Risk factors for reoperation following inguinal hernia repair: results from a cohort of patients from an integrated healthcare system.

PURPOSE: Inguinal hernia repair is one of the most common operations performed globally. Identification of risk factors that contribute to hernia recurrence following an index inguinal hernia repair, especially those that are modifiable, is of paramount importance. Therefore, we sought to investigate risk factors for reoperation following index inguinal hernia repair. METHODS: 125,133 patients aged ≥ 18 years who underwent their first inguinal hernia repair with mesh within a large US integrated healthcare system were identified for a cohort study (2010-2020). Laparoscopic, robotic, and open procedures were included. The system's integrated electronic health record was used to obtain data on demographics, patient characteristics, surgical characteristics, and reoperations. The association of these characteristics with ipsilateral reoperation during follow-up was modeled using Cox proportional-hazards regression. Risk factors were selected into the final model by stepwise regression with Akaike Information Criteria, which quantifies the amount of information lost if a factor is left out of the model. Factors associated with reoperation with p < 0.05 were considered statistically significant. RESULTS: The cumulative incidence of reoperation at 5-year follow-up was 2.4% (95% CI 2.3-2.5). Increasing age, female gender, increasing body mass index, White race, chronic pulmonary disease, diabetes, drug abuse, peripheral vascular disease, and bilateral procedures all associated with a higher risk for reoperation during follow-up. CONCLUSION: This study identifies several risk factors associated with reoperation following inguinal hernia repair. These risk factors may serve as targets for optimization protocols prior to elective inguinal hernia repair, with the goal of reducing reoperation risk.

University wellness program: the effectiveness of students as nutrition counselors.

The Whole Body Health Program at San Jose State University was designed for employees who were interested in improving their general nutritional intake and fitness. This university wellness program furnishes students in nutrition and other health-related fields with valuable training and experience while also providing university employees with a work-site wellness program. As part of the wellness program and under faculty supervision, nutrition students conduct the Dietary Assessment Program by interviewing, assessing, and counseling clients. To determine whether the program was effective in improving participants' dietary habits, 16 previous participants were contacted by telephone. Fourteen agreed to be reinterviewed, and new dietary data were collected. Both the original (pre-program) and current (post-program) 24-hour recalls were evaluated according to the Recommended Dietary Allowances (RDAs), polyunsaturated to saturated (P:S) fat ratio, and percent of energy from fat and from carbohydrate. Reported mean consumption of cholesterol decreased from pre- to post-program for all subjects (pre = 383 mg, post = 242 mg; p less than or equal to .05). Those originally consuming more than 300 mg achieved a greater decrease in reported cholesterol consumption (pre = 487 mg, post = 234 mg; p less than or equal to .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Cultural foods education: an exploratory study of dietitians and Plan IV programs in California.

California dietitians require skills in working with the large ethnic populations in that state. Cultural foods education needs must be identified and evaluated so that they can be appropriately addressed in the nutrition and dietetics curriculums. Dietitians employed in California hospitals were surveyed to assess their cultural foods knowledge and determine cultural foods education needs. Demographic and opinion data were requested, and knowledge of the food habits of the six largest ethnic groups in the state was tested. California colleges and universities offering ADA Plan IV programs were sent questionnaires regarding the goals, content, and methodology of and the enrollment in cultural foods courses. Results of the dietitian survey (no. = 184; response rate 51%) showed a positive association (p less than .05) between the total score on the cultural foods knowledge test (average score = 62% correct) and completion of a college cultural foods course. Results of the Plan IV program survey (no. = 16; response rate 93%) indicate that 86% of the colleges and universities offer at least one cultural foods course. In 53% of those colleges and universities, Plan IV students are required to take such a course. Course content corresponds well to needs identified in the answers to the dietitian questionnaire. More emphasis on "ethnic food habits" and "disease and food habits" is recommended in the nutrition and dietetics curriculums.

Nutritional status of HIV-infected patients during the early disease stages.

Nutritional status was monitored in two groups of patients infected with human immunodeficiency virus (HIV) for up to 16 months. Twenty-six subjects were recruited from patients enrolled in acquired immunodeficiency syndrome treatment protocols in the early stages of the disease. Body weight, percent body fat, serum albumin, total protein concentration, hemoglobin, hematocrit, and total lymphocyte count were monitored monthly. Four-day food intake records were kept every 4 months. In the 19 patients followed for 16 months (Group 1), a significant (p less than .05) decrease was observed in body weight, percent body fat, body mass index (BMI), and total protein concentration. Seven subjects (Group 2), with more advanced disease than Group 1, demonstrated a significant (p less than .05) decrease in total lymphocyte count over a 5-month period. This latter group fell just below the normal range for hemoglobin and hematocrit concentrations during the study period. With the exception of a decrease in vitamin B-6, zinc, and total energy intake, food records closely matched the Recommended Dietary Allowance for the age group. Thus, we conclude that decreases in body weight, percent body fat, and BMI may be the earliest indication of decreased nutritional status in HIV-infected patients.

Concept mapping: an effective instructional strategy for diet therapy.

Concept mapping is an instructional strategy that requires learners to identify, graphically display, and link key concepts in instructional reading material. Although proven effective in numerous disciplines as a means to promote critical thinking and self-directed learning, concept mapping has not been tested in diet therapy. The objective of this study was to implement concept mapping as a small-group, cooperative learning strategy in an upper-division diet therapy course and to evaluate student attitudes about the effect of concept mapping on knowledge, self-directed learning, problem-solving, and collaborative skills. Students in the first semester (n = 27) initially learned course material by lecture (4 weeks) followed by an integrated mapping/lecture format (12 weeks); the second semester (n = 25) used an integrated mapping lecture format for the full 16 weeks. At the end of both semesters, students completed a 10-item original survey questionnaire. Responses for first (n = 25) and second (n = 21) semesters were analyzed independently. Results indicated that a majority of students thought participation in concept mapping enhanced knowledge of diet therapy principles (n = 19 of 25; 18 of 21), self-directed learning (n = 14 of 25; 18 of 21), critical thinking (n = 21 of 25; 14 of 21), problem-solving (n = 22 of 25; 16 of 21), and collaboration (n = 24 of 25; 20 of 21) skills. When noncooperation of teammates was a factor, concept mapping was viewed as more frustrating and time consuming than lecture. This study demonstrated concept mapping as an effective learning strategy for diet therapy; it improves students' ability to engage in self-directed learning, critical thinking, collaboration, and creative problem solving. Results suggest that concept mapping is most effective when accompanied with comprehensive training, coordinated lectures, instructor guidance, and long-term practice.

Southeast Asian renal exchange list.

More than 340,000 Southeast Asians (SE Asians) have immigrated to the United States since 1971. By 1984, 76,000 SE Asians had settled in California. In areas of the U.S. with large SE Asian populations, many foods specific to those people are readily available. Approximately 5% of the total U.S. population has medical problems that lead to kidney disease. Many SE Asian refugees have prior medical problems, such as hepatitis B, that may make them at significantly higher risk for kidney disease. A modified renal exchange list (excluding milk, carbohydrate supplement, and fat group) was developed. This list, made up of foods readily available and commonly eaten by the largest group of SE Asian immigrants, the Vietnamese, categorizes foods by protein, potassium, and caloric content. A separate list, indicating the phosphorus content of these foods, is also included. Asian grocery stores were visited to identify foods available for purchase by SE Asians. The foods were identified, and nutrient composition was found in food composition tables. Because the Vietnamese diet is high in potassium and sodium, planning renal diets poses problems for both patients and dietitians. Close monitoring of diet can retard the progression of renal disease. An exchange list such as this assists both dietitians and renal patients in this important task.

Physicians' perceptions of the role of clinical dietitians are changing.

We surveyed a selected group of physicians to determine their opinions regarding appropriate activities and educational background for hospital dietitians. Questionnaires were mailed to 401 physicians listed in the yellow pages of the 1988 San Jose/Santa Clara, Calif, telephone directory. Physicians were chosen from nutrition-related specialties such as cardiology, endocrinology, and gastroenterology. Questionnaires were returned by 123 (30%) physicians. Most physicians viewed dietitians as contributing members of the health care team. However, they believed that the physician should be responsible for ordering therapeutic diets. Most physicians (98%) agreed that one of the most important duties of the dietitian is to assure patient satisfaction with food served. Physicians (94%) also believed that presenting current nutrition information to hospital personnel is an important activity. Counseling patients was an area most physicians (99%) thought should be included in the educational background of dietitians. Sixty percent of the physicians indicated that it is important for the dietitian to understand blood and urine laboratory values. These results indicate that the perceived status of hospital dietitians by physicians has improved since earlier studies.

Pre-exercise carbohydrate meals: application of glycemic index.

PURPOSE: The purpose of this study was to compare postprandial glycemic, insulinemic, and physiologic responses to a pre-exercise meal calculated to have a low glycemic index (LGI) with one calculated to have a moderately high glycemic index (HGI); each meal provided three foods totaling 1.5 g carbohydrate/kg body weight. METHODS: After an overnight fast, 10 trained cyclists consumed one of the test meals or water 30 min before cycling 2 h at 70% of maximum oxygen uptake (VO2max), followed by cycling to exhaustion at 100% of VO2max. RESULTS: Plasma insulin levels were significantly lower (P < 0.05) after LGI than after HGI through 20 min of exercise. Significantly higher (P < 0.05) respiratory exchange ratios were observed after HGI than after LGI until 2 h of exercise. At that time plasma glucose levels were significantly higher and ratings of perceived exertion lower (P < 0.05) after LGI compared with after HGI. Time to exhaustion was 59% longer after LGI (206.5+/-43.5 s) than after HGI (129.5+/-22.8 s). CONCLUSIONS: These results suggest a pre-exercise LGI may positively affect maximal performance following sustained exercise. The LGI maintained higher plasma glucose levels at the end of 2 h of strenuous exercise than the HGI, which may have better supported subsequent maximal effort.

The reliability of muscle function analysis using different methods of stimulation.

BACKGROUND: The purpose of our study was to determine the reliability of nonvolitional muscle function analysis (MFA) by determining the day-to-day and within-day reliability of conventional electrical stimulation and a newer, magneto-electrical stimulation method, using standard laboratory methodology. METHODS: Ten healthy, human immunodeficiency virus-negative adult men volunteered as subjects. MFA consisted of measuring the maximal relaxation rate, for magneto-electrical stimulation at 1 Hz and conventional electrical stimulation at 20 Hz, and force-frequency ratios using conventional electrical stimulation at 10 Hz:20 Hz and 10 Hz:50 Hz. Within-day and day-to-day reliability were determined by calculating the coefficient of variation (CV) for all subjects. RESULTS: Maximal relaxation rate using magneto-electrical stimulation had a significantly lower CV compared with the other nonvolitional MFA methods (p = .002). CONCLUSIONS: Maximal relaxation rate using magneto-electrical stimulation was more reliable and technically easier than the other muscle function parameters examined. However, the day-to-day CV of muscle function parameters is larger than traditional nutrition assessment techniques. Development within the field should strive to improve testing techniques so that the reliability of MFA will allow definition of a range of normal values against which an individual's value can be compared. Until this is available, the precision and reliability of MFA restrict its use to research and population studies.

Diet counseling in a multicultural society.

Successful diet counseling is dependent on culturally sensitive communication strategies. Health care practitioners can improve cross-cultured counseling through a four-step process. First, they must become familiar with their own cultural heritages. Second, they must become acquainted with the cultural background of each client. Third, through an in-depth cross-cultural interview, they must establish the client's cultural background, food habit adaptations made in the United States, and personal preferences. Fourth, they must modify diets based on unbiased analysis of the dietary data. The best chance for compliance occurs when diets are modified with consideration for client's cultural and personal preferences.

The development and pilot testing of a multimedia CD-ROM for diabetes education.

The multimedia CD-ROM program, Take Charge of Diabetes, was found to be accurate, easy to use, and enjoyable by the clients and health professionals who completed the pilot study. Participants perceived an increase in knowledge after completing the five modules. Two of the participants verbally stated that the program clarified information for them and they wished they had had such a program when they were first diagnosed with diabetes. Further evaluation is needed to generalize the effect of the program on knowledge of diabetes because the pilot study was not designed to fully evaluate the effectiveness of the program on knowledge level or behavior change. Behavior change resulting in better control of blood sugar levels and hemoglobin A1c within normal range is the goal for diabetes education. The person who lives with diabetes must learn self-care methods. To accomplish that, the person must be able to comprehend the material presented. CAI programs provide an individualized, interactive, and interesting way to learn about diabetes and self-care, using visual effects and audio to support the written text. CAI can provide an element of excitement that is not available with other conventional methods. Providing prompt reinforcement of correct answers in quiz sections and including positive written messages can increase patients' self-confidence and self-esteem. Computer-assisted instruction is not intended to replace personal contact with physicians and diabetes educators, but rather complement this contact, reinforce learning, and possibly increase self-motivation to take charge of one's diabetes.

Accelerated improvement of alcoholic liver disease with enteral nutrition.

This prospective study compared the effects of tube-fed nutrition with those of a regular diet in alcoholic liver disease. The high prevalence of malnutrition in patients with alcoholic liver disease requires clarification of the benefits of aggressive nutritional support. Patients were randomly assigned a regular diet without or with tube-fed supplementation, delivering 1.5 g/kg protein and 167 kJ/kg daily. Comparisons of encephalopathy, antipyrine clearance, metabolic rate, and biochemical parameters were performed weekly for 4 weeks. Sixteen patients receiving enteral supplementation had antipyrine half-life (50% vs. 3% reduction), serum bilirubin (25% vs. 0% reduction), and median encephalopathy scores that improved more rapidly than those of controls. Initially, 15 controls did not consume adequate calories to meet measured resting energy expenditure. Aggressive nutritional intervention accelerated improvement in alcoholic liver disease. Adverse effects did not offset the demonstrated benefits of a 2-cal/mL, casein-based tube-fed supplement. These findings support the use of standard, casein-based solutions in the treatment of alcoholic liver disease and as the control condition for future studies.