Herniography in symptomatic patients following inguinal hernia repair.

Patients with symptoms at the site of a previous inguinal hernia repair may constitute a diagnostic dilemma. The usefulness of herniography in the assessment of these patients was evaluated at 54 symptomatic sites in 46 subjects. Ten persistent or recurrent hernias were shown by herniography, only 2 of which were definitely detected on physical examination. The herniogram was normal at 44 sites, of which, on physical examination, 5 were equivocal and 1 was diagnosed as a definite hernia. On the unoperated-on or asymptomatic side, a total of 14 hernias were shown herniographically. Of these hernias, 8 were not detected on physical examination. Herniography was found to be more sensitive than physical examination in detecting hernias at the symptomatic, previously operated-on sites, as well as at the unoperated-on or asymptomatic sites. When a herniogram provides corroborative evidence that hernia has not recurred, the need for reexploration may be eliminated.     

Lipid peroxidation and inguinal hernia repair. Tension-free vs. Andrews technique

AIM OF THE STUDY: To evaluate the early effect of inguinal hernia repair by the tension-free method compared to the conventional Andrew's technique on lipid peroxidation. PATIENTS-METHODS: Thirty-four patients subjected to elective hernia repair were enrolled in the study divided in two groups. Group A (n=18) underwent hernia repair by the tension-free method using a polypropylene mesh. Group B (n=16) underwent hernia repair by the Andrew's technique (i.e. a modification of the Bassini's technique). Venous blood samples were drawn preoperatively and at 12, 24 and 48 h postoperatively. Malondialdehyde (MDA) was estimated by the thiobarbiturate assay. RESULTS: Neutrophil counts were significantly higher in patients of group B compared to group A at 12 and 48 h postoperatively. Concentrations of fibrinogen were similar between the two groups. MDA was significantly higher in patients of group B hours compared to group A at 12, 24 and 48 h postoperatively. Positive correlation was found between neutrophil counts and MDA at 12 h (r: +0.43, P: 0.015) and 48 h (r: +0.496, P: 0.005) but not at 24 h. No correlation was found between serum fibrinogen and MDA. CONCLUSION: Hernia repair by the Andrews's technique elicits a sustained triggering of lipid peroxidation, compared to the tension-free method.     

Prevalence and determinants of caesarean section in Jamaica.

The prevalence and determinants of primary caesarean section in Jamaica were estimated from a survey of women aged 14-49 years. Among 2328 women reporting 2395 live hospital births during the period January 1984 to May 1989, the prevalence of caesarean section was 4.1%. Repeat caesarean sections accounted for 1.3% of the hospital births during that period. Of the medical complications studied, prolonged labour and/or cephalopelvic disproportion carried the highest risks of primary caesarean section, followed by breech presentation, maternal diabetes, a high birth-weight baby, maternal hypertension, and a low birth-weight baby. The risk of primary caesarean section increased with maternal age, decreased with parity, was higher for urban than for rural residents, and was higher for births in private versus government hospitals.     

Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost

Objective: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. Design: A randomised controlled trial of 403 patients with inguinal hernias. Setting: Two acute general hospitals in London between May 1995 and December 1996. Subjects: 400 patients with a diagnosis of groin hernia, 200 in each group. Main outcome measures: Time until discharge, postoperative pain, and complications; patients’ perceived health (SF-36), duration of convalescence, and patients’ satisfaction with surgery; and health service costs. Results: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (χ²=6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was £335 (95% confidence interval £228 to £441) more than the cost of open repair. Conclusion: This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.

Key messages

• In the 4 hours after surgery laparoscopic hernia repair with general anaesthesia causes more pain than open repair with local anaesthesia (mainly because of the anaesthesia used) and necessitates longer stay in hospital. Laparoscopic hernia repair, however, causes less pain than open hernia repair during the first 2 weeks after discharge
• Laparoscopic hernia repair results in fewer episodes of wound infection, persistent local pain, genital swelling, numbness, and constipation than open repair. Urinary disturbances are more common after laparoscopic than after open repair
• Patients’ perception of health 1 month after the operation (assessed with the SF-36) and satisfaction with treatment is superior for laparoscopic patients who also have a shorter period of convalescence after surgery
• The health service cost of day case laparoscopic repair is £335 more than the cost of open mesh hernioplasty performed on a day case basis

     

Size of newborn and caesarean section deliveries among teenagers in sub-Saharan Africa: evidence from DHS

This paper uses DHS data from 20 countries in sub-Saharan Africa, collected in the late 1990s and early 2000s, to examine perceived size of newborn and Caesarean section deliveries among teenagers in the region. A comparison between teenagers and older women, based on logistic regression analyses for individual countries, as well as multilevel logistic analyses applied to pooled data across countries, and controlling for the effects of important socioeconomic and demographic factors, shows that in general, births to teenagers are more likely to be small in size but are less likely to be delivered by Caesarean section compared with births among older women. An examination of the country-level variations shows significant differences in perceived size of newborn and Caesarean section deliveries between countries. However, the observed pattern by maternal age does not vary significantly between countries, suggesting that these patterns are generalizable for the region. For teenagers with characteristics associated with higher odds of Caesarean section, being in a country with an overall higher rate particularly amplifies their individual probability.     

Trends in the twinning rate in Johannesburg, South Africa, 1969-1989 and estimated twinning rates for 1990.

Birth statistics for the Johannesburg Metropolitan Region were collected for 757 151 confinements from 1969 to 1989 (467513 Black, 194375 White, 67250 Coloured and 28013 Indian confinements). From 1969 to 1978 data on the sexes of twins were also collected for 375 203 of the confinements (203 504 Black, 129 631 White, 28 253 Coloured and 13 815 Indian confinements). A twin confinement was defined as two deliveries during one confinement. Twinning rates (TRs), defined as the number of twin confinements per 1000 total confinements, were calculated per year for each population group and from 1969-1978 estimates of the relative proportions of dizygotic (DZ) and monozygotic (MZ) twins were calculated and thus the relative DZTRs and MZTRs. A significant decline in Black and Coloured TRs was observed between 1969 and 1989. A significant decline in Black DZTR but not Black MZTR was observed between 1969 and 1978, the Coloured twin sample was too small to show significant trends over this period. It is probable that the overall decline in Black twinning may be explained by a decline in the DZTR. An analysis of birth statistics for 159 748 confinements (134 504 Black and 25 244 White confinements) collected as part of a prospective study of TRs in the Johannesburg Metropolitan Region from 1988 to 1990, indicated that the Black TR continued to decline at least until the end of 1990. TRs in the Johannesburg Metropolitan Region calculated from City Health Department birth statistics collected from 1988 to 1990 were: 13.8 and 10.77 for the Black and White populations, respectively. TRs for this period calculated from the combined birth statistics of 14 hospitals, nursing homes and maternity clinics across the region were: 12.4 and 10.88 for the Black and White populations, respectively.     

The long-term effect of mesh bioprosthesis in inguinal hernia repair on testicular nitric oxide metabolism and apoptosis in rat testis

Polypropylene mesh is the most widely used material in inguinal hernia repair. Although polypropylene mesh is known as an inert material, it is experimentally proven that mesh generates a chronic inflammatory tissue reaction. The aim of the present study was to investigate the long-term effects of polypropylene mesh material used in inguinal hernia operations on testicular function, testicular nitric oxide (NO) metabolism and germ cell-specific apoptosis in rats. The study comprised 40 male rats that were randomly allocated into two groups. In group 1, the left spermatic cord was elevated and a 0.5 x 1 cm polypropylene mesh was placed behind the left inguinal spermatic cord and group 2 consisted of the sham-operated controls. Blood samples were taken at 6 months preoperatively and postoperatively after to assess luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels for hormonal evaluation. Testicular NO was evaluated by the Griess method, apoptosis by a TUNEL method and inducible nitric oxide synthase (iNOS) and endothelial NOS (eNOS) expressions by immunohistochemical staining. Mild (+) eNOS expression was observed in all specimens. Mild (+) iNOS expression was only detected in ipsilateral testis of the mesh-implanted study group. Apoptotic cells were not detected in any samples. We are of the opinion that long-term polypropylene mesh implantation has no effect on testicular hormonal function and only a limited effect on nitric oxide levels and this effect is not sufficient to cause apoptosis in testis that could lead to infertility. It seems that mesh implantation is a reliable method in inguinal hernia repair; however, further work is required by more sensitive methods to fully elucidate the potential testicular damage.     

A model for managing epilepsy in a rural community in Africa.

As most Malawians with epilepsy consider treatment of seizures to be the domain of traditional healers and attend hospital only when they require treatment for burns which they suffer during fits, steps were taken to encourage people with epilepsy to attend hospital for regular treatment with anticonvulsant drugs. At first only a few patients attended, but within two years 461 had registered at the hospital and two mobile clinics. Publicity was spread through the area action committee, which was organised by the area chief. The main drug used was phenobarbitone. After treatment was given for six months seizures were fully controlled in 40 (56%) out of 71 patients. A further 20 (28%) had greatly improved. As news of the clinics spread other health units adopted the model, and eventually over 3000 patients with epilepsy were receiving regular treatment at 45 units throughout Malawi.     

Comparison of the plasma and hernia sac tissue copper levels in direct and indirect inguinal hernia patients

Although the inguinal hernia is among the most commonly encountered and well-described health problems all over the world, the etiology is still controversial. The aim of this study was to compare the plasma and hernia sac tissue copper levels in direct and indirect inguinal hernia patients. Plasma and hernia sac tissue copper levels obtained from patients operated under spinal anesthesia with primary direct (group I, n = 55, 45 male, mean age = 45.68 yr) and indirect (group II, n = 55, 40 male, mean age = 38.57 yr) hernias were detected by atomic absorption spectrophotometer. Significantly lower plasma and hernia sac tissue copper levels were detected in group I in comparison to group II (p < 0.001). Both plasma and hernia sac tissue copper levels were significantly lower in males when we compare the patients according to their sex characteristics, including both direct and indirect hernia groups (p < 0.05 and p < 0.01, respectively). Age was not a significant factor. The plasma and hernia sac tissue copper levels were significantly lower in direct hernia patients in comparison to indirect hernia patients. Copper is a cofactor of lysyl oxidase, an important enzyme in collagen tissue metabolism, so there might be a defect in the collagen synthesis of direct hernia patients because of the decreased activity of the lysyl oxidase. Further investigations are necessary to clarify this concept.     

Rights and responsibilities in rural South Africa: implications for gender,generation, and personhood

In the rural Eastern Cape, South Africa, contests over the meaning and merit of human rights feature prominently in intergenerational and intergendered conflicts. In this article I identify and analyse a tension between amalungelo (a socially embedded and relational form of rights) and irhayti (a Xhosaization of the English ‘[human] right’) as a means of exploring the interpersonal tensions that arise through the production and contestation of the subject positions that human rights set in motion. Using the examples of elders’ complaints of neglect, and of young men's accusations of human rights violations on the part of women, I ground this investigation in men's and elders’ explanations of how human rights enable morally reprehensible actions, and are implicated in what they perceive to be a climate of interpersonal neglect. In analysing these claims, I show that gendered and generational conflict in this region is grounded in uncertainty about the content of gendered and generational subject positions themselves, and speaks to the relative moral value of autonomous versus relational forms of personhood. Moreover, I show that where inequality and interdependence are intrinsic to the ways in which gendered and generational subject positions are constituted and understood, human rights serve both to destabilize the content of these subject positions in ways that render appropriate gendered and generational sociality unclear, and also to bring into question the relative moral value of autonomous versus more relational forms of personhood.     

Repeated insemination in Michigan Holstein-Friesian cattle: Incidence, descriptive epidemiology and estimated economic impact

Twenty-two Michigan dairy herds participating in a computerized herd-health program were studied to determine the incidence and epidemiologic characteristics of repeat-breeder syndrome. A cow with repeat-breeder syndrome was defined as having been inseminated three or more times within the same lactation. Repeat-breeder syndrome was observed in 24% of 3,309 lactations. Cost components associated with unsuccessful inseminations included costs of delayed conception, extra inseminations, extra veterinary service and losses due to culling. Lactations with repeat-breeder syndrome were associated with a loss of approximately $385. An estimated extra cost of $140 was associated with a second insemination, $279 with three inseminations, $429 with four inseminations and $612 with five inseminations.