. Protocols for early simultaneous comprehensive CT (NCCT + CTA + CTP) were associated with lower odds of time delays (OR = 0.34; 95% CI, 0.21-0.55). Rescanning was associated with lower odds of home discharge (OR = 0.53; 95% CI, 0.30-0.95). CONCLUSIONS: A sequential approach to CT-based imaging may be significantly associated with prolonged acute stroke evaluations. Adoption of early simultaneous comprehensive CT could minimize treatment delays and improve outcomes.

Epidemiological, clinical and biomarker profile of pediatric patients infected with COVID-19.

BACKGROUND: Given the limited and diverse nature of published literature related to COVID-19 in pediatrics, it is imperative to provide evidence-based summary of disease characteristics for guiding policy decisions. We aim to provide comprehensive overview of epidemiological, clinical and biomarker profile of COVID-19 infection in pediatric population. METHODS: For this umbrella review, published systematic reviews from PubMed and pre-print databases were screened. Literature search was conducted from December 2019 to April 2021. Details of clinical, radiological and laboratory features were collected from each review. Qualitative observations were synthesized and pooled prevalence of mortality and asymptomatic cases were assessed using meta-analysis. RESULTS: Evidence synthesis of 38 systematic reviews included total 1145 studies and 334 398 children and adolescents. Review revealed that COVID-19 is relatively milder with better prognosis in pediatrics. However, patients with comorbidity are at higher risk. Meta-analysis of reviews showed that 21.17% (95% CI: 17.818-24.729) of the patients were asymptomatic and mortality rate was 0.12% (95% CI: 0.0356-0.246). Though there was no publication bias, significant heterogeneity was observed. Fever (48-64%) and cough (35-55.9%) were common symptoms, affecting almost every alternate patient. Ground-glass opacities (prevalence range: 27.4-61.5%) was most frequent radiographic observation. Rise in C-reactive protein, lactate dehydrogenase and D-dimer ranged from 14% to 54%, 12.2-50% and 0.3-67%, respectively. Some of the included reviews (44.7%-AMSTAR; 13.2%-GRADE) were of lower quality. CONCLUSION: Current umbrella review provides most updated information regarding characteristics of COVID-19 infection in pediatrics and can be used to guide policy decision regarding vaccination prioritization, early screening and identification of at-risk population.

Low vitamin D levels and prognosis in a COVID-19 pediatric population: a systematic review.

We aim to study the relationship between vitamin D level, risk and severity of Coronavirus disease of 2019 (COVID-19) infection in pediatric population through systematic review. We searched PubMed, CINAHL, EMBASE, Cochrane Library and Google Scholar from December 2019 to June 2021 for retrieving articles studying association between vitamin D deficiencies with COVID-19. Qualitative details were synthesized in evidence table and quantitative data was used for deriving pooled estimate through meta-analysis. After initial search of 2261 articles, eight eligible studies (two reviews) were included in the systematic review. Meta-analysis of the quantitative data (six studies) showed pooled prevalence of vitamin D deficiency as 45.91% (95% CI: 25.148-67.450). In infected pediatric patients, low levels of vitamin D increased the risk of severe disease (odds ratio-5.5; 95% CI: 1.560-19.515; P = 0.008). It was also found that children and adolescents having vitamin D deficiency had greater risk of COVID infection as compared to patients with normal vitamin D levels. Improvement in disease severity with vitamin D supplementation was also noted. The systematic review showed that almost half of the pediatric COVID patients suffer from vitamin D deficiency. It is also clear that the low level of vitamin D is associated with greater risk of infection and poorer outcome in pediatrics.

International Initiative for Outcomes (INFO) for vitiligo: workshops with patients with vitiligo on repigmentation.

BACKGROUND: There is no cure or firm clinical recommendations for the treatment of vitiligo. One of the main issues is the heterogeneity of outcome measures used in randomized controlled trials for vitiligo. OBJECTIVES: To define successful repigmentation from the patients' point of view and to propose how and when repigmentation should be evaluated in clinical trials in vitiligo. METHODS: We conducted three workshops with patients with vitiligo and their parents or caregivers. Workshop 1 was held at World Vitiligo Day (Detroit, MI), workshop 2 at the University of Texas Southwestern Medical Center and workshop 3 at the Vitiligo and Pigmentation Institute of Southern California, University of California. RESULTS: Seventy-three participants were recruited. Consensus on the following questions was achieved unanimously: (i) the definition of 'successful repigmentation' was 80-100% of repigmentation of a target lesion and (ii) both an objective and a subjective scale to measure repigmentation should be used. CONCLUSIONS: This was the largest patients' outcomes workshop. We followed the guidance from the CSG-COUSIN and the Vitiligo Global Issues Consensus Group. Our recommendations to use percentage of repigmentation quartiles (0-25%, 26-50%, 51-79%, 80-100%) and the Vitiligo Noticeability Scale are based on the best available current evidence. A limitation of the research is that the workshops were conducted only in the U.S.A., due to pre-existing organisational support and the availability of funding.

The effect of melasma on self-esteem: A pilot study.

Melasma is a common disorder of hyperpigmentation characterized by tan or brown macules and patches affecting sun-exposed areas, particularly the face. Melasma has been shown to have a significant impact on the quality of life and self-esteem of those affected. We interviewed six patients who were diagnosed with moderate-to-severe melasma with regard to the effect of their disorder on their self-esteem. All patients reported a significant negative effect on their quality of life and self-esteem. With successful therapy using a triple combination of cream and oral tranexamic acid to treat their melasma, all reported a marked improvement in self-esteem. Physicians who treat patients with melasma should be aware of its profound psychosocial effects and the improvement that successful melasma treatment can have on self-esteem.

Effects of Radiation Exposure on the Cost-Effectiveness of CT Angiography and Perfusion Imaging in Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND AND PURPOSE: CT angiography and perfusion imaging is an important prognostic tool in the management of patients with aneurysmal subarachnoid hemorrhage. The purpose of this study was to perform a cost-effectiveness analysis of advanced imaging in patients with SAH, incorporating the risks of radiation exposure from CT angiography and CT perfusion imaging. MATERIALS AND METHODS: The risks of radiation-induced brain cancer and cataracts were incorporated into our established decision model comparing the cost-effectiveness of CT angiography and CT perfusion imaging and transcranial Doppler sonography in SAH. Cancer risk was calculated by using National Cancer Institute methodology. The remaining input probabilities were based on literature data and a cohort at our institution. Outcomes were expected quality-adjusted life years gained, costs, and incremental cost-effectiveness ratios. One-way, 2-way, and probabilistic sensitivity analyses were performed. RESULTS: CT angiography and CT perfusion imaging were the dominant strategies, resulting in both better health outcomes and lower costs, even when incorporating brain cancer and cataract risks. Our results remained robust in 2-way sensitivity analyses varying the prolonged latency period up to 30 years, with either brain cancer risk up to 50 times higher than the upper 95% CI limit or the probability of cataracts from 0 to 1. Results were consistent for scenarios that considered either symptomatic or asymptomatic patients with SAH. Probabilistic sensitivity analysis confirmed our findings over a broad range of selected input parameters. CONCLUSIONS: While risks of radiation exposure represent an important consideration, CT angiography and CT perfusion imaging remained the preferred imaging compared with transcranial Doppler sonography in both asymptomatic and symptomatic patients with SAH, with improved health outcomes and lower health care costs, even when modeling a significantly higher risk and shorter latency period for both cataract and brain cancer than that currently known.

Surgical resection of a rare cutaneous manifestation of Scedosporium apiospermum in a patient who underwent renal transplant.

A man aged 47 years who was immunosuppressed following renal transplantation for focal segmental glomerulosclerosis was referred to the Plastic Surgery team for management of a painful, chronic, granulomatous lesion of the right forearm. Serial ultrasound scans and MRI scans were not diagnostic, but microbiological specimens tested positive for the fungus Scedosporium apiospermum The renal transplant graft-which was failing-was removed, allowing him to cease immunosuppression. He then underwent a resection of the lesion and reconstruction with a split thickness skin graft. Analysis of the specimen revealed fibrosis, granulomatosis and a collection of S. apiospermum He was started on voriconazole which, in conjunction with his surgical resection, appears to have kept the disease at bay. With increasing numbers of solid organ transplants and improved survival, this case highlights the growing burden of rare, opportunistic infections, the difficulty in diagnosis and the need for specialist intervention.

Nanodelivery of Parthenolide Using Functionalized Nanographene Enhances its Anticancer Activity.

Advances in anticancer chemotherapy have been hindered by the lack of biocompatibility of new prospective drugs. One significant challenge concerns water insolubility, which compromises the bioavailability of the drugs leading to increased dosage and higher systemic toxicity. To overcome these problems, nanodelivery has been established as a promising approach for increasing the efficacy and lowering the required dosage of chemotherapeutics. The naturally derived compound, parthenolide (PTL), is known for its anti-inflammatory and anticancer activity, but its poor water solubility limits its clinical value. In the present study, we have used carboxyl-functionalized nanographene (fGn) delivery to overcome the extreme hydrophobicity of this drug. A water-soluble PTL analog, dimethylamino parthenolide (DMAPT), was also examined for comparison with the anticancer efficacy of our PTL-fGn complex. Delivery by fGn was found to increase the anticancer/apoptotic effects of PTL (but not DMAPT) when delivered to the human pancreatic cancer cell line, Panc-1. The IC50 value for PTL decreased from 39 µM to 9.5 µM when delivered as a mixture with fGn. The IC50 of DMAPT did not decrease when delivered as DMAPT-fGn and was significantly higher than that for PTL-fGn. There were significant increases in ROS formation and in mitochondrial membrane disruption in Panc-1 cells after PTL-fGn treatment as compared to PTL treatment, alone. Increases in toxicity were also seen with apoptosis detection assays using flow cytometry, ethidium bromide/acridine orange/DAPI staining, and TUNEL. Thus, fGn delivery was successfully used to overcome the poor water solubility of PTL, providing a strategy for improving the effectiveness of this anticancer agent.

CT angiographic features of symptom-producing plaque in moderate-grade carotid artery stenosis.

BACKGROUND AND PURPOSE: Emerging evidence indicates that plaque imaging can improve stroke risk stratification in patients with carotid artery atherosclerosis. We studied the association between soft and hard (calcified) plaque thickness measurements on CTA and symptomatic disease status (ipsilateral stroke or TIA) in patients with moderate-grade carotid artery stenosis. MATERIALS AND METHODS: We measured soft-plaque and hard-plaque thickness on CTA axial source images in each carotid artery plaque in subjects with NASCET 50%-69% ICA stenosis. We used logistic regression and receiver operating characteristic analyses to assess the strength of the association between thickness measurements and prior stroke or TIA. RESULTS: Twenty of 72 vessels studied (27.7%) had ischemic symptoms ipsilateral to the side of moderate-grade carotid stenosis. Each 1-mm increase in soft plaque resulted in a 3.7 times greater odds of a prior ipsilateral ischemic event (95% CI, 1.9-7.2). Conversely, for each 1-mm increase in hard plaque, the odds of being symptomatic decreased by approximately 80% (OR, 0.22; 95% CI, 0.10%-0.48%). Receiver operating characteristic analysis showed an area under the curve of 0.88 by using soft-plaque thickness measurements to discriminate between asymptomatic and symptomatic plaques. Sensitivity and specificity were optimized by using a maximum soft-plaque thickness of 2.2 mm, which provided a sensitivity of 85% and a specificity of 83%. CONCLUSIONS: Simple CTA plaque-thickness measurements might differentiate symptomatic and asymptomatic moderate-grade carotid artery plaque. With further prospective validation, CTA plaque measures could function as an easily implementable tool for risk stratification in carotid artery disease.