New medical FICO score sparks controversy, questions

Jeremy M. Simon, On Thursday July 28, 2011, 8:00 am EDT

Within the next 12 months, whether you like it or not, about 10 million Americans are expected to be scored -- much like a credit score -- on how likely they are to fill a prescription and take all the pills the doctor ordered, on schedule.

FICO , creator of the widely used credit score that predicts whether you'll borrow responsibly, is now rolling out its new Medication Adherence Score.

FICO based its score on a formula that predicts whether you will take your prescription drugs. FICO says that since correct use of medication is important for patients, medical providers, insurers and pharmaceutical companies, the Medication Adherence Score will help achieve that goal. They predict it will improve therapy effectiveness and reduce health care costs.

The company says those who score low can be targeted for extra reminders and educational efforts, with the goal of making patients more likely to complete their prescribed regimens.

"It's very important to identify those people who may need that additional education and that additional help," says Dave Shellenberger, senior principal consultant in FICO's health care division.

Critics aren't so sure. Since the score uses information on patients' employment, homeownership and living situations, they say that in the current economic environment, the Medication Adherence Score may unfairly target people who have found themselves in challenging financial situations. It could also, they say, open the door for a new way for insurance companies to charge different prices for different scores. This happened in recent years to consumers buying auto insurance: The cost of those policies are now likely based on an auto insurance credit score .

What's in the score?
FICO launched the Medication Adherence Score on June 23, 2011. To create the scoring algorithm, FICO looked at data from a random sample of several million anonymous patients provided by a large pharmacy benefits manager. FICO observed patients who filled (or refilled) their prescriptions and patients who failed to, with the company then identifying those variables that best predicted medication adherence. For the Medication Adherence Score, those variables include age, gender, family size and asset information -- such as the likelihood of car ownership -- data also used by direct marketing companies. FICO says that with only a patient's name and address, it can pull the remainder of the necessary information from publicly available sources.

The scores range from 1 to 500. "The higher the score, the higher the likelihood a patient will be adherent to a drug regimen," FICO's Shellenberger says. FICO says patients who score 400 or higher are likely to take medication as prescribed, while those who score below 200 are at high risk of not taking medication. According to FICO, patients who earn a low score may receive a medication reminder in the form of an email, letter or phone call from their doctor -- tactics that would be too costly to apply across the board.

FICO says those who wouldn't want to receive notices should contact their health care providers and ask about their opt-out policies. High scorers who appear likely to take all their meds probably won't be contacted.

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Robotic surgery gains popularity

Patients appreciate faster recovery; surgeons report ability to see better

By Rhiannon Meyers

Corpus Christi Caller Times

Posted July 23, 2011 CORPUS CHRISTI — As the patient lay motionless on the table, her belly exposed and marked for a hysterectomy, Dr. Laura Shelton prepped for surgery.Shelton removed her plastic face shield and pulled off her sanitized surgeon's gown. She sank into a rolling chair, pushed up her long sleeves to the elbows and kicked off her tennis shoes.

For the next hour, Shelton performed the hysterectomy in a pair of pink and gray ankle socks sitting at a console 6 feetfrom the patient.

A live video feed from within the woman's abdomen illuminated Shelton's pale blue eyes as she worked a set of joysticks guiding robotic arms that cut, cauterized and sutured.

This, Shelton said, is the future of surgery.

The growing popularity of this pricey equipment — which can cost more than $2 million, according to some estimates — has sparked a debate on the merits and risks of robotic surgery.

Both local hospital systems now have surgical robots in an effort, hospital officials say, to provide minimally invasive surgery that shortens patients' hospital stays. Christus Spohn Health System bought one last year and Corpus Christi Medical Center added one in January.

Surgeons who use the robots say the technology allows patients to recover quicker because they lose less blood — less than a tablespoon, in some cases — and the incisions are smaller, sometimes less than half an inch.

"We can have them back on their feet in a week instead of six weeks," said Dr. Stan Shoemaker, an obstetrician/gynecologist who operates at Corpus Christi Medical Center. "It's a much more attractive alternative."

Advocates also say robotic surgery causes less physical strain on the surgeon and could lengthen a doctor's career in the operating room. Shoemaker said the robot also allows him to perform more challenging surgeries in a minimally invasive way.

"I'm not nearly as frightened about a tough case," Shoemaker said.

But others argue that the benefits are overstated and driven by marketing, at times by the robot's manufacturer, Intuitive Surgical Inc., which earned $1.4 billion in its last fiscal year.

One recent study suggested there was no solid scientific evidence to back claims that robotic surgery is more precise and results in less pain. The study, released in May by Johns Hopkins University School of Medicine researchers, also argued that hospitals often use Intuitive Surgical's promotional materials and fail to talk about robotic surgery risks, including claims that such surgeries can take more time, causing patients to remain under anesthesia longer, and that they are more costly.

There remains a healthy debate about the merits of traditional surgery versus the robotic procedure, said Dr. Benjamin Lowentritt, a urologist in Baltimore who solely offers robotic surgery.

"I don't think it does anyone any good to declare it as a cure-all and the perfect treatment," he said. "I would not advocate (open surgery) in my practice, but at the same time, I don't fault anyone for making that choice."

Still, Lowentritt said, it's difficult for any hospital to opt against offering robotic surgery because of the strong patient demand.

"I wouldn't want to go to a hospital that didn't have it for my prostate care," he said. "To be a center that provides the full complement of care to your patients, I think it is something that you should have."

Plus, he said, robotic surgery acts as a good recruiting tool for new surgeons.

"As time goes on, hospitals and communities that don't have them will more and more have difficulty attracting newer and recently trained physicians," he said.n n nFor the past 1½ years, Debra Cantu, 34, struggled with near-constant pelvic pain and an overactive bladder. She popped pain relievers at least three times a week and ran to the bathroom once an hour. She woke frequently at night to use the restroom.

Shelton diagnosed her with uterine fibroids, which are noncancerous tumors, and possibly endometriosis, a painful condition where tissue typically lining the uterus grows outside the uterus, becomes inflamed and eventually develops scar tissue and adhesions, which bind organs together and causes pelvic pain, according to the Mayo Clinic.

Shelton recommended giving Cantu a partial hysterectomy using Christus Spohn Health System's da Vinci robot.

The robots are controlled solely by the surgeon, who sits at a nearby console and views the surgery through a viewfinder, where the images are magnified 10 times and appear in 3D.

Robotic instruments, which look like miniature forceps, are inserted through tubes in the patient's body. The surgeon uses joysticks to direct them to pinch, cut and sew.

Using a pedal that looks like a car accelerator, the surgeon can move around a small, lighted camera, usually inserted through a tube in the patient's belly button, to peek around organs and zoom in on blood vessels. The surgeon uses another pedal to deliver bursts of electricity that cauterize, or burn, tissue and blood vessels to seal them and stop the bleeding.

As Shelton worked at the console Wednesday – shoeless, she said, so she could better feel the pedals – she navigated the instruments past organs and blood vessels that filled the flat-screen televisions on each side of the operating room.

Shelton pointed to scar tissue and adhesions that marred the inside of Cantu's pelvis and decided she had to do a complete hysterectomy. It was the only option, she said, that could relieve Cantu of her pain, even though it would force the mother of two into early menopause.

It was an option they had discussed in a pre-operative appointment, but once Shelton saw in excruciating detail the extent of the scarring from Cantu's endometriosis, she said she realized the problem was worse than expected. Cantu's ovaries had adhered to her abdominal wall and scar tissue was tucked underneath her uterus, a typically hard-to-reach area for a surgeon.

Shelton said she wouldn't have been able to see such detail with traditional surgery, which likely would have been more challenging.

"The visualization is key," she said. "I could see exactly where the adhesions were, exactly where to cut."

Lowentritt, who said he was skeptical at first of what he thought would be a gimmicky new technology, said the visualization provided by robotic surgery changed his mind.

"I feel like it has made me a much better surgeon because I could see for the first time in ways I couldn't with open surgery," he said.n n nWhile hospitals nationwide offer robotic surgery for a variety of procedures, from heart surgery to gastric bypass, the local hospitals so far only offer it for gynecological and urologic surgeries, such as hysterectomies and prostate removals.

All surgeons working with the robot must be trained.

Christus Spohn Health System bought its robot for urologists at Spohn Hospital Shoreline, but officials moved the robot in March to Spohn Hospital South so it could get more use, spokeswoman Katy Kiser said.

The hospital system has used it 115 times, and five gynecologist surgeons now operate on it, da Vinci representative Michael Isaac said. Kiser said the hospital system has plans to train more surgeons on the robot and expand its surgical offerings, but no plans to buy additional robots.

Corpus Christi Medical Center bought a newer version of the robot in January and surgeons there since have performed 150 gynecologic and urologic procedures, hospital spokeswoman Lisa Robertson said. Twelve hospital system surgeons are trained on the robot, she said.

Dr. Joseph Wagner, director of robotic surgery at Hartford Hospital in Connecticut, said he considers a robot thoroughly used at 500 cases a year.

He suggests hospitals consider expansion if their robots hit 350 to 400 annual operations, well above the usage level at Corpus Christi hospitals.

Kris Muller, spokeswoman for Corpus Christi Medical Center's parent company HCA, said robotic surgery does not cost patients more than traditional surgery. Some insurance policies cover the full cost, others do not, Shelton said.

n n n

While the debate continues about the cost of the technology and long-term benefits for patients, there seems to be little argument that robotic surgery is better for the surgeon.

Surgeons say robotic surgery leaves them less fatigued, allows them to see better within the body and gives them the ability more easily to suture, or sew tissue, than they could with traditional laparoscopic surgery, a type of minimally invasive surgery in which surgeons work at the bedside using long, slender, chopstick-like instruments inserted through small incisions in a patient's body.

Dr. Alan Nesbit, a urologist who operates at Corpus Christi Medical Center, said the robot is easier on his body than traditional laparoscopic procedures, which left him exhausted.

His knees, hips and back ached after standing for five or six hours at a patient's bedside, his arms positioned in an awkward manner over the patient's body.

"No matter how strong you are, it's a very physical surgery," he said.

Shoemaker said, without the robot, his persistent back pain and arthritis likely would have forced him to take a break from surgery. Robotic surgery allows him to rest his back by sitting in a cushy chair at a console, instead of standing for hours at a patient's bedside.

"It's extended my surgical career by 10 years," he said.

At Cantu's hysterectomy on Wednesday, Shelton chatted easily while she performed complicated maneuvers within Cantu's pelvis. As she flicked her wrists at the joysticks, the robotic instruments pushed a tiny, thin needle with barbed-wire-like thread in and out of the tissue. Shelton said she was operating within a space the size of a pingpong ball.

This is the kind of technique that, if done in a traditional laparoscopic way, would have been more difficult and physically draining, Shelton said.

"I feel like I'm going to go exercise now and I wouldn't have wanted to go exercise had I done it laparoscopically," she said after the surgery. "I would've been too sore. I would've said, 'I've done my exercise for the day.'"

n n n

Experts say robotic surgery is likely to expand in coming years, particularly as the technology improves. Surgeons say they expect the devices will get smaller and eventually provide tactile feedback, giving surgeons back the sense of feel that they traded for the magnified, high-definition vision that came with robotic surgery.

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FDA warns mesh used in surgery poses risk

Problems seen in vaginal procedure
By Deborah Kotz and Robert Weisman
Globe Staff / July 14, 2011
Women who have vaginal surgery to fix a common gynecologic condition called pelvic organ prolapse may wind up with more problems than benefits if a plastic mesh is used, according to a safety communication issued yesterday by the Food and Drug Administration.

The agency warned patients and surgeons to consider other options.

The FDA said it plans to convene an advisory committee of experts in the fall to determine whether to ban the mesh - manufactured by Natick-based Boston Scientific Corp., Covidien PLC of Mansfield, and several other companies - for this procedure.

About 100,000 women with pelvic organ prolapse are treated with plastic mesh each year, but in most cases, the agency said, the condition can be treated successfully without mesh.

Mesh-related problems reported to the FDA include pain ful sexual intercourse, infections, urinary problems, overall discomfort, and bleeding, usually from the mesh eroding through the stitched tissue or from skin contracting tightly around it.

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http://www.boston.com/lifestyle/health/articles/2011/07/14/fda_warns_mesh_used_in_vaginal_surgery_can_pose_risk

Mesh-related infections after hernia repair surgery

Mesh-related infections after hernia repair surgery
M. E. Falagas1,2, S. K. Kasiakou1Article first published online: 29 NOV 2004

DOI: 10.1111/j.1469-0691.2004.01014.x

Keywords:Hernia repair;infectious complications;mesh-related infection;Staphylococcus aureus;Staphylococcus spp
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Clinicians have been challenged in the past few years by an increasing variety of novel non-infectious and infectious complications following the widespread use of meshes after open or laparoscopic repair of hernias. The possibility of a mesh-related infection occurring weeks or even years after hernia repair, should be considered in any patient with fever of unknown origin, or symptoms and/or signs of inflammation of the abdominal wall following hernia repair. The reported incidence of mesh-related infection following hernia repair has been 1%–8% in different series, and this incidence is influenced by underlying co-morbidities, the type of mesh, the surgical technique and the strategy used to prevent infections. An approach that combines medical and surgical management is necessary for cases of mesh infection. The antimicrobial treatment regimen chosen initially should include coverage of Staphylococcus spp. and, particularly, Staphylococcus aureus.

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Within the last few years, the use of meshes has become standard procedure in hernia repair surgery throughout the world. Implantation of a mesh during the surgical management of this common problem has been found to reduce the rate of recurrence of a hernia. For example, use of a mesh for the repair of incisional hernias has been found in different studies to decrease the recurrence rates by an average of 30%[1–3], while in a randomised clinical trial involving 289 patients in which non-mesh vs. mesh repair of primary inguinal hernia was compared, it was found that recurrence rates were 7% for the non-mesh technique vs. 1% for mesh repair [4]. However, mesh-related complications have become increasingly important. Such complications include seromas, adhesions, chronic severe pain, migration and rejection of the mesh, and mesh-related infections.

The present review focuses on mesh-related infections. Data for the review were obtained from searches of Medline, Current Contents and references from relevant articles. In addition, several articles were identified through searches of the extensive files of the authors. The search terms were ‘mesh’, ‘infection’, ‘open hernia surgery’, ‘laparoscopic hernia repair’, ‘inguinal hernia repair’, ‘infectious complications’, ‘biomaterials’, ‘antibiotic prophylaxis’ and ‘prevention’. All English language papers were carefully reviewed.
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Important advances in research and development by the biomedical materials industry have led to the production of relatively inert and biocompatible surgical meshes. However, it has been noted in clinical practice that surgical meshes can trigger various responses when implanted in the human body, including inflammation (known as foreign body reaction), fibrosis, calcification, thrombosis and infection.

Foreign body reaction refers to a process in which proteins such as albumin and fibrinogen are absorbed initially by the surface of the polymer. Subsequently, the physiochemical properties of each polymer result in the degradation of the absorbed proteins. This process results in the attraction and stimulation of macrophages, which respond by releasing inflammatory substances and growth factors. Other inflammatory cells (T-lymphocytes, polymorphonuclear cells, eosinophils, plasma cells and fibroblasts) are then attracted to the surface of the polymer, leading to the formation of a granuloma. Such granulomas are characterised by locally increased cell turnover, which may continue for periods of several years after the implantation of the mesh. Foreign body reaction also depends on the surface area of the mesh that is in contact with the host tissue [5]. Clinical manifestations of foreign body reaction are seroma, rejection, migration of mesh, adhesions and pain.

Meshes made of non-absorbable polymers have been used most frequently in clinical practice. The main non-absorbable polymers are polyester, polypropylene and expanded polytetrafluoroethylene. However, given the fact that absorbable polymers are associated less frequently with foreign body reactions and adhesion, newer meshes are made of a combination of absorbable and non-absorbable polymers [6,7]. The mechanical and biological properties of meshes are associated with the type of tissue structure (woven or knitted) and the type of fibre used (mono- or multifilament) [8]. The pore size of the mesh also plays a role in the safety and tolerability of surgical meshes [9].
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Mesh-related infections following surgery occur relatively infrequently compared with other device-related infections. However, they are of considerable clinical importance, not only for the patients and surgeons, but also for other medical specialists. The question of whether the incidence of infectious complications is higher after hernia repair involving the use of a mesh, in comparison with older techniques not involving use of a mesh, remains controversial. The results of a recent trial in which a comparison was made between umbilical hernia repair with or without a mesh in 200 adults showed that the rate of post-operative complications, including infection, was similar following both procedures [10]. A similar result was obtained in a meta-analysis of 20 trials (5016 participants) of open mesh vs. non-mesh repair of groin hernias [11]. In contrast, the results of a randomised trial of 160 patients with simple or complex hernias who underwent suture repair, skin graft or mesh repair showed that the rate of infectious complications was lower following suture repair than following the other two techniques. In addition, mesh implantation led to an increased rate of infections following repair of both simple and complex hernias [12]. A further study showed that the use of mesh during the repair of a ventral hernia or a hernia defect > 10 cm in size was associated significantly with an increased number of wound complications [13].

Incidences of mesh-related infection after hernia repair of up to 8% have been reported (Table 1) [14–18]. The rate of infection is influenced considerably by underlying co-morbidity, and seems to be increased in patients with diabetes, immunosuppression or obesity. Of great interest is whether the type of prosthetic material or the precise technique used for hernia repair can influence the incidence of mesh infection. In most recent published trials, the differences in complication rates following different surgical approaches and the use of different meshes have been compared. However, none of these studies focused specifically on the mesh-related infection rates. Leber et al.[19] conducted a retrospective cohort analysis of 200 patients who underwent open repair of abdominal incisional hernias with prosthetic material, with the aim of determining whether the incidence of long-term complications was influenced by the surgical technique. The authors concluded that the precise surgical approach did not influence the incidence of long-term complications significantly, including mesh infection. Although several authors have suggested that the laparoscopic approach to hernia repair has fewer post-operative complications compared to open repair, there are no clear, specific data regarding mesh-related infection rates [20–22].

Table 1. Incidence of mesh infection after laparoscopic or open hernia repair surgery Reference Study population (n) Technique of hernia repair Incidence of mesh infection
Heniford et al.[14] 407 Laparoscopic ventral and incisional hernia repair 0.98%
Heniford et al.[15] 822 Laparoscopic ventral hernia repair 0.7%
Kirshtein et al.[16] 103 Laparoscopic incisional hernia repair 2%
Petersen et al.[17] 121 Open incisional hernia repair 7%
Cobb et al.[18] 95 Open incisional hernia repair 8%

There is no consensus in the literature as to whether the use of non-absorbable mesh for incisional hernia repair is contraindicated in potentially contaminated surgical settings. Recently published data have indicated that the rate of mesh-related infections is comparable for ‘clean’ surgical procedures and for cases where potentially contaminated surgical procedures, such as appendectomy, cholocystectomy or enterectomy, are performed at the same time as incisional hernia repair [23,24].

The influence of mesh type on the incidence of infection was investigated in a recent study; the results showed that the use of multifilament polyester mesh resulted in a higher incidence of infection, small bowel obstruction and enterocutaneous fistula formation than the use of other types of mesh (knitted monofilament polypropylene, polytetrafluoroethylene or woven polypropylene) [19]. In addition, studies in experimental animals have shown that microporous mesh is associated with higher rates of infection and/or development of seromas, whereas macroporous mesh is associated with a higher incidence of adhesive and erosive events. Microporous mesh has a pore diameter of 10 µm, with the result that bacteria can penetrate the mesh, but polymorphonuclear leukocytes (with a diameter of 75 µm) cannot. This means that the bacteria in the mesh are protected from immunological defence mechanisms [25–27].
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The reported interval between hernia repair and the manifestation of a mesh infection ranges from 2 weeks to 39 months [28]. Patients usually present with symptoms and signs of local acute inflammation (a combination of pain, erythema, tenderness, swelling and increased temperature in the abdominal wall in the area of the mesh). In addition, patients may have systemic manifestations such as fever, malaise, chills or rigors. A mesh-related infection can sometimes manifest with a discharging fistula, or with an intra-abdominal abscess. Rare cases of patients who presented with osteomyelitis following inguinal hernia surgery with implantation of a polypropylene mesh have been reported [29].
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The usual causative organisms associated with cases of mesh infection are Staphylococcus spp., especially Staphylococcus aureus, Streptococcus spp. (including group B streptococci), Gram-negative bacteria (mainly Enterobacteriaceae), and anaerobic bacteria (including Peptostreptococcus spp.) [28]. In a study of mesh-related infections following incisional herniorrhaphy, 63% of the microorganisms isolated were methicillin-resistant S. aureus (MRSA) [18]. Rarely, mesh infections are caused by Candida spp. or Mycobacterium spp. [30,31].

Mesh infections can manifest with chronic, persistent or recurrent symptoms and signs. The infecting agents in some of these reported cases were small-colony variants, usually of S. aureus. The main characteristic of these infections is that they respond poorly to antimicrobial treatment regimens [32].
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The most important point regarding the prevention of mesh-related infections is that foreign body reactions depend on the amount of the prosthesis (mesh) used. For this reason, surgeons should try to minimise the area of mesh that is introduced during the hernia operation, since the inserted foreign material is an ideal medium for bacterial colonisation [33].

In addition, four main approaches to the prevention of mesh infection have been used. First, the wound can be rinsed with an antibiotic-containing solution, starting immediately after the dissection of the hernia sac, and then intermittently until the skin is sutured. It has been shown in an animal model that this approach inhibits the adhesion of bacteria to the surface of the mesh, as well as their growth [34]. Moreover, in a randomised trial of 162 patients who underwent inguinal hernia repair, there were no wound infections following the application of a single dose of cefamandole directly to the wound [35]. However, the effectiveness of lavage with solutions containing antimicrobial agents is controversial, since antibiotics require a defined duration of contact with pathogens, while lavage is usually a more rapid process.

A second approach involves the use of material placed in front of the mesh to slowly deliver an antimicrobial agent locally. In a randomised trial, the use of gentamicin-laced collagen tampons was tested in 301 patients undergoing prosthetic groin hernia repair. The collagen tampons were placed in front of the mesh before the aponeurosis of the external oblique muscle was sutured. This new technique resulted in fewer post-operative infections in comparison with 294 patients undergoing surgical repair for the same hernia without the use of gentamicin-containing collagen tampons [36].

Third, a mesh containing embedded antimicrobial agents can be used. Such a mesh is thought to help prevent bacterial adhesion and colonisation when implanted in wounds, with a subsequent reduced likelihood of post-operative infections.

Finally, traditional intravenous perioperative administration of antimicrobial agents can be used. Although hernia repair operations are classified as clean surgery, the administration of intravenous antibiotics perioperatively has been shown to be beneficial if a prosthetic material (mesh) is involved [37,38].

All of the above-mentioned strategies seem to be beneficial in reducing the incidence of mesh-related infection after hernia repair. However, no definitive recommendation can be made in favour of any particular approach in the absence of comparative outcome data. The current standard preventive strategy for other types of surgery, i.e., the perioperative administration of appropriate intravenous antibiotics, may be used until new data regarding alternative preventive strategies become available. At the present time, additional strategies to prevent mesh-related infections, such as the use of gentamicin-laced collagen tampons with a mesh, are best reserved for patients at high risk of infection, such as diabetic and obese patients.
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A clinician should strongly consider the possibility of a mesh-related infection in any patient who presents with fever of unknown aetiology, symptoms and/or signs of inflammation of the abdominal wall in the area of the mesh, or other less common clinical manifestations of mesh infection, such as an enterocutaneous fistula or abdominal abscess in the area of the mesh.

Imaging techniques, including ultrasound and/or computerised tomography, can be useful for the diagnosis of mesh infection. Such techniques usually reveal an area of inflammation in the subcutaneous fat around the mesh, which has different echogenic or density characteristics, respectively, from that in other conditions, such as seroma. Additionally, the results of these imaging tests can indicate the presence of a fistula or an abscess.

It is important that no attempt should be made to perform a diagnostic paracentesis of mesh-related seromas when there are no symptoms and/or signs of inflammation of the abdominal wall. This is because of the real possibility of introduction of bacteria into the area of seroma during paracentesis, leading to the transformation of an aseptic reaction into an infectious process.

When a mesh-related infection occurs, a combined medical and surgical approach involving intravenous antimicrobial agents and complete surgical removal of the mesh is the preferred management strategy. For a variety of reasons, monotherapy with intravenous antibiotics generally has a poor outcome. The most important of these reasons relates to the fibroblastic response of the organism to the polymer of the implanted mesh, which results in the development of a thick fibrous capsule surrounding the mesh. Consequently, when an infection is established, this capsule restricts the penetration of antimicrobial agents into the infected mesh. In addition, it is well known that Staphylococcus spp., which are the most common causative organisms in mesh infections, produce a biofilm on the prosthesis, with the result that the microorganisms are protected simultaneously from antibiotics and the immune responses of the host organism [39].

Incomplete removal of the mesh should be suspected in any case with persistent or recurrent symptoms and/or signs of mesh infection. However, the results of a recent study suggested that the management of infected mesh might differ according to the type of mesh used. Specifically, it was suggested that infection of polyester or polypropylene mesh might be managed with drainage and antimicrobial agents only, whereas the infected mesh should be surgically removed in cases of infection involving expanded polytetrafluoroethylene mesh [17].
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Clinicians should promptly consider the possibility of mesh infection in any patient who has undergone hernia repair surgery involving a mesh, and who has fever of unknown aetiology or symptoms and/or signs of infection of the abdominal wall. There is no adequate evidence in the literature concerning the specific risk factors for such infections. Whether the surgical technique used for the repair of a hernia or the precise type of implanted mesh influences the rate of development of a mesh-related infection remains to be clarified.

As yet, there are no published reports of comparative trials of different antimicrobial regimens for the management of mesh-related infections. Consequently, no definitive recommendations can be made concerning the preferred medical management strategy. However, given the known facts regarding the microbial aetiology of mesh-related infections, and the pathogenesis and characteristics of infections involving other types of prosthetic material, antimicrobial agents used for the treatment of mesh-related infection should at least include coverage for Staphylococcus spp.

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Conclusions
References
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