human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Inguinal hernias in women are relatively rare , and an outcome in this specific subgroup of hernias has not been documented in the literature . An analysis was performed using data from the prospect i ve recording of 3,696 female inguinal hernia repairs in the national Danish hernia data base , in the 5.5 year period from January 1 , 1998 to June 30 , 2003 , where observation time specific reoperation rates were used as a proxy for recurrence . In the 3,696 female inguinal herniorrhaphies recorded , the overall reoperation rate was 4.3 % , which is slightly higher compared to male inguinal herniorrhaphies  ( 3.1 % ) ( P=0.001 ) . The reoperation rate was independent of the type of surgical repair . In 41.5 % of the reoperations a femoral hernia was found , compared to 5.4 % in males . Female inguinal herniorrhaphy is followed by a higher reoperation rate than in males , and is unrelated to the type of repair . The frequent finding of a femoral hernia at reoperation suggests the need for the exploration of the femoral canal at the primary operation The European Hernia Society ( EHS ) is proud to present the EHS Guidelines for the Treatment of  Inguinal Hernia in Adult Patients . The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare . They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS . They are evidence -based and , when necessary , a consensus was reached among all members . The Guidelines have been review ed by a Steering Committee . Before finalisation , feedback from different national hernia societies was obtained . The  Appraisal of Guidelines for REsearch and Evaluation ( AGREE ) instrument was used by the Cochrane Association to vali date the Guidelines . The Guidelines can be used to adjust local protocol s , for training purpose s and quality control . They will be revised in 2012 in order to keep them up date d. In between revisions , it is the intention of the Working Group to provide every year , during the EHS annual congress , a short up date of new high-level evidence ( r and omised controlled trials [ RCTs ] and meta-analyses ) . Developing guidelines leads to questions that remain to be answered by specific research . Therefore , we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment . In addition , a short summary , specifically for the general practitioner , is given . In order to increase the practical use of the Guidelines by consultants and residents , more details on the most important surgical techniques , local infiltration anaesthesia and a patient information sheet is provided . The most important challenge now will be the implementation of the Guidelines in daily surgical practice . This remains an important task for the EHS . The establishment of an EHS school for teaching inguinal hernia repair surgical techniques , including tips and tricks from experts to overcome the learning curve ( especially in endoscopic repair ) , will be the next step . Working together on this project was a great learning experience , and it was worthwhile and fun . Cultural differences between members were easily overcome by educating each other , respecting different views and always coming back to the principles of evidence -based medicine . The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project BACKGROUND An association between smoking and impaired wound healing has been reported in retrospective studies . The smoking status of a surgical patient may be confounded by social and medical parameters . We have evaluated the effect of smoking in a test wound in volunteers , with special reference to a reliable scientific match between smokers and nonsmokers . METHODS In a prospect i ve open study with blinded assessment , 19 smoking ( 20 cigarettes/day ) and 18 nonsmoking healthy volunteers were matched with respect to baseline characteristics . The deposition of total protein and mature collagen ( expressed as hydroxyproline ) was assessed in an exp and ed polytetrafluoroethylene wound healing model implanted subcutaneously for 10 days . RESULTS The nonsmokers had a 1.8 times higher median amount of hydroxyproline than the smokers ( p < 0.01 ) . The deposition of hydroxyproline was negatively correlated with the consumption of tobacco both before ( r = -0.44 ; p < 0.01 ) and during the study ( r = -0.48 ; p < 0.005 ) . The impairment was specific for the production of collagenous proteins and not other proteins . CONCLUSIONS The synthesis of subcutaneous collagen in smokers is specifically impeded , indicating an impaired wound-healing process . Because mature collagen is the main determinator of strength of an operative wound , the results support the view that patients should be advised to stop smoking before an operation Background Large-scale data for the optimal inguinal hernia repair in younger men with an indirect hernia is not available . We analysed nationwide data for risk of reoperation in younger men after a primary repair using a Lichtenstein operation or a conventional non-mesh hernia repair .  Methods Prospect i ve recording of all inguinal hernia repairs  from 1 January 1998 to 31 December 2005 in the national Danish Hernia Data base , using reoperation rate as a proxy for recurrence . We included only men between the age of 18 and 30 years with a primary repair of a primary indirect inguinal hernia . Results A primary sutured repair was performed in 1,120 men ( median age 23 years , range 18–30 ) and a Lichtenstein mesh repair in 2,061 young men ( 24 years , range 18–30 ) ( total 3,181 patients ) . The observation time after  conventional hernia repair  was median 62 months ( range 0–96 ) and 41 months ( range 0–96 ) after a Lichtenstein repair . The cumulative incidence of reoperation at 5 years was 1.6 % ( Lichtenstein ) versus 3.9 % ( sutured repair ) , while overall reoperation rates were almost three-fold as high after a sutured repair ( 39 reoperations , overall reoperation rate = 3.5 % ) compared to a Lichtenstein repair ( 24 reoperations , overall reoperation rate = 1.2 % ; P = 0.0003 ) . Conclusions Lichtenstein repair for an indirect inguinal hernia reduces the risk of recurrence in young men between the age of 18 and 30 years compared with a sutured repair . The use of a Lichtenstein mesh repair in young males must be balanced against the risk of chronic pain Laparoscopic transperitoneal hernioplasty ( TAPP ) repair  of inguinal hernias is thought to be a difficult surgical technique with high complication rates . The present study evaluated TAPP based on prospect i ve documentation BACKGROUND We sought to determine perioperative variables predictive of complications or recurrence for patients undergoing surgical repair of inguinal hernias . PATIENTS AND METHODS Using data from the Veterans Affairs trial , regression analyses were utilized to identify perioperative factors significantly associated with complications ( overall , short-term and long-term ) , long-term pain , and to develop a risk model for recurrence . RESULTS Recurrent and scrotal hernias were predictors for short term and overall complications , regardless of technique . Older age and higher Mental Component Score of the SF-36 were associated with higher risk of long term complications in the open group while prostatism and increased body mass index were the significant predictors in the laparoscopic group . Long-term pain complaints decreased as patient age increased in both groups . Patient and surgeon factors were predictive of recurrence but varied greatly depending on surgical technique . CONCLUSIONS Regardless of technique , scrotal and recurrent hernias were associated with a greater risk of complications and younger patients had more long-term pain . Predictors of recurrence vary based on surgical technique Cigarette smokers deposit less collagen , expressed as hydroxyproline , in granulation tissue than nonsmokers . We studied the effect of abstinence from smoking and transdermal nicotine patches on deposition of hydroxyproline , proline , type I procollagen , and total proteins . Fifty-four healthy smokers were studied during 10 days of smoking and again from days 10 to 20 following smoking cessation . After the first 10 days of abstinence they were r and omized to double-blind treatment with transdermal nicotine patches of 25 mg/day or placebo for a period of 10 days . During this period and during smoking , an exp and ed polytetrafluoroethylene tube was implanted into the subcutis . Following removal of the implant , total amino acids and peptides were extracted . Hydroxyproline and proline were analyzed by high-pressure liquid chromatography , type I procollagen was analyzed by enzyme-linked immunoassay , and total proteins were determined colorimetrically . In the 39 subjects who complied with the study protocol , abstinence from smoking did not affect the deposition of hydroxyproline , proline , type I procollagen , or total protein in the implants . During abstinence , the type I procollagen level increased by 18 % in the transdermal nicotine patches group and decreased by 10 % in the placebo group ( p<0.05 ) . We conclude that 20 days of abstinence from smoking does not affect collagen deposition in granulation tissue . However , in abstinent smokers , transdermal nicotine patches appears to increase type I collagen synthesis OBJECTIVE To establish a register of  inguinal hernia surgery  that allows audit and analyses of data from several centres . DESIGN Prospect i ve recording of data on a common protocol . SETTING Eight Swedish hospitals . SUBJECTS All groin hernia operations done for patients over 15 years old from January 1992 to December 1994 . MAIN OUTCOME MEASURES Methods of repair , postoperative complications including mortality , day surgery rate , and reoperations for recurrence . RESULTS During the three years studied 4879 hernia operations were undertaken in 4474 patients .  Postoperative mortality within 30 days of operation for emergency and elective hernia repairs was 3.5 % and 0.07 % , respectively . Of all herniorrhaphies 798 ( 16 % ) were done for recurrences , 142 of these after operations between 1992 and 1994 . At 24 months 4 % of all operations had been redone because of recurrences with highly significant variations among hospitals ranging from 1.5 % to 6.7 % . Postoperative complications within 30 days after operation , direct hernia , recurrent hernia , and the use of absorbable sutures were associated with an increased risk of reoperation . CONCLUSIONS A quality register recorded voluntarily can identify significant interhospital differences in outcome as well as variables associated with an increased risk of reoperation , thereby raising quality awareness and facilitating the process of improvement Objective :  Inguinal  hernias are very common disorders , especially in men , with inguinal herniorrhaphy being one of the most frequently performed general surgical procedures in men . Theoretically , obesity might increase the risk of groin hernia by increasing intra-abdominal pressure . The objective of the present study was to investigate whether overweight and obesity in middle age could significantly predict future groin hernia  in men . Summary Background Data : Design : Prospect i ve cohort study ; Setting : General population of men living in Gothenburg , Sweden ; Participants : A community-based sample of 7483 men aged 47 to 55 years were followed-up from baseline ( 1970–1973 ) for a maximum of 34 years . Main Outcome Measures : A diagnosis of groin hernia according to the Swedish hospital discharge register . Results : A total of 1017 men ( 13.6 % ) were diagnosed with groin hernia .  An inverse relationship was found between body mass index ( BMI ) and risk of groin hernia . With each BMI unit ( 3–4 kg ) , the relative risk for groin hernia decreased by 4 % ( P < 0.0001 ) . Compared with men of normal weight , obese men had a 43 % lower risk ( P = 0.0008 , 95 % confidence interval 21%–59 % ) . Heavy smokers demonstrated a 26 % lower risk for groin hernia ( P = 0.003 , 95 % confidence interval 10%–39 % ) . Diabetes , high physical activity , and blood pressure were not associated with groin hernia . Entering other variables potentially associated with groin hernia , as age , BMI , smoking , and serum cholesterol , in a multivariable analysis left the risk estimates for BMI and smoking virtually unchanged . Conclusions : In a large community-based sample of middle-aged men overweight and obesity were associated with a lower risk for groin hernia during an extended follow-up . Obesity , in comparison with normal weight , reduced the risk of groin hernia by 43 % . A reduced risk of groin hernia was also noted in heavy smokers . Obviously , hernia may be more easily detected in lean men but a true protective effect can not be excluded Background During totally extraperitoneal ( TEP ) endoscopic repair of inguinal hernias , it is possible to see the internal opening of the femoral canal . The aim of our study was to determine the incidence of synchronous femoral hernias found in patients undergoing TEP endoscopic inguinal hernia repair .  Method This was a retrospective review of prospect ively collected data on 362 consecutive patients who underwent 484 TEP endoscopic inguinal hernia repairs during a  
    Output:
    
agent
We found that female sex , direct inguinal hernias at the primary procedure , operation for a recurrent inguinal hernia , and smoking were significant risk factors for recurrence after inguinal hernia surgery .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Inguinal hernias in women are relatively rare , and an outcome in this specific subgroup of hernias has not been documented in the literature . An analysis was performed using data from the prospect i ve recording of 3,696 female inguinal hernia repairs in the national Danish hernia data base , in the 5.5 year period from January 1 , 1998 to June 30 , 2003 , where observation time specific reoperation rates were used as a proxy for recurrence . In the 3,696 female inguinal herniorrhaphies recorded , the overall reoperation rate was 4.3 % , which is slightly higher compared to male inguinal herniorrhaphies  ( 3.1 % ) ( P=0.001 ) . The reoperation rate was independent of the type of surgical repair . In 41.5 % of the reoperations a femoral hernia was found , compared to 5.4 % in males . Female inguinal herniorrhaphy is followed by a higher reoperation rate than in males , and is unrelated to the type of repair . The frequent finding of a femoral hernia at reoperation suggests the need for the exploration of the femoral canal at the primary operation The European Hernia Society ( EHS ) is proud to present the EHS Guidelines for the Treatment of  Inguinal Hernia in Adult Patients . The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare . They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS . They are evidence -based and , when necessary , a consensus was reached among all members . The Guidelines have been review ed by a Steering Committee . Before finalisation , feedback from different national hernia societies was obtained . The  Appraisal of Guidelines for REsearch and Evaluation ( AGREE ) instrument was used by the Cochrane Association to vali date the Guidelines . The Guidelines can be used to adjust local protocol s , for training purpose s and quality control . They will be revised in 2012 in order to keep them up date d. In between revisions , it is the intention of the Working Group to provide every year , during the EHS annual congress , a short up date of new high-level evidence ( r and omised controlled trials [ RCTs ] and meta-analyses ) . Developing guidelines leads to questions that remain to be answered by specific research . Therefore , we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment . In addition , a short summary , specifically for the general practitioner , is given . In order to increase the practical use of the Guidelines by consultants and residents , more details on the most important surgical techniques , local infiltration anaesthesia and a patient information sheet is provided . The most important challenge now will be the implementation of the Guidelines in daily surgical practice . This remains an important task for the EHS . The establishment of an EHS school for teaching inguinal hernia repair surgical techniques , including tips and tricks from experts to overcome the learning curve ( especially in endoscopic repair ) , will be the next step . Working together on this project was a great learning experience , and it was worthwhile and fun . Cultural differences between members were easily overcome by educating each other , respecting different views and always coming back to the principles of evidence -based medicine . The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project BACKGROUND An association between smoking and impaired wound healing has been reported in retrospective studies . The smoking status of a surgical patient may be confounded by social and medical parameters . We have evaluated the effect of smoking in a test wound in volunteers , with special reference to a reliable scientific match between smokers and nonsmokers . METHODS In a prospect i ve open study with blinded assessment , 19 smoking ( 20 cigarettes/day ) and 18 nonsmoking healthy volunteers were matched with respect to baseline characteristics . The deposition of total protein and mature collagen ( expressed as hydroxyproline ) was assessed in an exp and ed polytetrafluoroethylene wound healing model implanted subcutaneously for 10 days . RESULTS The nonsmokers had a 1.8 times higher median amount of hydroxyproline than the smokers ( p < 0.01 ) . The deposition of hydroxyproline was negatively correlated with the consumption of tobacco both before ( r = -0.44 ; p < 0.01 ) and during the study ( r = -0.48 ; p < 0.005 ) . The impairment was specific for the production of collagenous proteins and not other proteins . CONCLUSIONS The synthesis of subcutaneous collagen in smokers is specifically impeded , indicating an impaired wound-healing process . Because mature collagen is the main determinator of strength of an operative wound , the results support the view that patients should be advised to stop smoking before an operation Background Large-scale data for the optimal inguinal hernia repair in younger men with an indirect hernia is not available . We analysed nationwide data for risk of reoperation in younger men after a primary repair using a Lichtenstein operation or a conventional non-mesh hernia repair .  Methods Prospect i ve recording of all inguinal hernia repairs  from 1 January 1998 to 31 December 2005 in the national Danish Hernia Data base , using reoperation rate as a proxy for recurrence . We included only men between the age of 18 and 30 years with a primary repair of a primary indirect inguinal hernia . Results A primary sutured repair was performed in 1,120 men ( median age 23 years , range 18–30 ) and a Lichtenstein mesh repair in 2,061 young men ( 24 years , range 18–30 ) ( total 3,181 patients ) . The observation time after  conventional hernia repair  was median 62 months ( range 0–96 ) and 41 months ( range 0–96 ) after a Lichtenstein repair . The cumulative incidence of reoperation at 5 years was 1.6 % ( Lichtenstein ) versus 3.9 % ( sutured repair ) , while overall reoperation rates were almost three-fold as high after a sutured repair ( 39 reoperations , overall reoperation rate = 3.5 % ) compared to a Lichtenstein repair ( 24 reoperations , overall reoperation rate = 1.2 % ; P = 0.0003 ) . Conclusions Lichtenstein repair for an indirect inguinal hernia reduces the risk of recurrence in young men between the age of 18 and 30 years compared with a sutured repair . The use of a Lichtenstein mesh repair in young males must be balanced against the risk of chronic pain Laparoscopic transperitoneal hernioplasty ( TAPP ) repair  of inguinal hernias is thought to be a difficult surgical technique with high complication rates . The present study evaluated TAPP based on prospect i ve documentation BACKGROUND We sought to determine perioperative variables predictive of complications or recurrence for patients undergoing surgical repair of inguinal hernias . PATIENTS AND METHODS Using data from the Veterans Affairs trial , regression analyses were utilized to identify perioperative factors significantly associated with complications ( overall , short-term and long-term ) , long-term pain , and to develop a risk model for recurrence . RESULTS Recurrent and scrotal hernias were predictors for short term and overall complications , regardless of technique . Older age and higher Mental Component Score of the SF-36 were associated with higher risk of long term complications in the open group while prostatism and increased body mass index were the significant predictors in the laparoscopic group . Long-term pain complaints decreased as patient age increased in both groups . Patient and surgeon factors were predictive of recurrence but varied greatly depending on surgical technique . CONCLUSIONS Regardless of technique , scrotal and recurrent hernias were associated with a greater risk of complications and younger patients had more long-term pain . Predictors of recurrence vary based on surgical technique Cigarette smokers deposit less collagen , expressed as hydroxyproline , in granulation tissue than nonsmokers . We studied the effect of abstinence from smoking and transdermal nicotine patches on deposition of hydroxyproline , proline , type I procollagen , and total proteins . Fifty-four healthy smokers were studied during 10 days of smoking and again from days 10 to 20 following smoking cessation . After the first 10 days of abstinence they were r and omized to double-blind treatment with transdermal nicotine patches of 25 mg/day or placebo for a period of 10 days . During this period and during smoking , an exp and ed polytetrafluoroethylene tube was implanted into the subcutis . Following removal of the implant , total amino acids and peptides were extracted . Hydroxyproline and proline were analyzed by high-pressure liquid chromatography , type I procollagen was analyzed by enzyme-linked immunoassay , and total proteins were determined colorimetrically . In the 39 subjects who complied with the study protocol , abstinence from smoking did not affect the deposition of hydroxyproline , proline , type I procollagen , or total protein in the implants . During abstinence , the type I procollagen level increased by 18 % in the transdermal nicotine patches group and decreased by 10 % in the placebo group ( p<0.05 ) . We conclude that 20 days of abstinence from smoking does not affect collagen deposition in granulation tissue . However , in abstinent smokers , transdermal nicotine patches appears to increase type I collagen synthesis OBJECTIVE To establish a register of  inguinal hernia surgery  that allows audit and analyses of data from several centres . DESIGN Prospect i ve recording of data on a common protocol . SETTING Eight Swedish hospitals . SUBJECTS All groin hernia operations done for patients over 15 years old from January 1992 to December 1994 . MAIN OUTCOME MEASURES Methods of repair , postoperative complications including mortality , day surgery rate , and reoperations for recurrence . RESULTS During the three years studied 4879 hernia operations were undertaken in 4474 patients .  Postoperative mortality within 30 days of operation for emergency and elective hernia repairs was 3.5 % and 0.07 % , respectively . Of all herniorrhaphies 798 ( 16 % ) were done for recurrences , 142 of these after operations between 1992 and 1994 . At 24 months 4 % of all operations had been redone because of recurrences with highly significant variations among hospitals ranging from 1.5 % to 6.7 % . Postoperative complications within 30 days after operation , direct hernia , recurrent hernia , and the use of absorbable sutures were associated with an increased risk of reoperation . CONCLUSIONS A quality register recorded voluntarily can identify significant interhospital differences in outcome as well as variables associated with an increased risk of reoperation , thereby raising quality awareness and facilitating the process of improvement Objective :  Inguinal  hernias are very common disorders , especially in men , with inguinal herniorrhaphy being one of the most frequently performed general surgical procedures in men . Theoretically , obesity might increase the risk of groin hernia by increasing intra-abdominal pressure . The objective of the present study was to investigate whether overweight and obesity in middle age could significantly predict future groin hernia  in men . Summary Background Data : Design : Prospect i ve cohort study ; Setting : General population of men living in Gothenburg , Sweden ; Participants : A community-based sample of 7483 men aged 47 to 55 years were followed-up from baseline ( 1970–1973 ) for a maximum of 34 years . Main Outcome Measures : A diagnosis of groin hernia according to the Swedish hospital discharge register . Results : A total of 1017 men ( 13.6 % ) were diagnosed with groin hernia .  An inverse relationship was found between body mass index ( BMI ) and risk of groin hernia . With each BMI unit ( 3–4 kg ) , the relative risk for groin hernia decreased by 4 % ( P < 0.0001 ) . Compared with men of normal weight , obese men had a 43 % lower risk ( P = 0.0008 , 95 % confidence interval 21%–59 % ) . Heavy smokers demonstrated a 26 % lower risk for groin hernia ( P = 0.003 , 95 % confidence interval 10%–39 % ) . Diabetes , high physical activity , and blood pressure were not associated with groin hernia . Entering other variables potentially associated with groin hernia , as age , BMI , smoking , and serum cholesterol , in a multivariable analysis left the risk estimates for BMI and smoking virtually unchanged . Conclusions : In a large community-based sample of middle-aged men overweight and obesity were associated with a lower risk for groin hernia during an extended follow-up . Obesity , in comparison with normal weight , reduced the risk of groin hernia by 43 % . A reduced risk of groin hernia was also noted in heavy smokers . Obviously , hernia may be more easily detected in lean men but a true protective effect can not be excluded Background During totally extraperitoneal ( TEP ) endoscopic repair of inguinal hernias , it is possible to see the internal opening of the femoral canal . The aim of our study was to determine the incidence of synchronous femoral hernias found in patients undergoing TEP endoscopic inguinal hernia repair .  Method This was a retrospective review of prospect ively collected data on 362 consecutive patients who underwent 484 TEP endoscopic inguinal hernia repairs during a  
    Output:
    