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Purpose: Relying solely on in-person encounters to assess long-term outcomes of hernia repair leads to substantial loss of information and patients lost-to-follow-up, hindering research and quality improvement initiatives. We aimed to determine if inguinal hernia recurrences could be assessed using the Ventral Hernia Recurrence Inventory (VHRI), a previously existing patient-reported outcome (PRO) tool that can be administered through the telephone and has already been validated for diagnosing ventral hernia recurrence.Methods: A prospective, multicentric comparative study was conducted. Adult patients from two centers (United States and Brazil) at least 1 year after open or minimally invasive inguinal hernia repair were asked to answer the questions of the VHRI in relation to their prior repair. A physical exam was then performed by a blinded surgeon. Testing characteristics and diagnostic performance of the PRO were calculated. Patients with suspected recurrences were preferentially recruited.Results: 128 patients were enrolled after 175 repairs. All patients answered the VHRI and were further examined, where a recurrence was present in 32% of the repairs. Self-reported bulge and patient perception of a recurrence were highly sensitive (84-94%) and specific (93-94%) for the diagnosis of an inguinal hernia recurrence. Test performance was similar in the American and Brazilian populations despite several baseline differences in demographic and clinical characteristics.Conclusion: The VHRI can be used to assess long-term inguinal hernia recurrence and should be reestablished as the Hernia Recurrence Inventory (HRI). Its implementation in registries, quality improvement efforts, and research could contribute to improving long-term follow-up rates in hernia patients. [ABSTRACT FROM AUTHOR]

Background: Umbilical hernias present commonly during pregnancy secondary to increased intra-abdominal pressure. As a result, umbilical hernia incarceration or strangulation may affect pregnant females. The purpose of this study is to detail the operative management and 30-day outcomes of umbilical hernias in pregnant patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).Methods: All female patients undergoing umbilical hernia repair during pregnancy were identified within the ACS-NSQIP. Preoperative patient variables, intraoperative variables, and 30-day patient morbidity and mortality outcomes were investigated using a variety of statistical tests.Results: A total of 126 pregnant patients underwent umbilical hernia repair from 2005 to 2014; 73 (58%) had incarceration or strangulation at the time of surgical intervention. The majority of patients (95%) underwent open umbilical hernia repair. Superficial surgical site infection was the most common morbidity in patients undergoing open umbilical hernia repair.Conclusions: Based on review of the ACS-NSQIP database, the incidence of umbilical hernia repair during pregnancy is very low; however, the majority of patients required repair for incarceration of strangulation. When symptoms develop, these hernias can be repaired with minimal 30-day morbidity to the mother. Additional studies are needed to determine the long-term recurrence rate of umbilical hernia repairs performed in pregnant patients and the effects of surgical intervention and approach on the fetus. [ABSTRACT FROM AUTHOR]

Purpose: Wide variation in care and costs exists regarding the management of abdominal wall hernias, with unproven benefit for many therapies. This work establishes a specialty society-based solution to improve the quality and value of care delivered to hernia patients during routine clinical management on a national scale.Methods: The Americas Hernia Society Quality Task Force was charged by the Americas Hernia Society leadership to develop an initiative that utilizes the concepts of continuous quality improvement (CQI). A disease-based registry was created to collect information for CQI incorporating real-time outcome reporting, patient reported outcomes, stakeholder engagement, and collaborative learning methods to form a comprehensive quality improvement effort.Results: The Americas Hernia Society Quality Collaborative (AHSQC) was formed with the mission to provide health care professionals real-time information for maximizing value in hernia care. The initial disease areas selected for CQI were incisional and parastomal hernias with ten priorities encompassing the spectrum of care. A prospective registry was created with real-time analytic feedback to surgeons. A data assurance process was implemented to ensure maximal data quality and completeness. Four collaborative meetings per year were established to meet the goals of the AHSQC. As of the fourth quarter 2014, the AHSQC includes nearly 2377 patients at 38 institutions with 82 participating surgeons.Conclusions: The AHSQC has been established as a quality improvement initiative utilizing concepts of CQI. This ongoing effort will continually refine its scope and goals based on stakeholder input to improve care delivered to hernia patients. [ABSTRACT FROM AUTHOR]

Purpose: The study objective is to document value created by real-world evidence from the Abdominal Core Health Quality Collaborative (ACHQC) for regulatory decisions. The ACHQC is a national effort that generates data on hernia repair techniques and devices., Methods: Two retrospective cohort evaluations compared cost and time of ACHQC analyses to traditional postmarket studies. The first analysis was based on 25 reports submitted to the European Medicines Agency of 20 mesh products for post-market surveillance. A second analysis supported label expansion submitted to the Food and Drug Administration, Center for Devices and Radiological Health for a robotic-assisted surgery device to include ventral hernia repair. Estimated costs of counterfactual studies, defined as studies that might have been done if the registry had not been available, were derived from a model described in the literature. Return on investment, percentage of cost savings, and time savings were calculated., Results: 45,010 patients contributed to the two analyses. The cost and time differences between individual 25 ACHQC analyses (41,112 patients) and traditional studies ranged from $1.3 to $2.2 million and from 3 to 4.8 years, both favoring use of the ACHQC. In the second label expansion analysis (3,898 patients), the estimated return on investment ranged from 11 to 461% with time savings of 5.1 years favoring use of the ACHQC., Conclusions: Compared to traditional postmarket studies, use of ACHQC data can result in cost and time savings when used for appropriate regulatory decisions in light of key assumptions., (© 2024. The Author(s).)

Purpose: Elective repair of large incisional hernias using posterior component separation with transversus abdominis release (TAR) has acceptable wound morbidity and long-term recurrence rates. The outcomes of using this reconstructive technique in the non-elective setting remains unknown. We aim to report 30-day outcomes of TAR in non-elective settings., Methods: All patients undergoing open TAR in non-elective settings were identified within the Americas Hernia Society Quality Collaborative (AHSQC). A retrospective review was conducted and outcomes of interest were 30-day Surgical Site Infections (SSI), Surgical Site Occurrences (SSO), SSOs requiring procedural intervention (SSOPI), medical complications, and unplanned readmissions and reoperations., Results: Fifty-nine patients met inclusion criteria. Mean BMI was 36.6 ± 8.9 kg/m 2 and mean hernia width was 14.4 ± 7.2 cm. Forty (67.8%) were recurrent hernias. Pain (88%) and bowel obstruction (79.7%) were the most frequent indications for surgery. Surgical field was classified as clean in 69.5% of cases, with an 88% use of permanent synthetic mesh and fascial closure achieved in 93.2% of cases. There were 15 (25.4%) total wound events, 8 (13.6%) were SSIs. There were 8 (13.6%) SSOPIs, 6 of which were wound opening, 1 wound debridement, and 1 percutaneous drainage. At least one wound or medical complication was reported for 37% of the patients. There were no mortalities., Conclusion: Not surprisingly, TAR in the non-elective setting is associated with increased wound morbidity requiring procedural interventions and reoperations compared to what has previously been reported for elective cases. The long-term consequences of this wound morbidity with regard to hernia recurrence are as of yet unknown.

Although pulmonary diseases are important causes of illness and death in patients with human immunodeficiency virus (HIV) infection, advances in treatment and the demographics of HIV-infected populations are changing their incidence and manifestations. The rates of acquires immune deficiency syndrome (AIDS)- related mortality and opportunistic infections have fallen drastically since the introduction of highly active antiretroviral therapy (HAART) in 1996. The risk of developing specific disorders is related to the degree of immunosuppression, HIV risk group, area of residence, and use of antiretroviral treatments and prophylaxis against common infections. HIV-infected drug users are at increased risk for developing bacterial pneumonia and tuberculosis. Bronchitis and sinusitis occur commonly in the general population, but more frequently in HIV-infected persons. With progressive immunocompromise, the risk of developing bacterial pneumonia, Pneumocystis carinii pneumonia, and tuberculosis increases.

Despite the improvements in the prognosis associated with the development of highly active antiretroviral therapy (HAART), more than 410,000 people in the United States were reported to have died from acquired immune deficiency syndrome (AIDS) by the end of 1998. The number of people living with human immunodeficiency virus (HIV) infection and AIDS in the United States continues to increase, estimated at more than 370,000 in 1998, and there is good reason for optimism that HIV infection may be a controllable disease in many people. Nevertheless, an estimated 27,000 persons still died of AIDS in the United States in 1997, and AIDS is still a leading cause of death in the age group 25 to 44 years. Despite the dramatic treatment advances for HIV infection and improving survival following an AIDS diagnosis, many patients still present with life-threatening complications of HIV infection for three major reasons. Highly active antiretroviral therapy and prophylaxis against Pneumocystis carinii and other infections are not effective in all patients, despite rigorous adherence to treatment. Others adhere to these therapies poorly. Finally, many patients present with advanced disease, unaware that they have HIV infection until they develop a serious opportunistic infection. Therefore, the AIDS epidemic and its burden of illness will continue, and decisions regarding the appropriateness of intensive care for individual patients will be inevitable. The impact of AIDS in Africa and Asia is far more devastating than in the United States and Europe, and most HIV-infected persons in the world live in the underdeveloped nations where intensive care is often unavailable. This article will deal with intensive care in patients with HIV in developed nations.

Bacterial pneumonia, specifically pneumococcal infection, is a frequent cause of morbidity and mortality in persons infected with human immunodeficiency virus (HIV). It causes morbidity directly and possibly progression of HIV infection. The clinical presentation and response to therapy are usually similar to that of patients without HIV infection, although radiographic presentations may be atypical. There is a higher incidence of invasive disease and extrapulmonary disease, and mortality may be increased in HIV-infected patients. HIV infection impairs the host response to pneumococcus in a variety of ways. Colonization with Streptococcus pneumoniae may be prolonged for reasons that are incompletely understood. Concern about the rising prevalence of resistant pneumococcal strains is increasing, but the clinical relevance is uncertain. At least 90% of the strains that cause invasive disease are present in the 23-valent pneumococcal vaccine. The response to vaccination declines as immunodeficiency progresses; however, the potential benefit to responders is great and the risk is minimal. Therefore, this vaccine is recommended for all HIV-infected persons.

The course of pneumonia caused by pyogenic bacteria and Pneumocystis carinii was examined in a multicity cohort study of HIV infection. The median duration of survival among 150 individuals following initial bacterial pneumonia was 24 months, compared with 37 months among 299 human immunodeficiency virus (HIV)-infected control subjects matched by study site and CD4 lymphocyte count (P<.001). For 152 subjects with P. carinii pneumonia, median survival was 23 months, compared with 30 months for 280 matched control subjects (P = .002). Median durations of survival associated with the two types of pneumonia differed by only 47 days, despite a higher median CD4 lymphocyte count associated with bacterial pneumonia. These results suggest that both P. carinii pneumonia and bacterial pneumonia are associated with a significantly worse subsequent HIV disease course. The similarity of prognosis after one episode of bacterial pneumonia vs. an AIDS-defining opportunistic infection and the proportion of cases occurring in association with a CD4 lymphocyte count of >200 suggest that measures to prevent bacterial pneumonia should be emphasized.

Background: The resurgence of tuberculosis in the United States is largely linked to the human immunodeficiency virus (HIV) epidemic. Despite this link, the epidemiology of tuberculosis and preventive strategies in patients infected with HIV are not completely understood., Objectives: To determine the incidence and predictors of tuberculosis in HIV-infected persons., Design: Prospective, multicenter cohort study., Setting: Community-based cohort of persons with and without HIV infection at centers in the eastern, midwestern, and western United States., Participants: 1130 HIV-seropositive patients without AIDS who were followed for a median of 53 months (814 homosexual men, 261 injection drug users, and 55 women who had acquired HIV through heterosexual contact)., Measurements: Delayed hypersensitivity response to purified protein derivative (PPD) tuberculin and mumps antigen, CD4 T-lymphocyte counts, and frequency of tuberculosis., Results: 31 HIV-seropositive patients developed tuberculosis (0.7 cases per 100 person-years [95% CI, 0.5 to 1.0]). The most important demographic risk factor was location (adjusted risk ratio for eastern compared with midwestern and western United States, 4.1 [CI, 2.0 to 8.4]). Tuberculosis occurred more frequently in persons with CD4 counts of less than 200 cells/mm3 (1.2 cases per 100 person-years [CI, 0.7 to 1.9]) than in those with higher counts (0.5 cases per 100 person-years [CI, 0.3 to 0.8]). The rate of tuberculosis was highest among tuberculin converters (5.4 cases per 100 person-years [CI, 1.1 to 15.7]), lower among patients who were PPD positive at first testing (4.5 cases per 100 person-years [CI, 1.6 to 9.7]), and lowest among patients who remained PPD negative (0.4 cases per 100 person-years [CI, 0.2 to 0.7]). Tuberculosis was not reported among persons who had PPD reactions of 1 to 4 mm. Compared with that of patients who tested positive for mumps, the risk for tuberculosis of those who tested negative was increased about sevenfold if they were PPD positive (P < 0.03) and fourfold if they were PPD negative (P < 0.02)., Conclusions: Incidence of tuberculosis was higher in the eastern United States, in patients with CD4 counts of less than 200 cells/mm3, and in PPD-positive patients. Analysis of tuberculin reaction size supports the current interpretive criteria of the Centers for Disease Control and Prevention. Nonreactivity to mumps antigen indicated increased risk for tuberculosis independent of PPD response.