Chronic pain following inguinal hernia repair

Introduction: In the past five years chronic post herniorrhaphy pain has become the predominant post operative complication following the common procedure of inguinal hernia repair. However information regarding the precise aetiological factors of this chronic post surgical pain is lacking. To date no previous studies have assessed the long term outcome of patients who report chronic severe pain following inguinal hernia surgery. There are no studies assessing the presence of preoperative pain and the effect of surgical intervention on these pain scores. One factor thought to contribute to post herniorrhaphy chronic pain is the mesh type used by the surgeon. The characteristics of two different mesh types are evaluated with respect to postoperative chronic pain. Aims: The aim of the first study was to assess the outcome of patients who report severe or very severe pain three months after groin hernia repair. The aim of the second study was to quantify patients’ pain from their inguinal hernia prior to surgery and to examine the effect of surgery on this pain. The aim of the third study was to compare the composite partially absorbable and ultimately lighter weight (Vypro 11) mesh with an example of a conventional polyprolene mesh (Atrium) in a tension free repair of an inguinal hernia. Methods: One hundred and twenty five patients were identified as experiencing severe chronic pain at 3 months post herniorrhaphy, from the prospective National Hernia database1 of 5506 patients (97% of total) between 1 April 1998 and 31 march 1999. These 125 patients were assessed at 30 months post-surgery, with the use of the modified SF36 quality of life questionnaire. For the second study, consecutive patients referred for elective inguinal hernia repair between January 1998 and October 2000 completed visual analogue pain scores (VAS) pre- and 1 year post-repair. These patients were Western Infirmary patients who were part of a larger multicentre clinical trial comparing local versus general anaesthesia 2 for inguinal hernia repair. The third study examined patients who were involved in a multicentre trial comparing the incidence and severity of chronic pain following elective inguinal hernia repair, comparing the light weight or partially absorbable (PA) to the standard heavy weight or non-absorbable (NA) mesh. Results: In the first study, of the 125 patients who experienced severe chronic pain at three months post repair, at 30 months post-surgery 25% had persistent, unchanged chronic pain 45% had a reduction in pain to mild or very mild, and 29% were pain-free. In the 25% of patients that had persistence of severe chronic pain, the symptoms had a significant effect on all daily activities and quality of life, for example in measurement of general enjoyment of life, those with mild pain scored 2.32 (1.5-3.13) compared to 7.14 (5.97 - 8.30) in those with persistent severe pain (P<0.05) . In the second study 63% of patients completed VAS scores at follow-up. Prior to surgery the majority of patients had no pain or only mild pain at rest (80.5%) or on movement (58.8%). At 1 year follow-up the mean (SD) VAS score reduced by 2.9 (1.2) at rest, and reduced by 9.2 (1.8) on movement. However the majority of the beneficial effect was seen in those with moderate to high pre=operative pain scores. Those with preoperatively VAS score >10 had a reduction of 22.8 (3.7) at rest, compared to a slight increase in pain (+1.8) in those with no pain pre-operatively (P10, and little change in pain, -0.3 (1.6), in those with no, or only mild, preoperative pain (P<0.05). In the third study 162 patients received the PA mesh and 159 received the NA mesh. The PA mesh was not associated with less pain at 1 year postoperatively, compared to the NA mesh, with the proportion experiencing any pain being 39.5% in the PA group compared to 51.6% in the NA group (P=0.033). The proportion experiencing severe pain was similar, being 3% for the PA group and 4% for the NA group, and the recurrence rate was greater with the PA mesh compared to the NA mesh (4.9% versus 0.6%, P=0.037). Conclusion: Of those with chronic severe pain at 3 months post inguinal hernia repair, the majority will have still have some pain at 30 months post operatively. The greatest benefit in terms of pain reduction in patients undergoing inguinal hernia repair is experienced by those with the more severe preoperative pain. From our data there is no clear overall benefit in using the PA mesh over the standard mesh, as whilst pain scores were slightly lower in the PA group, this was countered by a higher recurrence rate. Further attention to the multiple factors that contribute to pain post-inguinal hernia repair is required, including the development of superior mesh technology

Urinary liver fatty acid-binding protein: another novel biomarker of acute kidney injury

Liver fatty acid-binding protein (L-FABP) binds selectively to intracellular free unsaturated fatty acids and lipid peroxidation products during hypoxic tissue injury. Urinary L-FABP is a potential biomarker for the detection and assessment of acute kidney injury (AKI). Ferguson et al. have demonstrated in a cross-sectional study that urinary L-FABP is an excellent biomarker of AKI and may be useful in predicting dialysis-free survival. This study did not assess utility for early diagnosis of AKI

Subphenotypes in acute kidney injury : a narrative review

Acute kidney injury (AKI) is a frequently encountered syndrome especially among the critically ill. Current diagnosis of AKI is based on acute deterioration of kidney function, indicated by an increase in creatinine and/or reduced urine output. However, this syndromic definition encompasses a wide variety of distinct clinical features, varying pathophysiology, etiology and risk factors, and finally very different short- and long-term outcomes. Lumping all AKI together may conceal unique pathophysiologic processes specific to certain AKI populations, and discovering these AKI subphenotypes might help to develop targeted therapies tackling unique pathophysiological processes. In this review, we discuss the concept of AKI subphenotypes, current knowledge regarding both clinical and biomarker-driven subphenotypes, interplay with AKI subphenotypes and other ICU syndromes, and potential future and clinical implications.Peer reviewe

Subphenotypes in acute kidney injury : a narrative review

Acute kidney injury (AKI) is a frequently encountered syndrome especially among the critically ill. Current diagnosis of AKI is based on acute deterioration of kidney function, indicated by an increase in creatinine and/or reduced urine output. However, this syndromic definition encompasses a wide variety of distinct clinical features, varying pathophysiology, etiology and risk factors, and finally very different short- and long-term outcomes. Lumping all AKI together may conceal unique pathophysiologic processes specific to certain AKI populations, and discovering these AKI subphenotypes might help to develop targeted therapies tackling unique pathophysiological processes. In this review, we discuss the concept of AKI subphenotypes, current knowledge regarding both clinical and biomarker-driven subphenotypes, interplay with AKI subphenotypes and other ICU syndromes, and potential future and clinical implications.Peer reviewe

The characteristics and outcomes of patients with colorectal cancer in New Zealand, analysed by Cancer Network.

AIM: The incidence of colorectal cancer (CRC) in New Zealand is high by international standards. Approximately 1,200 people in New Zealand die from this disease per year. Outcomes in New Zealand following a CRC diagnosis are poor. We aimed to describe the characteristics and outcomes of patients diagnosed with CRC across the four regional cancer networks in New Zealand. METHOD: Patient demographics, tumour characteristics and survival outcomes for all patients diagnosed with CRC between 2006 and 2015 were analysed retrospectively from the National Cancer Registry (NZCR) and National Mortality collection and were linked by National Health Index (NHI) number. RESULTS: A total of 29,221 CRC cases were recorded during the 10-year study period, of which the majority were cancer of the colon (67.9%). In this sample, 42.0% were >75 years, 52.1% were male and 88.1% were New Zealand European. After adjustment for factors such as age, gender, ethnicity year of diagnosis, cancer extent, cancer grade, lymph node and cancer site, cancer-related and all-cause survival were not significantly different by cancer network for those aged 75 years, those living in the Central and Midland Cancer Network had a higher risk of dying of CRC compared to those in the Northern Cancer Network (1.12, 95% CI: 1.03-1.22 and 1.10, 95% CI: 1.02-1.18 respectively). Overall, Māori and Pacific people had worse cancer-specific and all-cause survival than New Zealand European. CONCLUSION: No regional variations were seen within New Zealand for the characteristics and survival outcomes of patients 75, which is supportive of the international literature regarding outcomes for the elderly and CRC. We continue to show disparity in outcomes for Māori and Pacific patients diagnosed with CRC in New Zealand

Environmental Health Organisations against Tobacco

Implementing the World Health Organisation (WHO) Framework Convention on Tobacco Control (FCTC) relies heavily on enforcement. Little is known of the way different enforcement agencies operate, prioritise or network. A questionnaire was sent to representatives of the International Federation of Environmental Health (IFEH) in 36 countries. Tobacco control was given low priority. Almost two thirds did not have any tobacco control policy. A third reported their organisation had worked with other agencies on tobacco control. Obstacles to addressing tobacco control included a lack of resources (61%) and absence of a coherent strategy (39%)

Identification of Incident CKD Stage 3 in Research Studies

In epidemiologic research, incident chronic kidney disease (CKD) is commonly determined by laboratory tests performed at planned study visits. Given the morbidity and mortality associated with CKD, persons with incident disease may be less likely to attend scheduled visits, affecting observed associations. The objective of this study was to quantify loss-to-follow-up by CKD status, and to determine whether supplementation with diagnostic code data improves capture of incident CKD