Incidence of incisional hernias following single-incision versus traditional laparoscopic surgery: a meta-analysis.

PURPOSE: To compare, using a meta-analysis of randomized controlled trials, the risk of incisional hernia in patients undergoing single-incision laparoscopic surgery to those undergoing traditional laparoscopic surgery. METHODS: MEDLINE and EMBASE databases were searched. Randomized controlled trials comparing single-incision laparoscopic surgery to traditional laparoscopic surgery and which reported incisional hernias over a minimum 6-month follow-up period were eligible. Risk of bias was assessed as outlined in the Cochrane Handbook. Pooled odds ratios were calculated using RevMan. RESULTS: Of 309 identified studies, 22 were included in this meta-analysis. Pooled results showed higher odds of incisional hernia following single-incision laparoscopic surgery relative to traditional laparoscopic surgery (odds ratio 2.83, 95% CI 1.34-5.98, p = 0.006, I2 = 0%). There was no difference in the odds of incisional hernias requiring surgical repair (p = 0.10). Subgroup analysis found no difference in the odds of incisional hernias based on procedure type (p = 0.69) or method of follow-up (p = 0.85). The quality of evidence was determined to be moderate. CONCLUSION: Single-incision laparoscopic surgery is associated with a threefold increase in the odds of incisional hernia compared with traditional laparoscopic surgery.

Prevention of venous thromboembolic disease following primary total knee arthroplasty. A randomized, multicenter, open-label, parallel-group comparison of enoxaparin and warfarin.

BACKGROUND: Patients treated with total knee arthroplasty are at high risk for the development of venous thromboembolism postoperatively. This study compared the efficacy and safety of two common thromboprophylactic agents, enoxaparin (a low-molecular-weight heparin) and warfarin. METHODS: Three hundred and forty-nine patients were included in a prospective, randomized, multicenter, open-label, parallel-group clinical trial. Treatment with enoxaparin (30 mg, administered subcutaneously twice daily) or warfarin (adjusted to an international normalized ratio of 2 to 3) was initiated during the immediate postoperative period, within eight hours after the surgery, and was continued for four to fourteen days. Venous thromboembolism was defined as deep-vein thrombosis documented by contrast venography, symptomatic deep-vein thrombosis documented by lower-extremity ultrasonography, or symptomatic pulmonary embolism confirmed by a positive lung scan or pulmonary angiography. RESULTS: In the all-treated-patients group, eighty (45%) of the 176 warfarin-treated patients had venous thromboembolism: fifty-nine (34%) had distal deep-vein thrombosis; twenty (11%), proximal deep-vein thrombosis; and one (0.6%), pulmonary embolism. Venous thromboembolism developed in significantly fewer (p = 0.0001) enoxaparin-treated patients (forty-four of 173; 25%): forty-one (24%) had distal deep-vein thrombosis, three (2%) had proximal deep-vein thrombosis, and none had pulmonary embolism. The enoxaparin-treated patients also had a significantly lower prevalence of proximal deep-vein thrombosis (p = 0.002). The estimated odds for the development of venous thromboembolism were 2.52 times greater (95% confidence interval, 2.00 to 3.19) with warfarin than they were with enoxaparin. Major hemorrhage occurred in four warfarin-treated patients and nine enoxaparin-treated patients; with the numbers available, this difference was not significant (p = 0.17). Clinically important operative-site hemorrhage occurred in six (3%) of the warfarin-treated patients and twelve (7%) of the enoxaparin-treated patients (p = 0.15). CONCLUSIONS: A fixed 30-mg subcutaneous dose of enoxaparin, administered twice daily, with the first dose administered within eight hours after the completion of surgery, was significantly more effective than adjusted-dose warfarin in reducing the occurrence of asymptomatic venous thromboembolism, including proximal deep-vein thrombosis, in patients undergoing total knee arthroplasty. With the numbers available, there was no significant difference between groups with regard to the occurrence of major hemorrhagic complications; however, the rate of overall hemorrhagic complications was higher in the enoxaparin group.

Urogenital atrophy: prevention and treatment.

Fifteen percent of premenopausal women, 10-40% of postmenopausal women, and 10-25% of women receiving systemic hormone therapy experience urogenital atrophy. The most common symptoms are dryness, burning, pruritus, irritation, and dyspareunia. Estrogen loss, drugs, and chemical sensitivities are causes. Estrogen or hormone replacement therapy (ERT-HRT) is the treatment of choice in postmenopausal women. Dosages prescribed for menopause symptoms or to prevent osteoporosis (and, potentially, other conditions) can restore the vagina to premenopausal physiology and relieve symptoms. Concomitant progestins are necessary for women with an intact uterus to minimize or eliminate estrogen-induced endometrial cancer. Low-dosage oral and vaginal ERT can relieve urogenital atrophy but might not produce systemic effects. Progestins are not necessary with vaginal rings and vaginal tablets. If ERT is given only to treat urogenital atrophy, estrogen creams 1 or 2 times/week may prevent recurrence after symptoms are resolved. Progestins are not required for occasional estrogen cream use. Vaginal moisturizers provide longer relief by changing the fluid content of endothelium and lowering vaginal pH. Vaginal lubricants provide short-term relief. Women with contraindications to ERT-HRT could use lubricants for intercourse-related dryness or moisturizers for more continuous relief. The lay press promotes agrimony, black cohosh, chaste tree, dong quai, witch hazel, and phytoestrogens for vaginal dryness and dyspareunia; however, no evidence exists to support these specific claims. Pharmacists should be actively involved in identifying, preventing, and treating urogenital atrophy.

Evaluation of warfarin initiation regimens in elderly inpatients.

STUDY OBJECTIVE: To compare initial warfarin doses of 5 mg or below and doses above 5 mg in hospitalized elderly. DESIGN: Retrospective review of charts identified from computerized pharmacy records. SETTING: County teaching hospital. PATIENTS: Inpatients aged 65 years or older receiving at least three warfarin doses. INTERVENTION: We measured the time to first international normalized ratio (INR) of 2.0 or greater, bleeding complications, number of warfarin doses held, and vitamin K use. MEASUREMENTS AND MAIN RESULTS: The average initial low dose (33 patients) was 4.8 +/- 0.8 mg and the average initial high dose (40 patients) was 9.0 +/-1.2 mg. The mean time to first INR of 2.0 or greater was similar, 3.4 and 3.0 days, respectively (p=0.38). The low-dose group had fewer bleeds (7 vs 13, p=0.28) and doses held (11 vs 18 patients, p=0.27, 30 vs 50 doses). Four patients in each group received vitamin K (p=0.8). Forty-four percent of patients with an INR of 4 or above and 48% of patients who had a dose held were on a long-term drug or had a new drug added that could cause a major drug interaction with warfarin. CONCLUSION: In this pilot study, hospitalized elderly who received a low versus high initial dose of warfarin achieved therapeutic INRs in a similar time and had lower but not significantly different safety outcomes.

Prevention of venous thromboembolism: adherence to the 1995 American College of Chest Physicians consensus guidelines for surgical patients.

BACKGROUND: The American College of Chest Physicians addressed the dilemma of identifying optimal therapy for venous thromboembolism (VTE) prophylaxis and published their Fourth Consensus Conference on Antithrombotic Therapy in 1995, with recommendations for prophylactic therapy. Despite these recommendations, appropriate VTE prophylactic therapy is underused. OBJECTIVES: To examine routine practices in the prevention of VTE in high-risk surgical patients and to determine the extent of adoption of grade A prophylactic therapies as recommended by the American College of Chest Physicians. METHODS: Retrospective medical record review in 10 teaching or community-based hospitals located in the United States. Medical charts of 1907 patients were randomly selected for review from the population of patients who underwent high-risk major abdominal surgery, total hip replacement, hip fracture repair, or total knee replacement between January 1, 1996, and February 28, 1997. RESULTS: Of 1907 patients, VTE prophylaxis was used in 89.3%; use was 93.7% in each of the 3 orthopedic surgery groups and 75.2% in the high-risk major abdominal surgery group. The percentage of patients receiving grade A therapy was highest in the hip replacement group (84.3%) vs. the other groups (knee replacement, 75.9%; hip fracture repair, 45.2%; abdominal surgery, 50.3%). CONCLUSIONS: The use of grade A prophylaxis was related to the type of surgery, with the highest use seen in total hip replacement and the lowest in hip fracture repair. One in 4 patients who underwent high-risk major abdominal surgeries failed to receive any form of VTE prophylaxis. Publication of consensus statements alone may be insufficient to ensure the incorporation of important new clinical information into routine practice.

Prevention and treatment of osteoporosis in the elderly.

Due to age-associated bone losses, all elderly are prone to osteoporosis, which often leads to fractures. Fractures frequently result in dependency and institutionalization, as well as physical deformities that may lead to respiratory and cardiovascular problems. Currently, no drugs exist to promote new bone formation. Thus care of the elderly focuses primarily on lifestyle modification and increased dietary intake of calcium and vitamin D; decreased intake of caffeine, phosphates, and alcohol; smoking cessation; increased exercise; and drugs. Drugs for preventing osteoporosis include supplemental calcium and vitamin D, hormone replacement therapy, and alendronate. Drugs that enhance bone loss or increase the likelihood of falls should be eliminated, if possible, or the dosages adjusted. Making residences safer will also help to minimize the potential for falls. Drugs for treating osteoporosis include hormone replacement therapy, alendronate, and nasal calcitonin. The prevention and treatment plan is individualized for each patient, taking into account personal preferences, risk factors for osteoporosis and fracture, concomitant diseases and drug therapies, efficacy and tolerance of osteoporosis therapy, quality of life, life expectancy, finances, and health insurance coverage.

A modified agar medium for the screening of proteolytic activity of starter cultures for meat fermentation purposes.

An agar medium, used in the screening of proteolytic activity of dairy-related bacteria, was adapted for assessing the proteolytic capacity of bacteria which were of possible use in meat fermentations. Freeze dried myofibrils, extracted from pork muscle, were incorporated in the medium. The agar plates were inoculated with 20 microl of overnight cultures of different starter strains, and incubated at 30 degrees C for 48 h. After incubation, proteolytic bacteria produced clear zones. Coomassie brilliant blue stain was employed to facilitate the detection of these zones. Proteolytic activity was confirmed in an enzymatic test.

Pharmacokinetic and pharmacologic variation between different estrogen products.

Due to the complex nature of endogenous and exogenous hormone concentration, formation, and metabolism and assay complexity, the pharmacokinetics of estrogen are difficult to study. Oral estrogens have minimal systemic bioavailability (2% to 10%) due to gut and liver (first-pass) metabolism. High concentrations of estrone are achieved with oral administration, whereas higher concentrations of estradiol are generally achieved after percutaneous absorption. Although vaginal products (such as gel, rings, etc.) are administered locally, they achieve high serum concentrations. Estradiol and estrone concentrations and estradiol-to-estrone ratios vary with different estrogen therapies. Approximately 95% to 98% of estradiol is bound loosely to albumin or tightly to sex hormone binding globulin, the major binding protein. The terminal half lives for the different estrogen compounds (after oral or intravenous administration) vary from 1-12 hours. Some conversion rates have been calculated between estrogen and its metabolites. Smoking decreases achievable estrogen concentrations, and has a greater effect on oral products. Oral contraceptives have been found to decrease antipyrine clearance. In the one study evaluating conjugated estrogens, antipyrine clearance was not altered. Oral contraceptives have a variable effect on the elimination of medications. Acetaminophen clearance is increased, whereas clearance of some benzodiazepines, caffeine,and prednisolone is decreased. Phenytoin increases the metabolism of conjugated estrogens. The various estrogen products may produce different clinical effects based on composition. The metabolites (minor components) of conjugated estrogens have been found to have significant effects on lipid concentrations, uterine weight, liver generated compounds, and bone resorption. Because transdermal products bypass the first-pass effect, delayed or decreased effects on lipid profiles and liver generated compounds have been observed.

Accuracy of 2- and 8-hour urine collections for measuring creatinine clearance in the hospitalized elderly.

The accuracy of 2- and 8- hour urine collections for estimating creatinine clearance was compared with that of the standard 24-hour procedure in 45 hospitalized elderly patients (age > or = 65 yrs) with indwelling urethral catheters. Urine was collected at blocked intervals from 0-2, 2-8, and 8-24 hours and then added together to determine the 8- and 24-hour clearances. The mean 8-hour creatinine clearance was not significantly different from the 24-hour value, whereas the mean 2-hour creatinine clearance was significantly different. The 8-hour value was less biased (2.2 and 10.7 ml/min, respectively) and more precise (11.7 and 25.3 ml/min, respectively) than the 2-hour value. Regardless of age, renal function, serum creatinine level, or diuretic use, the 8-hour value was less biased, usually more precise, and clinically more accurate. Thus it can be used in stable, hospitalized, elderly patients with indwelling catheters to determine degrees of renal impairment and provide optimum drug dosing.

Evaluation of medication knowledge in elderly patients.

OBJECTIVE: To identify problems with medication knowledge, self-estimated compliance, and recall of medication education in a group of elderly patients. DESIGN: Survey. SETTING: Medicine and geriatric clinics at a county hospital. PATIENTS: Patients greater than or equal to 60 years old and taking at least one prescription medication. MAIN OUTCOME MEASUREMENTS: Medication knowledge, self-estimated compliance, and recall of medication education. RESULTS: The percent of geriatric patients correctly stating 76-100 percent of their medication doses, uses, and frequencies was 30, 64, and 66 percent, respectively. Fifteen patients (34 percent) stated they never missed a medication dose and 27 (61 percent) remembered to take their medications by memory alone. Sixteen and 86 percent, respectively, of the patients from the medicine and geriatric clinics could not recall receiving verbal or written educational material. Only 27 percent of patients recalled having been told about possible adverse reactions. The most frequently cited providers of medication information were physicians. CONCLUSIONS: Specially designed multidisciplinary medication education programs with repeated written and verbal reinforcement for elderly patients may improve patients' knowledge about their medications, recognition and management of adverse reactions, and compliance.

Short- and long-term retention of a nursing home education program on metered-dose inhaler technique.

OBJECTIVE: To evaluate an education program on metered-dose inhaler (MDI) technique designed for nurses and trained medication aides (TMAs). DESIGN: The education program included a handout, a lecture incorporating a videotape on correct inhaler and device technique, and hands-on experience with placebo inhalers. The participants' ability to verbalize and demonstrate correct MDI technique was assessed by the same two-person teams before, immediately after, and two months after the program. SETTING: Five nursing homes. PARTICIPANTS: Fifty-six nurses and TMAs practicing in nursing homes. MAIN OUTCOME MEASURES: Learning and retention. RESULTS: The participants' mean (+/- SD) verbal and demonstration scores increased immediately after the program by 68 +/- 18 points for verbalization and 47 +/- 16 points for demonstration. The participants were always better at demonstrating than verbalizing MDI technique. The participants' baseline verbal and demonstration scores correlated with the amount learned. Learning was influenced by the individual nursing home (verbal and demonstration) and personal use (demonstration only), but not by academic degree, previous training, past instruction of a patient, or current care of a patient who was receiving inhaler therapy. After two months, the scores were lower than immediately after the program test by 0-92 points for verbalization and 10-80 points for demonstration; however, the mean scores were still significantly greater (p less than 0.05) than the baseline scores. Retention of knowledge on the correct technique was greater for the demonstration component. Retention was influenced only by the nursing home in which the participant worked, and not any of the other variables. CONCLUSIONS: Our structured education program significantly improved inhaler technique; however, to maintain retention of the material, the program should be frequently repeated.

Predictive performance of equations to estimate creatinine clearance in hospitalized elderly patients.

OBJECTIVE: To ascertain the clinical accuracy of equations that estimate creatinine clearance to predict the correct drug doses in hospitalized elderly patients DESIGN: Single 24-hour creatinine clearance measurement compared with estimated creatinine clearances derived from eight equations using total and modified ideal body weight SETTING: Nonintensive care medical and surgical units at a county hospital PATIENTS: 15 patients with urethral catheters were enrolled in each of three age groups: 65-75, 76-85, and greater than or equal to 86 years MAIN OUTCOME MEASUREMENTS: Drug-dose predictions, bias, precision, and absolute errors RESULTS: The bias for all equations was -4.0-42.0 mL/min (-0.07-0.70 mL/s) and the precision was 10.8-47.4 mL/min (0.18-0.88 mL/s). The Jelliffe 1973, Hull et al., and Mawer et al. equations were the least biased and the Jelliffe 1973 was the most precise, followed by the Mawer et al., Hull et al., and Cockcroft-Gault equations. The percent of patients with absolute percent errors greater than 20 percent were 38 percent for Jelliffe 1973, 36 percent for Mawer et al., 40 percent for Hull et al., and greater than 50 percent for the other equations. The percent of patients receiving correct drug doses was 67 percent for Jelliffe 1973, 58 percent for Gates, 51 percent for Mawer et al. and Hull et al., and less than 50 percent for the other equations. Within various age, renal function, serum creatinine, and albumin subgroups, the Jelliffe 1973 estimates were least biased and most precise, followed by the Cockcroft-Gault estimates. Generally, estimates using modified lean body weight performed better than did those using total body weight. CONCLUSIONS: The Jelliffe 1973 equation with modified lean body weight was the best equation, followed by the Cockcroft-Gault equation. Even with the best equation, 33 percent of the patients would have received an incorrect drug dose. Therefore, some elderly patients may still require a measured creatinine clearance.

Consistency of evaluators assessing inhaler technique.

Since correct inhaler technique is vital for maximum efficacy, the evaluation of technique in patients or health care professionals involved in education programs or research projects is essential. Inconsistency could lead to confused patients and inaccurate research findings. This study is the first to determine interrater consistency with assessing recitation and demonstration of inhaler technique and, if needed, was designed to improve consistency until 95% agreement was achieved. A checklist for correct inhaler technique was constructed by consolidating information from the literature and package inserts. Initially three evaluators were used, however, a fourth evaluator was added for the last two trials to create teams to improve consistency. Percent agreement, probability and kappa scores were calculated. Six trials evaluating inhaler technique of 56 health care professionals at five different sites, revisions of the checklist, and evaluator teams were required to increase overall percent agreement from 81% to 98%. Agreement increased substantially on the verbal component because of specific changes made in the checklist and the objective nature. Demonstration steps consistently had lower agreement than verbal steps. Agreement on the demonstration component was more difficult because of subjectivity involved in observing a subject actuate the inhaler at the correct time, inhale or exhale slowly, and hold one's breath. The relative rankings of percent agreement and kappa scores were the same, however, kappa scores allowed differentiation of agreement due to chance and ability. To achieve interrater consistency, training and practice are required. Interrater consistency should be achieved to ensure accurate reporting of research results on inhaler technique and education of patients.

The effect of multiple doses of phenylpropanolamine on the blood pressure of patients whose hypertension was controlled with beta blockers.

Single-dose phenylpropanolamine (PPA) can cause blood pressure elevation in healthy volunteers and in patients whose hypertension is controlled with beta blockers. Few data exist on the effect of long-term PPA dosing on blood pressure in normotensive or hypertensive patients. Therefore, we studied the effect of multiple PPA doses in seven hypertensive men whose blood pressure was controlled with beta blockers. These patients had previously demonstrated a mean increase in blood pressure after 25 mg PPA compared to placebo. Each patient received 25 mg PPA 3 times a day for 6.3 days. Five patients completed the study. After drug therapy on days 1 and 7, statistically significant increases in the peak measured systolic and diastolic blood pressures from baseline were found, with ranges of maximum increase 3-22 mm Hg and 0-16 mm Hg, respectively. The peak measured blood pressures on days 1 and 7 were significantly different from placebo values for both systolic and diastolic pressures. The area under the blood pressure-time curve and the change between baseline and peak for systolic and diastolic blood pressures on days 1 and 7 were not significantly different. Tolerance and hypersensitivity were not detected. Several doses of PPA did not alter the blood pressure effect from the first-dose response, however, caution and close monitoring are still necessary for these patients.

Continuous intravenous terbutaline infusions for adult patients with status asthmaticus.

Since absorption of nebulized and subcutaneous terbutaline may be delayed or decreased during episodes of severe asthma, a preliminary trial of intravenous terbutaline was instituted in five adult patients with status asthmaticus. The terbutaline was administered as a bolus followed by a continuous infusion of 0.1-0.4 micrograms/kg/min. Although three patients may have received some improvement, the impact of intravenous terbutaline could not be distinguished from other concomitant therapy. All patients experienced tolerable adverse reactions. Further research to evaluate higher doses administered early in the hospital course and to determine receptor sensitivity needs to be conducted.

Management of chemotherapy-induced nausea and vomiting.

Cancer chemotherapy is associated with numerous toxicities such as nausea and vomiting (emesis). The frequency, onset, and duration of emesis depend largely on the emetogenic potential of specific agents. An exact mechanism for chemotherapy-induced emesis (CIE) is not known but is thought to occur through several noxious actions and numerous neuronal pathways. The three types of CIE are acute, delayed, and anticipatory. Nonchemotherapy causes of emesis should be considered before diagnosing CIE. Once the diagnosis is established, antiemetic regimens should be recommended based on characteristics of the patients and the agents. Phenothiazines, butyrophenones, cannabinoids, metoclopramide, corticosteroids, and benzodiazepines have been successful in preventing and treating CIE. Combinations of these drugs have also been successful and are still being investigated for improved emetic protection with fewer adverse reactions. Investigational agents such as serotonin antagonists may prove to be effective with few toxic effects. Despite the minimal information available on delayed and anticipatory nausea and vomiting, attempts should be made to treat them. Suggested guidelines for the management of CIE have been developed.

The effect of single-dose phenylpropanolamine on blood pressure in patients with hypertension controlled by beta blockers.

We studied the effect of phenylpropanolamine on blood pressures in seven patients whose hypertension was controlled with beta blockers. Rapid-release phenylpropanolamine 25 mg and placebo were given on separate days according to a double-blind, randomized, two-period crossover design. The crossover analyses detected significant drug effects without carryover or period effects for both systolic and diastolic pressures. The peak systolic blood pressures after phenylpropanolamine averaged 8 mm Hg higher than those measured after placebo. Similarly, the peak diastolic pressures after phenylpropanolamine averaged 4.9 mm Hg higher than those with placebo. Baseline weights, blood pressures, and pulses did not significantly differ between patient groups or change significantly across study periods. Usual single and therapeutic doses of phenylpropanolamine caused small but statistically significant increases in blood pressure. If such changes are not considered when antihypertensive therapy is altered or initiated, patients may receive excessive or unnecessary drugs.

The effects of urine pH modification on the pharmacokinetics and pharmacodynamics of phenylpropanolamine.

To determine whether urinary alkalinization had an effect on the plasma pharmacokinetics and pharmacodynamics of phenylpropanolamine, a double-blind crossover study was conducted in four healthy, normotensive male volunteers. The subjects received 25 mg immediate-release phenylpropanolamine and either placebo or sodium bicarbonate in a balanced randomized order. The bicarbonate treatment consisted of 6 g sodium bicarbonate 30 min prior to the phenylpropanolamine and then 3 g sodium bicarbonate every 4 hr for the next 16 hr. During the control treatment, phenylpropanolamine and a placebo for bicarbonate (lactose) were given on the same schedule. Blood and urine samples were collected over 24 hr and analyzed by HPLC. A supine blood pressure and pulse were obtained before each blood sample. The bicarbonate treatment significantly increased the urine pH throughout the study period and decreased phenylpropanolamine renal clearance by 33.5%. The apparent total-body clearance was also decreased by 31.5% and resulted in higher postabsorptive plasma phenylpropanolamine concentrations in each subject as compared to the control treatment. Both systolic and diastolic blood pressures changed significantly from baseline in both treatments. The bicarbonate treatment was accompanied by significantly higher diastolic blood pressures than in the control treatment, but there was no effect on systolic blood pressures. Generally, when the blood pressure-concentration pairs were plotted chronologically, clockwise hysteresis curves resulted. Heart rates did not change significantly from baseline values for either treatment. In this small group of normotensive healthy male volunteers, urinary alkalinization significantly depressed the renal clearance of phenylpropanolamine, producing higher postabsorptive phenylpropanolamine plasma concentrations and a small but significant increase in the diastolic blood pressure.