Comparing laparoscopic and open inguinal hernia repair in octogenarians.

PURPOSE: To compare outcomes of laparoscopic and open inguinal hernia repair in elderly patients. METHODS: We retrospectively reviewed patients ≥80 years old undergoing laparoscopic or open inguinal hernia repair from October 2006 to July 2009 at our medical center. Descriptive statistics were calculated, and outcomes were compared using Fisher's exact test, Wilcoxon rank-sum test, and Student's t test; a p value <0.05 was considered significant. RESULTS: Open inguinal hernia repairs were performed in 58 patients, and laparoscopic repairs in 23 patients. There was no significant difference in average age (81 vs. 83 years, p = 0.09) or gender (91 % male vs. 74 % male, p = 0.1) for the laparoscopic versus open groups. Resident involvement (55 vs. 26 %, p = 0.02) was more common in the open group, and there was no difference in number of cases done for incarcerated hernias (17 vs. 13 %, p = 0.8) in the open versus laparoscopic groups. We observed a significant difference in hernia laterality and anesthesia type, with significantly more bilateral hernias (48 vs. 2 %, p ≤ 0.001) and more general anesthesia (100 vs. 31 %, p ≤ 0.001) in the laparoscopic compared with the open group. There were no significant differences in ASA score (p = 0.1), operating-room time (p = 0.6), urine output (p = 0.1), morbidity (p = 1), or mortality unrelated to the hernia surgery (13 vs. 22 %, p = 0.5) between the laparoscopic and open groups. At an average follow-up of 31 months (laparoscopic) and 19 months (open), only one recurrence occurred (open group). CONCLUSIONS: Despite subtle differences between the laparoscopic and open approaches to inguinal hernia repairs in octogenarians, both procedures are safe with similar outcomes.

Oral syphilis--re-emergence of an old disease with oral manifestations.

Three representative cases of oral primary syphilis are presented. We wish to highlight the resurgence of this disease, which has occurred recently in the western world, particularly in Europe and the United States of America. Since the initial presentation may be oral, it is important to include syphilis in the differential diagnosis of patients presenting to oral diagnostic clinics with atypical oral ulceration. Recent developments in the serological diagnostic tests and treatment are reviewed. Early diagnosis and treatment has significant implications, not only for the patient, but also for previous and future transmission to contacts. Early syphilis is a highly infectious disease in which the lesions heal spontaneously, despite inappropriate treatment which may appear curative, and yet the patient remains infectious. It is therefore important that clinicians maintain a high clinical index of suspicion and crucial that an accurate diagnosis be made at presentation.

Inflammatory bowel disease patients' decisions to use complementary therapies: links to existing models of care.

OBJECTIVE: In this paper we present emergent categories of factors that influence inflammatory bowel disease patients' decisions to use complementary therapies and discuss similarities between this work and existing models of care. METHODS: This combined methods study consisted of a quantitative survey followed by qualitative interviews. The results of the qualitative interviews are reported in this article. RESULTS: Major categories that emerged during qualitative analysis were the personal context (i.e. contextual issues that influenced the individual's experience of illness), impact (i.e. the impact that the experience of illness had on the individual), and action (i.e. actions taken to manage the individual's illness). DISCUSSION: Research in the areas if complementary therapy, biopsychosocial models, and patient-centered care, point to the importance of patient-physician communication. Our findings with people who have inflammatory bowel disease are in alignment with this previous body of work. By investigating the reasons for using complementary therapies among people who have a chronic illness, we make a substantive contribution to a growing body of literature that supports the need for continued emphasis on strengthening patient-physician relationships.

Development of healthy public policy: feminist analysis of conflict, collaboration and social change.

In the past two decades, the need for economic restructuring has served as a rationale for dismantling social programs in Canada. As it has been enacted, such social restructuring has disproportionately affected marginalized people, particularly women. In this article we explore the schism between the principles that underlie the development of healthy public policy and those that are driving current social policy development. Through this analysis we discuss the implications of policy development that is based upon principles of inequity, and we suggest that implementation of healthy public policy requires transformational change in the underlying principles of the social system. A policy shift based upon principles of equity and social justice has been espoused throughout the health promotion literature. We suggest that such a shift will be facilitated by strengthening collaborative relations among points of conflict within society and among policy makers and women's organizations.

Quantification of the response of equine apocrine sweat glands to beta2-adrenergic stimulation.

The aim of the present study was to characterise the quantitative sweating response of the horse to beta2-adrenergic stimulation. The sweating responses of 6 horses to the randomised infusion of 8 different adrenaline concentrations (0.025, 0.05, 0.075, 0.1, 0.2, 0.4, 1.0 or 2.0 microg/kg bwt/min), was investigated. Sweating rate (SR) and skin temperature (TSK) on the neck (N) and gluteal region (G), and plasma adrenaline and noradrenaline concentrations were measured. Peak SR was approximately 15 (N) and approximately 9 g/m2/min (G) during infusion of both 1.0 and 2.0 microg/kg bwt/min adrenaline. Sweat produced per nmol/l plasma adrenaline peaked during the infusion of 0.075 microg/kg bwt/min adrenaline. Higher adrenaline infusion concentrations resulted in a progressive decrease in the amount of sweat produced per nmol/l plasma adrenaline and a plateau of 6 g/m2/(nmol/l) plasma adrenaline was reached for infusions between 1.0 and 2.0 microg/kg bwt/min. Peak SR were far lower than we have previously reported during exercise. There was no evidence of sweat gland fatigue or vasoconstriction during infusion, suggesting saturation of sweat gland beta2 receptors. We conclude that sweating in the horse is under dual control from a combination of hormonal and neural mechanisms.

Spelling and the speech-language pathologist: there's more than meets the eye.

Interest in spelling and spelling difficulties has increased in recent years. Like reading, spelling is no longer viewed as a strictly visual process. Rather, the language basis of spelling is evident in the phonological, orthographic, morphological, and even syntactic knowledge required to be a good speller. Speech-language pathologists (SLPs) have expertise in basic language processes that enable them to play an important role in assessment and intervention for spelling problems. Underscoring the importance of this effort are the serious social and vocational consequences attached to poor spelling and the intractable nature of spelling problems. This article reviews information about spelling-language connections, the nature of spelling problems, and assessment and intervention principles or procedures that represent best practices based on current spelling research. Implications for SLPs working with students who have spelling difficulties are suggested throughout.

Undiagnosed alcoholism & prescription drug misuse among the elderly. Special considerations for home assessment.

Elderly patients are living longer than ever. Often, health care providers perceive this longevity as a measure of professional success. These patients don't always share this cheerful perspective. Living to a "ripe old age" can impose tremendous stress. An alarming number of these patients turn to alcohol and prescription drugs to escape the physical, emotional, spiritual, social and financial losses associated with aging.

General language performance measures in spoken and written narrative and expository discourse of school-age children with language learning disabilities.

Language performance in naturalistic contexts can be characterized by general measures of productivity, fluency, lexical diversity, and grammatical complexity and accuracy. The use of such measures as indices of language impairment in older children is open to questions of method and interpretation. This study evaluated the extent to which 10 general language performance measures (GLPM) differentiated school-age children with language learning disabilities (LLD) from chronological-age (CA) and language-age (LA) peers. Children produced both spoken and written summaries of two educational videotapes that provided models of either narrative or expository (informational) discourse. Productivity measures, including total T-units, total words, and words per minute, were significantly lower for children with LLD than for CA children. Fluency (percent T-units with mazes) and lexical diversity (number of different words) measures were similar for all children. Grammatical complexity as measured by words per T-unit was significantly lower for LLD children. However, there was no difference among groups for clauses per T-unit. The only measure that distinguished children with LLD from both CA and LA peers was the extent of grammatical error. Effects of discourse genre and modality were consistent across groups. Compared to narratives, expository summaries were shorter, less fluent (spoken versions), more complex (words per T-unit), and more error prone. Written summaries were shorter and had more errors than spoken versions. For many LLD and LA children, expository writing was exceedingly difficult. Implications for accounts of language impairment in older children are discussed.

Verb and noun morphology in the spoken and written language of children with language learning disabilities.

The purpose of this study was to investigate the use of verb and noun morphology in school-age children's spoken and written language. Sixty children, with and without language learning disabilities (LLD), each produced 2 spoken and 2 written language samples. The children's accuracy in using morphemes that mark verb finiteness (regular past tense, 3rd person singular present tense, copula, and auxiliary BE) was compared with their accuracy in using noun morphology (regular plural, possessive, articles). As would be expected, the typically achieving children, who were aged 7 to 12 years, had mastered the verb and noun morphology in spoken and written samples. The children with LLD, aged 10 to 12 years, also showed high accuracy in the spoken samples. On the other hand, they showed substantial difficulty in the written samples with the regular past tense, with errors in 26% of obligatory contexts. However, the children with LLD also had difficulty with the regular plural, with errors in 12% of obligatory contexts. For both the regular past tense and plural, all errors were errors of omission. These results indicate that finiteness marking remains an area of relative difficulty, but perhaps not the only grammatical difficulty, for children with language impairments in the school years.

SB-236057, a selective 5-HT1B receptor inverse agonist, blocks the 5-HT human terminal autoreceptor.

A novel compound, SB-236057 (1'-ethyl-5-(2'-methyl-4'-(5-methyl-1,3,4-oxadiazol-2-yl)biphenyl- 4-carbonyl)-2,3,6,7-tetrahydrospiro[furo[2,3-f]indole-3,4'-piperid ine]) has been shown to have high affinity for human 5-hydroxytryptamine1B (5-HT1B) receptors (pKi = 8.2) and displays over 75 or more-fold selectivity for the human 5-HT1B receptor over other 5-HT receptors, including the human 5-HT1D receptor, and a range of other receptors, ion channels and enzymes. In functional studies using [35S]GTPgammaS binding, SB-236057 displayed negative intrinsic activity (pEC50 = 8.0) at human 5-HT1B receptors stably expressed in Chinese Hamster Ovary (CHO) cells and caused a rightward shift of agonist concentration response curves consistent with competitive antagonism (pA2 = 8.9). SB-236057 potentiated [3H]5-HT release from electrically stimulated guinea pig or human cortical slices. SB-236057 also abolished the inhibitory effect of exogenously superfused 5-HT on electrically-stimulated release from slices of the guinea pig cortex. These studies using SB-236057 confirm that, in both the guinea pig and human cerebral cortex, the terminal 5-HT autoreceptor is of the 5-HT1B subtype.

Metabolic effects of nitric oxide synthase inhibition during exercise in the horse.

The effect of nitric oxide synthase (NOS) inhibition during exercise on lactate production was investigated in five Thoroughbred horses. A standard exercise test (SET), consisting of three canters (approximately 55 per cent VO2max), with walking and trotting between each canter, was performed twice (control and test, in random order) by each horse. Nphi-nitro-L-arginine methyl ester (L-NAME; 20 mg kg-1), a competitive inhibitor of NOS, induced a significant increase (P < 0.05) in plasma lactate [5.7 (2.9) vs 11.8 (3.8) mmol L-1], which continued to increase despite administration of L-arginine, the substrate for NOS. There were no differences in cardiac output (Q) or the total body oxygen consumption (VO) between each SET. The results show that non-specific inhibition of NOS isoforms during exercise in the horse increases plasma lactate concentration, although the mechanism/s remain uncertain.

Physiological responses of horses to a treadmill simulated speed and endurance test in high heat and humidity before and after humid heat acclimation.

To investigate whether horses were able to acclimate to conditions of high temperature and humidity, 5 horses of different breeds were trained for 80 min on 15 consecutive days on a treadmill at 30 degrees C and 80%RH. Training consisted of a combination of long duration low-intensity exercise, medium duration medium intensity exercise and short duration high intensity exercise. Between training sessions the horses were maintained at 11+/-3 degrees C and 74+/-2%RH. Before (PRE-ACC) and after acclimation (POST-ACC) the horses undertook a simulated Competition Exercise Test (CET), designed to represent the Speed and Endurance Test of a 3-day event, at 30 degrees C/80%RH. Maximal oxygen uptake (VO2PEAK) was not changed following acclimation (PRE-ACC 141+/-8 ml/min/kg bwt vs. POST-ACC 145+/-9 ml/min/kg bwt [STPD], P>0.05). Following acclimation, 4 of the 5 horses were able to complete a significantly greater amount of Phase D in the CET (PRE-ACC 6.3+/-0.3 min vs. POST-ACC 7.3+/-0.3 min, P<0.05; target time = 8 min). Resting body temperatures (pulmonary artery [TPA], rectal [TREC] and tail-skin [TTSK] temperatures) were all significantly lower following acclimation. During exercise, metabolic heat production (M) and heat dissipation (HD), for the same exercise duration, were both significantly lower following acclimation (P<0.05), although heat storage (HS) was significantly higher (P<0.05). The higher heat storage following acclimation was associated with a lower TTSK for a given TPA and a decreased total fluid loss (% bodyweight, P<0.05). Plasma volume was not changed following acclimation. The relationship of sweating rate (SR) to TPA or TTSK on either the neck or the gluteal region was not significantly altered by acclimation, although the onset of sweating occurred at a lower TPA or TTSK following acclimation (P<0.05). The horses in the present study showed a number of physiological adaptations to a period of 15 days of exposure to high heat and humidity consistent with a humid heat acclimation response. These changes were mostly similar to those reported to occur in man and other species and were consistent with thermal acclimation and an increased thermotolerance, leading to an improved exercise tolerance. It is concluded that a 15 day period of acclimation is beneficial for horses from cooler and or drier climates, that have to compete in hot humid conditions and that this may redress, to some extent, the decrement in exercise tolerance seen in nonacclimated horses and reduce the risk of heat related disorders, such as heat exhaustion.

Thermoregulatory strategies during short-term exercise at different intensities.

Previously we have observed a decline in sweating rate (SR) during high intensity exercise in an incremental test protocol. In man, the sweating sensitivity (SR/degree C) has been shown to vary with exercise intensity. The aim of the present study was to determine if thermoregulatory responses in the horse, a prolific sweater with a high rate of metabolic heat production, were modified by exercise intensity. The effect of 3 separate exercise intensities (50 (S), 70 (M) and 90% (F) VO2peak on neck (SRN) and gluteal sweating rate (SRG), pulmonary artery (TPA), rectal (TREC) and skin temperatures on the neck (TSK-N) and gluteal region (TSK-G) were investigated. Horses were exercised for approximately 2 min at each exercise intensity in a randomised order. The rate of increase in TPA increased with exercise intensity (P < 0.05) (0.27 +/- 0.05, 0.43 +/- 0.04 and 0.77 +/- 0.05 degree C/min during S, M and F, respectively. The TPA and TSK temperatures at the onset of sweating were not different between exercise intensities (P > 0.05). Despite the increased rate of heat production with increasing exercise intensity, sweating sensitivity decreased on both the neck (P < 0.05) (18.2 +/- 3.4 (S), 12.0 +/- 3.5 (M) and 2.9 +/- 0.7 (g/m2/min)/degree C (F)[ and gluteal region (P < 0.05) (8.9 +/- 2.0 (S), 5.1 +/- 1.7 (M) and 0.8 +/- 0.3 (g/m2/min)/degree C (F)[. During exercise at 90% VO2peak sweating sensitivity and the rate of increase in skin temperature were markedly reduced compared to at 70% VO2peak. The present investigation demonstrates that the drive to thermoregulate is overridden during short-term, high-intensity exercise, resulting in greater heat storage (TPA) as a result of a lower SR sensitivity.

Sweating and skin temperature responses of normal and anhidrotic horses to intravenous adrenaline.

Anhidrosis has been recognised for over half a century, but despite some excellent epidemiological studies, there has been little progress in understanding the aetiology of the condition. Using a modified ventilated capsule, we obtained dynamic, quantitative data on sweating responses in anhidrotic horses and normal sweating controls from the same environment. Ten horses with current seasonal anhidrosis and 10 matched normal sweating controls were selected. Each horse was given two 10 min infusions of 1 and 2 micrograms/kg/min adrenaline, separated by at least 6 h. Sweating responses and skin temperatures on the neck and gluteal region were measured. Plasma and sweat for analysis of total protein and electrolytes and plasma for analysis of adrenaline were collected. Anhidrotic horses produced significantly less sweat, had lower initial and peak sweat rates and a greater neck:gluteal ratio for sweat production. Plasma adrenaline at rest or at the time of peak sweating rate was not different between groups. In nearly three-quarters of the anhidrotic horses, the shape of the sweat rate against time curve was different compared to controls. Volume of sweat produced was significantly correlated with skin temperature on the neck of controls and anhidrotic horses and on the gluteal region of controls, but not anhidrotic horses. Plasma total protein and electrolyte concentrations were not different between groups. There were significant differences in sweat electrolyte concentrations between controls and anhidrotic horses. These differences were reduced when sweat electrolytes were expressed per g of total protein, and no differences existed when expressed as g/m2. This study has provided insight into the response of anhidrotic horses to beta 2 adrenergic stimulation and may be a useful technique to investigate this condition.

Building a feminist theoretical framework for screening of wife-battering: key issues to be addressed.

The purpose of this paper is to identify key questions which must be addressed in developing a woman-centred, that is feminist, theoretical framework for screening for wife battering in health settings. The health sector has not had a positive history in addressing women's health holistically or in terms of the social context of women's lives. This is notable in relation to the issue of wife battering, where attention is recent but growing and responses have been varied. On the other hand, violence against women is one of the greatest threats to their health and, therefore, it can be argued that the health sector has a major role to play in ending this violence. With the recent efforts within the health sector, a great deal has been accomplished; we have some consensus on what is an appropriate protocol for and the roles of health care providers. We are also making progress in developing training programs. Several things are still lacking an understanding of the systemic barriers to promotion of and participation in screening; sufficient program evaluations; sufficient attention to issues of diversity among women; and, a theoretical framework for practice which links these together.

Rehydration following exercise: effects of administration of water versus an isotonic oral rehydration solution (ORS).

The effects of administering (1) 6L isotonic oral rehydration solution (ORS), similar in composition to plasma (except for an elevated potassium concentration) and with an osmotic skeleton and (2) 6L water (no osmotic skeleton), were evaluated in five thoroughbred horses following exercise-induced dehydration. The horses were exercised on a treadmill for 10 min at walk (1.7 m.s-1; approximately 15% VO2max), 40 min at trot (3.7 m.s-1; approximately 25% VO2max) and 10 min at walk (1.7 m.s-1; approximately 15% VO2max). Exercise was undertaken on a 3 degrees incline at 30 degrees C/80% RH. Solutions of water or ORS at 20 degrees C were administered by nasogastric tube over 60s 5 min following exercise. Mean weight loss following exercise was 9.2 +/- 1.7 kg (2.0 +/- 0.4% body weight; mean +/- SEM) with water and 9.2 +/- 1.1 kg (2.0 +/- 0.2% body weight) with ORS and was not different between treatments (P > 0.05). Water treatment resulted in a fall in plasma [Na+] (approximately 3 mmol.L-1) and C1- (1-2 mmol.L-1) concentrations by 30 min after administration and the effect persisted until the end of the study (300 min post fluids). There was little change in plasma total protein (TP) from that at the end of exercise, suggesting a failure of water to restore or maintain PV. In contrast, ORS administration resulted in a small increase in plasma [Na+] (1-2 mmol.L-1) and [Cl-] (2-3 mmol.L-1) with a corresponding decrease in plasma TP. By 120 min post ORS, plasma TP and PV were no longer significantly different from rest or pre-exercise (P > 0.05), whilst with water, TP was elevated (approximately 3-4 g.L-1) and PV reduced (approximately 4-5 mL.kg-1). Total urine output was not significantly different between water (1096 +/- 135 mL) and ORS (750 +/- 215 mL, P > 0.05). Estimates of expected plasma volume and electrolyte concentration changes as a result of either treatment compared well with measured changes of TP and PV. On the basis of calculated or measured changes, it was estimated that only 1L of water contributed to rehydration following exercise compared to 4L isotonic, plasma-like ORS. The administration of 6L ORS restored the PV deficit induced by exercise with minimal or no disturbance of plasma electrolyte concentrations. In contrast, water alone resulted in minimal improvement in PV. When fluid intake after periods of fluid loss, such as induced by exercise or transport, is not accompanied by food intake, the present study has clearly demonstrated that water alone is ineffective in promoting rehydration compared with an isotonic, plasma-like ORS.

A multimethod research study on the use of complementary therapies among patients with inflammatory bowel disease.

CONTEXT: The purpose of this study was to gain a better understanding of the use of complementary therapies among patients with inflammatory bowel disease. OBJECTIVE: To examine factors influencing the use of complementary therapies, to explore patient-physician communication concerning those therapies, and to assess the effect of combining qualitative with quantitative research. DESIGN: In-depth qualitative interviews. PARTICIPANTS: Fourteen patients were selected from a quantitative study in which the use of complementary therapies among patients with inflammatory bowel disease was assessed. RESULTS: Patients reported using complementary therapies because of the serious side effects of medical treatment, because they felt conventional treatments did not help, and because complementary therapies were thought to be safe. Psychological and social factors for using complementary therapies must be considered and understood. Patients cited many reasons for not discussing the use of complementary therapies with their doctors. Adding qualitative data to quantitative research greatly increased the authors' understanding of factors that contribute to complementary therapy use. CONCLUSIONS: Multiple factors contribute to the decision to use complementary therapies among those with inflammatory bowel disease. Identifying these factors is important for educating physicians regarding their patients' use of complementary therapies and may contribute to improved patient-physician communication.

Complementary medicine use by patients with inflammatory bowel disease.

OBJECTIVE: The purpose of this study was to establish the degree and determinants of the use of complementary therapies by patients with inflammatory bowel disease (IBD) and their reasons for seeking them. METHODS: The first phase was a cross-sectional survey of 134 patients with IBD (98 with Crohn's disease, 34 with ulcerative colitis, and two indeterminate) using a mailed, structured questionnaire (response rate 70%). Determinants of complementary medicine use were examined using logistic regression. The second phase was an in-depth exploration using personal interviews of the beliefs and perceptions of 14 complementary medicine users about the management of their disease. Analysis was performed using standard qualitative techniques and the identification of important, patient-identified themes about the management of IBD. RESULTS: Complementary therapies had been used by 51% of patients in the previous 2 yr. Current use was reported by 33%, of whom one-half were using it for their IBD. Vitamins and herbal products were the most commonly reported therapies. In multivariate analysis, duration of disease > 10 yr and a history of hospitalization were independent predictors of complementary medicine use. The side effects and lack of effectiveness of standard therapies were the most commonly cited reasons for seeking complementary medicine. Sixty-two percent had told their doctor about their use of complementary medicine. CONCLUSION: Complementary medicine use is common in patients with IBD, especially among those with a longer duration of disease or a history of hospitalization.

Effects of administration of water versus an isotonic oral rehydration solution (ORS) at rest and changes during exercise and recovery.

The administration of 41 of an isotonic, plasma-like oral rehydration solution (ORS) with an osmotic skeleton and 41 of water (water; no osmotic skeleton), were evaluated in five thoroughbred horses. Solutions were administered by nasogastric tube 4 h after feeding. Uptake of deuterium, concentrations of plasma sodium, potassium, chloride, glucose, total protein and packed cell volume, pH, PCO2, HCO3-, total CO2, actual base excess, standard base excess, plasma volume and weight loss were assessed both at rest, and during and after exercise on a treadmill. Each horse underwent four experimental sessions (water-resting; ORS-resting; water-exercise; ORS-exercise). There was an indication of uptake of both water and ORS by 10 min post-administration. Based on the appearance of deuterium in plasma, there was no significant difference in the rate of uptake of water or ORS at rest, although there was a trend for the uptake of ORS to be slower than water during the exercise session. The mean decrease in total protein (TP, 3.0 g l-1) and the increase in plasma volume (PV, 4.6 ml kg-1) after administration of ORS at rest was greater (P < 0.05) than that of water (TP, 1.3 g l-1 and PV, -1.2 ml kg-1). There was no significant difference in TP or PV following administration of water or ORS during the exercise treatment. Exercise had little effect on plasma sodium concentration. The results confirmed that administration of 41 of isotonic, plasma-like ORS provided a much more distinct and durable contribution to the maintenance of plasma volume and circulation than administration of an equal amount of water at rest. Subsequent exercise may, however, mask some of the effects observed at rest.