National epidemiologic trends (2008-2018) in the United States for the incidence and expenditures associated with incisional hernia in relation to abdominal surgery.

PURPOSE: It is unknown whether the trend of rising incisional hernia (IH) repair (IHR) incidence and costs until 2011 currently persists. We aimed to evaluate how the IHR procedure incidence, cost and patient risk-profile have changed over the last decade relative to all abdominal surgeries (AS). METHODS: Repeated cross-sectional analysis of 38,512,737 patients undergoing inpatient 4AS including IHR within the 2008-2018 National Inpatient Sample. Yearly incidence (procedures/1,000,000 people [PMP]), hospital costs, surgical and patient characteristics were compared between IHR and AS using generalized linear and multinomial regression. RESULTS: Between 2008-2018, 3.1% of AS were IHR (1,200,568/38,512,737). There was a steeper decrease in the incidence of AS (356.5 PMP/year) compared to IHR procedures (12.0 PMP/year) which resulted in the IHR burden relative to AS (2008-2018: 12,576.3 to 9,113.4 PMP; trend difference P < 0.01). National costs averaged $47.9 and 1.7 billion/year for AS and IHR, respectively. From 2008-2018, procedure costs increased significantly for AS (68.2%) and IHR (74.6%; trends P < 0.01). Open IHR downtrended (42.2%), whereas laparoscopic (511.1%) and robotic (19,301%) uptrended significantly (trends P < 0.01). For both AS and IHR, the proportion of older (65-85y), Black and Hispanic, publicly-insured, and low-income patients, with higher comorbidity burden, undergoing elective procedures at small- and medium-sized hospitals uptrended significantly (all P < 0.01). CONCLUSION: IH persists as a healthcare burden as demonstrated by the increased proportion of IHR relative to all AS, disproportionate presence of high-risk patients that undergo these procedures, and increased costs. Targeted efforts for IH prevention have the potential of decreasing $17 M/year in costs for every 1% reduction.

Characterizing hernia centers in the United States: what defines a hernia center?

PURPOSE: A universal definition for what constitutes a hernia center does not exist. The purpose of this study was to characterize hernia centers in the United States by analyzing hernia centers and their non-hernia center counterparts. METHODS: A web-based search was conducted to identify defining features of hernia centers including faculty demographics and composition, research output, research funding, clinical trials, and website content. Hernia centers and non-hernia centers were compared. RESULTS: Most hernia centers (n = 36) are in urban areas (89%) and distributed evenly across regions of the United States. Hernia centers are associated with University program types (p = 0.001) while non-hernia centers are associated with University-Affiliate (p = 0.001) and Community (p = 0.02) program types. Hernia centers are associated with Abdominal Core Health Quality Collaborative participation (p = 0.01) and Center of Excellence by the Surgical Review Corporation certification (p = 0.005). Hernia centers are associated with presence of active clinical trials (p < 0.001) and number of clinical trials (p < 0.001). Hernia centers are associated with industry-sponsored trials (p < 0.001) but are not associated with NIH-sponsored trials. Fifty percent of hernia centers have PRS faculty. The vast majority of hernia center websites describe hernias treated (92%) and repair techniques (89%). The majority of hernia center mission statements emphasize an individualized care plan (61%) and multidisciplinary care (57%). Only 39% of websites and 17% of mission statements mention research. CONCLUSION: In the United States, hernia centers are clinically oriented, multidisciplinary surgical teams at predominantly urban, University programs that may use this title to attract patient referrals and industry sponsorship of clinical trials.

An evaluation of clinical and quality of life outcomes after ventral hernia repair with poly-4-hydroxybutyrate mesh.

PURPOSE: Despite continued efforts, recurrence after ventral hernia repair (VHR) remains a common problem. Biosynthetic Phasix™ (Poly-4-Hydroxybutyrate, P4HB) mesh combines the durability of synthetic mesh with the bio-resistance of biologics. P4HB has shown promising early outcomes, but long-term data are lacking. We examine patients following VHR with P4HB with at least 3 years of follow-up to assess clinical and patient reported outcomes (PROs). METHODS: Adult patients (≥ 18 years old) undergoing VHR with P4HB mesh between 10/2015 and 01/2018 by a single surgeon were retrospectively identified. Patients with < 36 months of follow-up were excluded unless they had a documented recurrence. Clinical outcomes and quality of life using the Hernia-Related Quality of Life Survey (HerQLes) were assessed. RESULTS: Seventy-one patients were included with a median age and body mass index of 61.2 and 31 kg/m2, respectively. Mesh was placed in the retromuscular (79%) and onlay (21%) planes with 1/3 of patients having hernias repaired in contaminated fields. There were no mesh infections, enterocutaneous fistulas, or mesh explantations. Nine patients (12.7%) developed recurrence at a median follow-up of 43.1 months [38.2-49.1]. Mesh plane, fixation technique, and Ventral Hernia Working Group were not associated with recurrence. Significant improvement in disease-specific PROs was observed and maintained at 3-year follow-up. CONCLUSION: Longitudinal clinical and quality of life outcomes after clean and contaminated VHR with P4HB are limited. Here, we conclude that P4HB is an effective and versatile mesh option for use in abdominal wall reinforcement.

Ventral hernia repair with synthetic mesh in a contaminated field: a systematic review and meta-analysis.

PURPOSE: The use of mesh in ventral hernia repair becomes especially challenging when associated with a contaminated field. Permanent synthetic mesh use in this setting is currently debated and this discussion is yet to be resolved clinically or in the literature. We aim to systematically assess postoperative outcomes of non-absorbable synthetic mesh (NASM) used in ventral hernia repair in the setting of contamination. METHODS: A literature search of PubMed, Embase, Scopus, Cinahl, and Cochrane Library identified all articles from 2000-2020 that examined the use of NASM for ventral hernia repair in a contaminated field. Postoperative outcomes were assessed by means of pooled analysis and meta-analysis. Qualitative analysis was completed for all included studies using a modified Newcastle-Ottawa scale. RESULTS: Of 630 distinct publications and 104 requiring full review, this study included 17 articles published between 2007 and 2020. Meta-analysis demonstrated absorbable mesh was associated with more HR (OR 1.89, 1.15-3.12, p = 0.008), SSO (OR 1.43, 0.96-2.11, p = 0.087), SSI (OR 2.84, 1.85-4.35, p < 0.001), and unplanned reoperation (OR 1.99, 1.19-3.32, p = 0.009) compared to NASM. CONCLUSION: The use of NASM for ventral hernia repair in a contaminated field may be a safe alternative to absorbable mesh, as evidenced by lower rates of postoperative complications. This review counters the current clinical paradigm, and additional prospective randomized controlled trials are warranted.

Characteristics of fowl cholera outbreaks in turkeys in Georgia in 1986.

Information was gathered from 64 cases of fowl cholera (FC) in turkey flocks through diagnostic case records, flock records, and telephone and mail surveys. Forty-five cases came from flocks of commercial turkeys, of which 15 were presented twice, and four came from mature breeder flocks. The prevalence of FC was 18.0% of commercial flocks and 14.7% of breeder flocks at risk. The average age at first diagnosis of FC was 90 days in commercial turkey flocks and 32 weeks 5 days in breeder flocks. Acute mortality was the most common presenting complaint, with a 0.37% average mortality in commercial flocks on the day of first presentation, 0.80% in commercial flocks presented a second time, and 0.43% in breeder flocks. Pasteurella multocida was cultured from 69.8% of the 361 tissue samples submitted from these cases. Novobiocin, penicillin, and chlortetracycline (CTC) had the greatest in vitro activity against isolates. Serotype 3-cross-4 was found in all 18 commercial flocks from which isolates were typed. All breeder flocks and 88.6% of commercial flocks were vaccinated before disease onset. Flocks were treated for an average of 14.3 days, most commonly with high levels of sulfadimethoxine and/or CTC. Body weights of affected birds were comparable to those of birds in unaffected flocks, but mortality and feed efficiency were worse.

Estimate of economic impact of fowl cholera in turkeys in Georgia in 1986.

Information gathered from cases of fowl cholera (FC) in commercial turkey flocks through case records, flock records, and telephone and mail surveys was used to estimate disease costs. The cost to the Georgia commercial turkey industry in 1986 from preventive measures, treatment of outbreaks, and production losses from the disease was estimated at $634,545. The cost of FC per kg of live production was estimated to be $0.015.

Gastritis with valproate therapy.

We have identified ten children who developed gastritis after prolonged anticonvulsant therapy that included either valproic acid or divalproex sodium. Presenting symptoms were primarily feeding difficulties, including anorexia and refusal to eat. Vomiting was present in two thirds of the patients, with diarrhea, weight loss, and abdominal pain occurring less frequently. Occult blood in stool samples was a late development. All patients responded to therapy with H2-receptor antagonists, oral antacids, or both, with prolonged treatment often necessary to prevent relapse. Although gastrointestinal tract side effects are common with the initiation of valproate sodium therapy, feeding difficulties after long-term treatment are less common. Gastritis should be suspected in children receiving valproate therapy when feeding difficulties arise, particularly if the symptoms are persistent or recurrent.

Diagnostic summary of 1986 turkey, broiler breeder, and layer necropsy cases at the University of Georgia.

Turkey, broiler breeder, and layer cases submitted for necropsy in 1986 to the University of Georgia were categorized by diagnosis, grouped by clinical features, season, age, and presenting history, and evaluated for statistically significant patterns. The most commonly diagnosed diseases were: fowl cholera in turkeys, 64 cases (34.4% of cases; 26.2% of diagnoses); staphylococcal arthritis/synovitis (SA/S) in broiler breeders, 35 cases (20.7%; 17.7%); and osteomalacia in layers, 17 cases (21.0%; 15.6%). In turkeys, fowl cholera, colibacillosis, and aspergillosis were significantly more common in the fourth, second, and third quarters of the year, respectively; enteritis and viral enteritis were more common in early grow-out, and osteomyelitis, SA/S, and synovitis were greatest in late grow-out. Overall, musculoskeletal problems in turkeys were more common in the third quarter and were less common in the first and fourth quarters. Erysipelas occurred most frequently in turkeys 50 to 112 days of age. In both broiler breeders and layers, SA/S was more common in the second quarter, and a history of musculoskeletal problems was less common in both post-peak-production broiler breeders and layers. Fowl pox was more common in the fourth quarter and in late-production broiler breeders. In layers, osteomalacia and Marek's disease were more common in the first and fourth quarters, respectively.

Disease prevalence in Georgia turkey flocks in 1986.

Disease prevalence in turkeys was estimated by totaling the flock size of necropsy cases submitted to the University of Georgia in 1986 for each disease reported and comparing it with the population at risk. Fowl cholera was the most prevalent disease in both commercial tom flocks (18.0%) and breeder hen flocks (14.7%). Prevalence of colibacillosis was 15.9% in commercial tom flocks, and prevalence of aspergillosis was 8.5% in commercial tom and 4.9% in breeder hen flocks.

Laryngotracheitis outbreak limited to a part of a chicken flock exposed to smoke and chemicals.

Laryngotracheitis was diagnosed in a flock of molted, caged table-egg-layers. Morbidity was restricted to an area of the house in which the birds had been exposed to smoke from a fire in the house and to a powdered chemical fire-extinguisher used on the fire. Mortality in this group began to rise 6 days after the fire and continued to be above normal for about 3 weeks. Feed consumption dropped for about 1 1/2 weeks after the fire but was normal or above normal during the rest of the disease outbreak. Egg production dropped slightly for 1 week after the fire, then returned to normal. Microscopic tracheitis in the exposed birds continued for 11 weeks after the fire. Hens outside of the smoke-affected area did not show histopathological changes or shed laryngotracheitis virus.