Outcomes of elective and emergency surgical repair of incisional hernia: a comparative observational study.

PURPOSE: Incisional hernia (IH) is a common complication following abdominal surgery. Surgical repair of IH is associated with the alleviation of symptoms and improvement of quality of life. Operative intervention can pose a significant burden to the patient and healthcare facilities. This study aims to describe and compare outcomes of elective and emergency surgical repair of IH. METHODS: This study is a single-centre comparative retrospective study including patients who had repair of IH. Patients were divided into Group I (Emergency) and Group II (Elective), and a comparison was conducted between them. RESULTS: Two hundred sixty-two patients were identified with a mean age of 61.8 ± 14.2 years, of which 152 (58%) were females. The mean BMI was 31.6 ± 7.2 kg/m2. More than 58% had at least one comorbidity. 169 (64.5%) patients had an elective repair, and 93 (35.5%) had an emergency repair. Patients undergoing emergency repair were significantly older and had higher BMI, p = 0.031 and p = 0.002, respectively. The significant complication rate (Clavien-Dindo III and IV) was 9.54%. 30 and 90-day mortality rates were 2.3% (n = 6) and 2.68% (n = 7), respectively. In the emergency group, the overall complications, 30-day and 90-day mortality rates were significantly higher than in the elective group, p ≤ 0.001, 0.002 and 0.001, respectively. Overall, 42 (16.1%) developed wound complications, 25 (9.6%) experienced a recurrence, and 41 (15.71%) were readmitted within 90 days, without significant differences between the two groups. CONCLUSION: Patients who underwent emergency repair were significantly older and had a higher BMI than the elective cases. Emergency IH repair is associated with higher complication rates and mortality than elective repair.

Onset of the humoral immune response of layer chicks vaccinated in ovo with strain F Mycoplasma gallisepticum vaccine and evidence of male-biased mortality.

Previous trials in which layers were in ovo-vaccinated against strain F Mycoplasma gallisepticum (FMG) showed that nearly 50% of the birds produced IgM antibody against FMG at 6 wk of age (WOA). Standard FMG vaccination application at 9 or 10 woa, result in this percentage at approximately 15 woa. This study investigated when FMG in ovo-vaccinated birds initiate a humoral immune response prior to 6 wk, and if sex influences this response. Hy-Line W-36 embryonated eggs were either not vaccinated (controls) or in-ovo vaccinated with a 50 µL volume of a 10-6 dilution of Poulvac MycoF vaccine (Zoetis). For each treatment group, 384 straight-run chicks were reared. At hatch and at 2, 3, 5, 7, 14, 21, and 28 d post-hatch, 54 birds per treatment were individually weighed and a blood sample was collected for Mycoplasma gallisepticum (MG) IgM antibody detection. ELISA was run on blood samples at 14, 21, and 28 d to distinguish IgG antibody production. At each age, BW was not different between vaccinated and control chicks (all P > 0.19). Males, however, outweighed females starting at d 5 (P = 0.02). Mortality was 1.0% for the control birds and 12.2% for the FMG birds during the first 2 wk. The majority (72.3%) of the mortalities in the FMG group were male. The percentage of control and FMG in ovo-vaccinated birds with IgM antibody production was 0% and 1.9% on d 7, 0% and 31.5% on d 14, 1.9% and 55.9% on d 21, and 0% and 60.6% on d 28, respectively. IgG antibody production in the FMG in ovo-vaccinated birds was 0.0% at 14 d, 2.9% at 21 d, and 21.2% at 28 d of age. All control birds tested negative for FMG-IgG production. In conclusion, the earliest detection of MG antibodies after in ovo vaccination with live FMG occurred at 7 d. Male layer chickens were more susceptible to the effects of an in ovo FMG vaccine than females.

Factors influencing parentage ratio in canine dual-sired litters.

Breeding a bitch with two different sires during a single estrous cycle has the potential to facilitate rapid genetic gain and improve reproductive performance within a canine breeding colony. There is limited data regarding the factors that contribute to the success of dual-sired litters in domestic dogs, and only anecdotal evidence suggesting that these litters rarely produce offspring from more than one sire. The objective of this prospective clinical study was to investigate multiple factors that likely affect the success of dual-sired litters on whelping rate, litter size and parentage ratio. These factors include: timing of artificial insemination (AI), order of sires, number of AI's per cycle, semen type, sperm quality and age of sire and bitch. Data collected over a 10 year period from twenty-nine estrous cycles (28 individual bitches of 10 different breeds) were evaluated after an initial AI with frozen semen from the 'genetically desired' sire and followed up with a second AI with either fresh (n = 9) or frozen (n = 16) semen or natural mating (n = 4) from a different, 'back up', sire. DNA parentage of each pup born was determined by using a primary panel of 288 SNPs. The whelping rate and litter size from previous single sire inseminations per estrous cycle, in the same bitches, (n = 16) over 25 estrous cycles using either fresh (n = 4) or frozen-thawed (n = 21) semen, were analyzed as controls. Of the 29 dual-sired breedings, 26 bitches whelped (89.7%), and 8 litters (30.8%) were of mixed parentage. In the litters of mixed parentage after a dual-sired breeding, a greater proportion of the offspring were from the second sire than the first sire (73.0% and 27.0% respectively; P < 0.05). Interestingly, in litters where all pups were of single sire parentage after a dual-sired breeding, 50.0% of the offspring were by the first sire and 50.0% were by the second sire. For litters of mixed or single paternity produced by dual-sired breeding there was no difference in average litter size. However, on a per estrous cycle basis for each bitch the whelping rate (89.7% v. 76.0%.) and litter size (5.5 ± 2.5 v. 4.0 ± 2.78) of all dual-sired breedings were greater (P < 0.05) compared to previous single-sired breedings (controls) respectively. This study demonstrates that offspring of mixed parentage derived from dual-sired breedings may be achieved. Furthermore, insemination with semen from two different sires may increase the whelping rate and litter size, which is an important consideration when using genetically valuable, or older individuals with potentially reduced fertility.

Interindividual and intraindividual variability in adolescent sleep patterns across an entire school term: A pilot study.

OBJECTIVES: This study aimed to investigate sleep patterns in adolescent males over a 12-week period (a 10-week school term and pre and post term holidays). DESIGN: Intensive longitudinal design, with sleep data collected daily via actigraphy for 81 consecutive days. SETTING: Five Secondary Schools in Adelaide, South Australia. PARTICIPANTS: Convenience sample of 47 adolescent males aged 14 to 17 years. MEASUREMENTS: Daily sleep duration, bedtimes, rise times, and sleep efficiency were collected via actigraphy with all (except sleep efficiency) also measured by sleep diary. Mood was measured weekly with Depression Anxiety Stress Scale-21 (DASS-21) and weekly wellbeing with the Satisfaction with Life Scale (SWLS). Age, body mass index, self-reported mood, life satisfaction, and chronotype preference assessed at baseline (pre-term holiday week) were included as covariates. RESULTS: Dynamic Structural Equation Modeling indicated significant but small fixed-effect and random-effect auto-regressions for all sleep variables. Collectively, these findings demonstrate day-to-day fluctuations in sleep patterns, the magnitude of which varied between individuals. Age, morningness, and mood predicted some of the temporal dynamics in sleep over time but other factors (BMI, life satisfaction) were not associated with sleep dynamics. CONCLUSIONS: Using intensive longitudinal data, this study demonstrated inter-individual and intra-individual variation in sleep patterns over 81 consecutive days. These findings provide important and novel insights into the nature of adolescent sleep and require further examination in future studies.

Impact of Introduction of a Clinical Pathway for the Management of Pyelonephritis on Obstetric Patients: a Quality Improvement Project

Aim To determine whether the introduction of a clinical pathway for the treatment of pyelonephritis in obstetric patients would improve outcomes. Methods This was a retrospective study conducted in a maternity hospital using quantitative analysis methods. Patients who met laboratory and clinical criteria for pyelonephritis during data collection were included. Results The study included analysis of 23 patients pre-intervention and 19 post-intervention. Baseline and patient characteristics were similar for both groups. A statistically significant difference was seen in 3 of 7 outcome measures. Increased use of gentamicin (13% Vs 52% p=0.006), Increased number of renal ultrasounds (17% Vs 47%, p=0.04) and increased use of prophylaxis (21% Vs 68%, p=0.003). The proportion of patients receiving ≥ 10 days of IV antimicrobials decreased from 48% to 21% post-intervention (p=0.07). Discussion This study has shown that the introduction of a pathway for the treatment of pyelonephritis in pregnancy had a positive impact on several important clinical outcomes.

Artificial intelligence for the real-time classification of intrapapillary capillary loop patterns in the endoscopic diagnosis of early oesophageal squamous cell carcinoma: A proof-of-concept study.

Background: Intrapapillary capillary loops (IPCLs) represent an endoscopically visible feature of early squamous cell neoplasia (ESCN) which correlate with invasion depth - an important factor in the success of curative endoscopic therapy. IPCLs visualised on magnification endoscopy with Narrow Band Imaging (ME-NBI) can be used to train convolutional neural networks (CNNs) to detect the presence and classify staging of ESCN lesions. Methods: A total of 7046 sequential high-definition ME-NBI images from 17 patients (10 ESCN, 7 normal) were used to train a CNN. IPCL patterns were classified by three expert endoscopists according to the Japanese Endoscopic Society classification. Normal IPCLs were defined as type A, abnormal as B1-3. Matched histology was obtained for all imaged areas. Results: This CNN differentiates abnormal from normal IPCL patterns with 93.7% accuracy (86.2% to 98.3%) and sensitivity and specificity for classifying abnormal IPCL patterns of 89.3% (78.1% to 100%) and 98% (92% to 99.7%), respectively. Our CNN operates in real time with diagnostic prediction times between 26.17 ms and 37.48 ms. Conclusion: Our novel and proof-of-concept application of computer-aided endoscopic diagnosis shows that a CNN can accurately classify IPCL patterns as normal or abnormal. This system could be used as an in vivo, real-time clinical decision support tool for endoscopists assessing and directing local therapy of ESCN.

The treatment of achalasia patients with esophageal varices: an international study.

Background: Treatment options for achalasia include endoscopic and surgical techniques that carry the risk of esophageal bleeding and perforation. The rare coexistence of esophageal varices has only been anecdotally described and treatment is presumed to carry additional risk. Methods: Experience from physicians/surgeons treating this rare combination of disorders was sought through the International Manometry Working Group. Results: Fourteen patients with achalasia and varices from seven international centers were collected (mean age 61 ± 9 years). Five patients were treated with botulinum toxin injections (BTI), four had dilation, three received peroral endoscopic myotomy (POEM), one had POEM then dilation, and one patient underwent BTI followed by Heller's myotomy. Variceal eradication preceded achalasia treatment in three patients. All patients experienced a significant symptomatic improvement (median Eckardt score 7 vs 1; p < 0.0001) at 6 months follow-up, with treatment outcomes resembling those of 20 non-cirrhotic achalasia patients who underwent similar therapy. No patients had recorded complications of bleeding or perforation. Conclusion: This study shows an excellent short-term symptomatic response in patients with esophageal achalasia and varices and demonstrates that the therapeutic outcomes and complications, other than transient encephalopathy in both patients who had a portosystemic shunt, did not differ to disease-matched patients without varices.

Minichromosomal Maintenance Component Complex 5 (MCM5) as a Marker of Barrett's Esophagus-Related Neoplasia: A Feasibility Study.

BACKGROUND: The endoscopic detection of esophageal cancer is suboptimal in both patients referred with dyspeptic symptoms and those enrolled in Barrett's surveillance programs. MCM5 expression in cells collected from gastric fluid may be correlated with the presence of dysplasia or adenocarcinoma. Analysis of this biomarker may improve the detection of cancer. METHODS: Sixty-one patients were enrolled at a single UK referral center. From each patient, 5-10 ml of gastric fluid was aspirated endoscopically. Patients were categorized according to their histology, normal, non-dysplastic Barrett's (NDBE), high-grade dysplastic Barrett's (HGD), and esophageal adenocarcinoma (EAC). All histology was confirmed by Seattle protocol biopsies or endoscopic mucosal resection. Samples were centrifuged, and the cell pellet was lysed. MCM5 expression levels were quantified using a proprietary immunoassay. The mean MCM5 expression was compared between groups by Kruskal-Wallis test. ROC curves were also used to assess diagnostic utility. RESULTS: The mean expression of MCM5 increases as patients progress from a normal esophagus to NDBE, HGD, and EAC (14.4; 49.8; 112.3; and 154.1, respectively). There was a significant difference in the MCM5 expression of patients with a normal esophagus compared to those with EAC (p = 0.04). There was a trend toward higher MCM5 expression in patients with EAC compared to those with NDBE (p = 0.34). MCM5 expression was a fair discriminator (AUC 0.70 [95% CI 0.57-0.83]) between patients without neoplasia (normal and NDBE) and those with early neoplasia (HGD and EAC). CONCLUSION: MCM5 expression in gastric fluid samples can differentiate patients with a histologically normal esophagus compared to those with early adenocarcinoma. Larger, powered studies are needed to assess whether it can be used to differentiate those with HGD from NDBE.

The role of the neutrophil:lymphocyte ratio (NLR) and the CRP:albumin ratio (CAR) in predicting mortality following emergency laparotomy in the over 80 age group.

INTRODUCTION: Emergency laparotomy in the elderly is an increasingly common procedure which carries high morbidity and mortality. Risk prediction tools, although imperfect, can help guide management decisions. Novel markers of surgical outcomes may contribute to these scoring systems. The neutrophil:lymphocyte ratio (NLR) and CRP:albumin ratio (CAR) have been associated with outcomes in malignancy and sepsis. We assessed the use of ratio NLR and CAR as prognostic indicators in patients over the age of 80 undergoing emergency laparotomy. METHODS: A retrospective analysis of all patients over the age of 80 who underwent emergency laparotomy during a 3 year period was conducted. Pre and post-operative NLR and CAR were assessed in relation to outcome measures including inpatient, 30-day and 90-day mortality. Statistical analysis was conducted with Mann-Whitney U, receiver operating characteristics, Spearmans rank correlation coefficient and chi-squared tests. RESULTS: One hundred and thirty-six patients over the age of 80 underwent emergency laparotomy. Median age was 84 years (range 80-96 years). Overall inpatient mortality was 19.2%. Pre-operative and post-operative NLR and CAR were significantly raised in patients with sepsis v no sepsis (p < 0.05). Pre-operative NLR was significantly associated with inpatient (p = 0.046), 30-day (p = 0.02) and 90-day mortality (p = 0.01) in patients with visceral perforation. A pre-operative NLR value of greater than 8 was associated with significantly increased mortality (p = 0.016, AUC:0.78). CAR was not associated with mortality. CONCLUSION: Pre-operative NLR is associated with mortality in patients with visceral perforation undergoing emergency laparotomy. NLR > 8 is associated with a poorer outcome in this group of patients. CAR was not associated with mortality in over-80s undergoing emergency laparotomy.