Introduction
Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia ...repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.
Methods
An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group’s first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as “strong” (recommendations) or “weak” (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term “should” refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores.
Results and summary
The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with “watchful waiting” since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon’s expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10–12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation “Hernia Center”. From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.
Conclusions
The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.
We present a detailed elemental abundance study of 90 F and G dwarf, turn-off, and subgiant stars in the Galactic bulge. Based on high-resolution spectra acquired during gravitational microlensing ...events, stellar ages and abundances for 11 elements (Na, Mg, Al, Si, Ca, Ti, Cr, Fe, Zn, Y and Ba) have been determined. Four main findings are presented: (1) a wide metallicity distribution with distinct peaks at Fe/H = -1.09, -0.63, -0.20, + 0.12, + 0.41; (2) a highfraction of intermediate-age to young stars where at Fe/H > 0 more than 35% are younger than 8 Gyr, and for Fe/H ≲-0.5 most stars are 10 Gyr or older; (3) several episodes of significant star formation in the bulge has been identified: 3, 6, 8, and 11 Gyr ago; (4) tentatively the "knee" in the α-element abundance trends of the sub-solar metallicity bulge is located at a slightly higher Fe/H than in the local thick disk. These findings show that the Galactic bulge has complex age and abundance properties that appear to be tightly connected to the main Galactic stellar populations. In particular, the peaks in the metallicity distribution, the star formation episodes, and the abundance trends, show similarities with the properties of the Galactic thin and thick disks. At the same time, the star formation rate appears to have been slightly faster in the bulge than in the local thick disk, which most likely is an indication of the denser stellar environment closer to the Galactic centre. There are also additional components not seen outside the bulge region, and that most likely can be associated with the Galactic bar. Our results strengthen the observational evidence that support the idea of a secular origin for the Galactic bulge, formed out of the other main Galactic stellar populations present in the central regions of our Galaxy. Additionally, our analysis of this enlarged sample suggests that the (V-I)0 colour of the bulge red clump should be revised to 1.09.
Water storage plays an important role in mitigating heat and flooding in urban areas. Assessment of the water storage capacity of cities remains challenging due to the inherent heterogeneity of the ...urban surface. Traditionally, effective storage has been estimated from runoff. Here, we present a novel approach to estimate effective water storage capacity from recession rates of observed evaporation during precipitation‐free periods. We test this approach for cities at neighborhood scale with eddy‐covariance based latent heat flux observations from 14 contrasting sites with different local climate zones, vegetation cover and characteristics, and climates. Based on analysis of 583 drydowns, we find storage capacities to vary between 1.3 and 28.4 mm, corresponding to e‐folding timescales of 1.8–20.1 days. This makes the urban storage capacity at least five times smaller than all the observed values for natural ecosystems, reflecting an evaporation regime characterized by extreme water limitation.
Plain Language Summary
Urban water storage plays an important role in mitigating urban flooding and affects urban heat via cooling through evapotranspiration (ET). Determining the amount of water that can be stored in a city remains challenging due to the variability in urban landscapes. The methodology presented estimates this water storage based on how ET declines over time during periods without precipitation. The estimated storage capacities amount to 1.3–28.4 mm, which is at least five times smaller than values that have been reported for natural ecosystems.
Key Points
A new method is applied to infer urban water storage capacity from evapotranspiration recession
Our analysis of evaporation observations reveals water is limiting within days in cities worldwide
Water storage capacity in cities is at least five times smaller than in natural systems
We report the discovery of OGLE-2016-BLG-1190Lb, which is likely to be the first Spitzer microlensing planet in the Galactic bulge/bar, an assignation that can be confirmed by two epochs of ...high-resolution imaging of the combined source-lens baseline object. The planet's mass, Mp = 13.4 0.9 MJ, places it right at the deuterium-burning limit, i.e., the conventional boundary between "planets" and "brown dwarfs." Its existence raises the question of whether such objects are really "planets" (formed within the disks of their hosts) or "failed stars" (low-mass objects formed by gas fragmentation). This question may ultimately be addressed by comparing disk and bulge/bar planets, which is a goal of the Spitzer microlens program. The host is a G dwarf, Mhost = 0.89 0.07 M , and the planet has a semimajor axis a ∼ 2.0 au. We use Kepler K2 Campaign 9 microlensing data to break the lens-mass degeneracy that generically impacts parallax solutions from Earth-Spitzer observations alone, which is the first successful application of this approach. The microlensing data, derived primarily from near-continuous, ultradense survey observations from OGLE, MOA, and three KMTNet telescopes, contain more orbital information than for any previous microlensing planet, but not quite enough to accurately specify the full orbit. However, these data do permit the first rigorous test of microlensing orbital-motion measurements, which are typically derived from data taken over <1% of an orbital period.
Spectral wave dissipation over a barrier reef Lowe, Ryan J.; Falter, James L.; Bandet, Marion D. ...
Journal of Geophysical Research - Oceans,
April 2005, Letnik:
110, Številka:
C4
Journal Article
Recenzirano
Odprti dostop
A 2 week field experiment was conducted to measure surface wave dissipation on a barrier reef at Kaneohe Bay, Oahu, Hawaii. Wave heights and velocities were measured at several locations on the fore ...reef and the reef flat, which were used to estimate rates of dissipation by wave breaking and bottom friction. Dissipation on the reef flat was found to be dominated by friction at rates that are significantly larger than those typically observed at sandy beach sites. This is attributed to the rough surface generated by the reef organisms, which makes the reef highly efficient at dissipating energy by bottom friction. Results were compared to a spectral wave friction model, which showed that the variation in frictional dissipation among the different frequency components could be described using a single hydraulic roughness length scale. Surveys of the bottom roughness conducted on the reef flat showed that this hydraulic roughness length was comparable to the physical roughness measured at this site. On the fore reef, dissipation was due to the combined effect of frictional dissipation and wave breaking. However, in this region the magnitude of dissipation by bottom friction was comparable to wave breaking, despite the existence of a well‐defined surf zone there. Under typical wave conditions the bulk of the total wave energy incident on Kaneohe Bay is dissipated by bottom friction, not wave breaking, as is often assumed for sandy beach sites and other coral reefs.
New International Maritime Organization regulations require shippers to classify all solid bulk cargo to indicate whether they are Harmful to the Marine Environment (HME). The objective of this work ...was to adapt the freshwater Transformation/Dissolution Protocol (T/DP) to marine water to provide a method to determine, when compared with marine Ecotoxicity Reference Values (ERVs), whether a metal-bearing substance is HME. The substances examined were: Cu2O powder; Ni metal powder; Co3O4 powder; and a Ni–Co–Fe alloy, as wire cuttings, which were the same substances examined in the freshwater T/D validation study and afforded comparisons of the reactivity, or measure of the rate and extent of metal release from the metal-bearing substances in freshwater versus marine conditions. The marine T/D method is suitable for conducting examinations of metal-bearing substances with a wide range of reactivities, from the relatively reactive Cu2O powder and the alloy to the Co3O4 powder, which was the least reactive.
•Existing freshwater protocol for metal substances' aquatic hazard classification adapted for marine waters•Method applied to a cuprous oxide powder, a Ni metal powder, a tricobalt tetraoxide powder and a Ni-Co-Fe alloy
Fear memories are acquired through neuronal plasticity, an orchestrated sequence of events regulated at circuit and cellular levels. The conventional model of fear acquisition assumes unimodal (for ...example, excitatory or inhibitory) roles of modulatory receptors in controlling neuronal activity and learning. Contrary to this view, we show that protease-activated receptor-1 (PAR1) promotes contrasting neuronal responses depending on the emotional status of an animal by a dynamic shift between distinct G protein-coupling partners. In the basolateral amygdala of fear-naive mice PAR1 couples to Gαq/11 and Gαo proteins, while after fear conditioning coupling to Gαo increases. Concurrently, stimulation of PAR1 before conditioning enhanced, but afterwards it inhibited firing of basal amygdala neurons. An initial impairment of the long-term potentiation (LTP) in PAR1-deficient mice was transformed into an increase in LTP and enhancement of fear after conditioning. These effects correlated with more frequent 2-amino-3-(5-methyl-3-oxo-1,2-oxazol-4-yl)propanoic acid (AMPA) receptor-mediated miniature post synaptic events and increased neuronal excitability. Our findings point to experience-specific shifts in PAR1-G protein coupling in the amygdala as a novel mechanism regulating neuronal excitability and fear.
PDF
