Laparoscopic totally extraperitoneal inguinal hernia repair in the elderly: A prospective control study

Inguinal hernia (IH) repair can be obtained with both open and laparoscopic techniques, which are usually performed using a transabdominal preperitoneal (TAPP) or a totally extraperitoneal (TEP) approach. The aim of the study was to evaluate whether the results of laparoscopic TEP IH repair in the elderly ( 6565 years old) are different with respect to results obtained in younger patients. One hundred and four consecutive patients (four women and 100 men, median age of 57 years, range=21-85 years) with unilateral (N=21, 20.2%) or bilateral (N=83, 79.8%) IH were prospectively enrolled in the study. Patients were divided into two groups according to their age: group A (N=68, 65.4%) aged <65 years and group B (N=36, 34.6%) aged 6565 years. The mean operative time was not significantly different between groups (48\ub120 vs. 52\ub120 min, p=0.33). One case of increased PaCO2 was observed in each group (p=0.72) and two and one case of pneumoperitoneum (p=0.57) in groups A and B, respectively. Two (1.9%) patients (one in each group; p=0.55) required TEP conversion. Mild postoperative complications developed in four patients of each group (p=0.44). After one-year follow-up, three (2.9%) recurrences occurred (group 1=1, group 2=2, p=0.55), both in patients who had undergone direct IH repair. The overall postoperative relative risk of complications related to age was 1.08 (95% confidence interval=0.91-1.27, p=0.53). In conclusion, our results suggest that in patients with IH scheduled for TEP repair, age does not represent a contraindication to surgery in terms of complication rate and postoperative results

Heart rate variability in critical care medicine: a systematic review.

BACKGROUND: Heart rate variability (HRV) has been used to assess cardiac autonomic activity in critically ill patients, driven by translational and biomarker research agendas. Several clinical and technical factors can interfere with the measurement and/or interpretation of HRV. We systematically evaluated how HRV parameters are acquired/processed in critical care medicine. METHODS: PubMed, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (1996-2016) were searched for cohort or case-control clinical studies of adult (>18 years) critically ill patients using heart variability analysis. Duplicate independent review and data abstraction. Study quality was assessed using two independent approaches: Newcastle-Ottowa scale and Downs and Black instrument. Conduct of studies was assessed in three categories: (1) study design and objectives, (2) procedures for measurement, processing and reporting of HRV, and (3) reporting of relevant confounding factors. RESULTS: Our search identified 31/271 eligible studies that enrolled 2090 critically ill patients. A minority of studies (15; 48%) reported both frequency and time domain HRV data, with non-normally distributed, wide ranges of values that were indistinguishable from other (non-critically ill) disease states. Significant heterogeneity in HRV measurement protocols was observed between studies; lack of adjustment for various confounders known to affect cardiac autonomic regulation was common. Comparator groups were often omitted (n = 12; 39%). This precluded meaningful meta-analysis. CONCLUSIONS: Marked differences in methodology prevent meaningful comparisons of HRV parameters between studies. A standardised set of consensus criteria relevant to critical care medicine are required to exploit advances in translational autonomic physiology.GLA is supported by a British Journal of Anaesthesia and Royal College of Anaesthetists Basic Science fellowship, British Oxygen Company grant from the Royal College of Anaesthetists and British Heart Foundation programme grant (RG/14/4/3073

Heart rate variability and myocardial infarction: systematic literature review and metanalysis

BACKGROUND: Heart rate, measured as beat-to-beat intervals, is not constant and varies in time. This property is known as heart rate variability (HRV) and it has been investigated in several diseases, including myocardial infarction (MI). The main hypothesis is that HRV embed some physiological processes that are characteristics of regulatory systems acting on cardiovascular system. It is possible to quantify such a complex behaviour starting from RR intervals properties itself with the idea that any event affecting the cardiac regulatory system significantly will disrupt and change HRV. In this article, we first review different methodologies previously published to calculate HRV indexes. We then searched literature for studies published on HRV and MI and we derive a metanalysis where published data allow calculation of composite outcomes. MATERIAL AND METHODS: Articles considered eligible for metanalysis were original retrospective/prospective studies investigating HRV after myocardial infarction, reporting follow up for mortality or significant cardiac complications. Random effect model was used to assessed for homogeneity and calculate composite outcome and its 95% confidence interval (CI). RESULTS: 21 studies were identified as eligible for subsequent analysis. Among these studies 5 large trials were eligible for metanalysis: "they included 3489 total post-MI patient with an overall mortality of 125/577 (21.7%) in patients with standard deviation of RR intervals (SDNN) less than 70 msec compared to 235/2912 (8.1%) in patients with SDNN > 70 msec". Metanalysis demonstrates that, after a MI, patients with SDNN below 70 msec on 24 hours ECG recording have almost 4 times more chance to die in the next 3 years. CONCLUSION: Results from metanalysis and other studies considered (but not included in the analysis) are consistent with the final finding, that a disrupted HRV dynamic (low SDNN) is associated with higher adverse outcome. In this perspective, although data are strongly positive for a direct relationship between SDNN and mortality after MI, SDNN value must be considered carefully on a single patient. The primary purpose of the metanalysis was to address whether studies conducted on HRV and MI were consistent rather than established a cut-off for SDNN. HRV is simple, non invasive and relatively not expensive to obtai