The impact of atraumatic fibrin sealant vs. staple mesh fixation in TAPP hernia repair on chronic pain and quality of life: results of a randomized controlled study.

BACKGROUND: Mesh reinforcement has become the standard of care in the open and laparoscopic repair of inguinal hernia. Chronic pain after inguinal hernia repair is often due to nerve injury by penetrating mesh fixation devices such as staples (ST), tacks, or sutures. In several studies on hernioplasty, atraumatic mesh fixation with fibrin sealant (FS) proved to be efficient in terms of fixation strength and elasticity. Unfortunately, most of these studies did not provide a standardized follow-up and assessment of the development of chronic pain (CP) and the quality of life (QoL). Therefore, a randomized controlled trial comparing CP and QoL after FS fixation of mesh with ST in transabdominal preperitoneal hernioplasty (TAPP) was performed at our department. The primary end point of our study was to assess the patient outcome by using a visual analog scale (VAS) and the short form 36 (SF-36). The evaluation of recurrence rates was the secondary aim. METHODS: According to the randomization, a macroporous mesh (TiMESH(®)) was fixed in group A (44 patients with 54 inguinal hernias) with FS (TISSEEL) or in group B (45 patients with 56 inguinal hernias) with ST (EMS(®) Stapler). The observation period was 1 year with regular clinical check ups and assessment of VAS and SF-36. RESULTS: Patient characteristics expressed by BMI, ASA scores, and Schumpelick hernia classification were similar in both treatment groups. In each group there was one recurrence within 8 (FS) and 9 months (ST) postsurgery. The mean preoperative pain values scored by VAS were 1.7 (range = 0-7.5) in the FS group and 2.2 (range = 0-6) in the ST group. Postoperative mean VAS scores measured at 1 year postsurgery were 0.4 (range = 0-3) in the FS group and 0.9 (range = 0-7.5) in the ST group. One year postsurgery there was no significant difference between the two groups with respect to the parameter pain in the SF-36 and VAS. CONCLUSION: Fibrin sealant fixation leads to a low rate of hernia recurrence and avoids tissue trauma. ST provide similar results in the hand of the expert but bear inherent risks of complications due to tissue perforation.

Adverse effects of polyvinylidene fluoride-coated polypropylene mesh used for laparoscopic intraperitoneal onlay repair of incisional hernia.

BACKGROUND: Polyvinylidene fluoride-coated polypropylene meshes have been developed specifically for intraperitoneal onlay mesh repair. They combine a macroporous design with biomechanical characteristics compatible with the abdominal wall and are reported to have favourable antiadhesive properties. This retrospective study reports complications related to one of these materials, DynaMesh. METHODS: Twenty-nine patients underwent intraperitoneal onlay mesh repair with DynaMesh at one of two hospitals. Patients characteristics, surgical procedures and postoperative analgesia were comparable at both sites. RESULTS: Six patients developed DynaMesh-related complications that required surgical reintervention by laparotomy within 1 year of operation. Surgical reintervention was for adhesions in five patients and the mesh had to be explanted in three. One mesh was explanted because of early infection. Adhesions to DynaMesh were found in two patients who had surgery for unrelated reasons. CONCLUSION: Laparoscopic intraperitoneal onlay DynaMesh repair was associated with a high rate of complications.

A comparison of a bovine albumin/glutaraldehyde glue versus fibrin sealant for hernia mesh fixation in experimental onlay and IPOM repair in rats.

BACKGROUND: Research in hernia repair has targeted new atraumatic mesh fixation to reduce major complications such as chronic pain and adhesion formation. The efficacy and safety of two surgical adhesives, viz. Artiss® (FS, fibrin sealant containing 4 IU thrombin) and Bioglue® (AGG, bovine serum albumin/glutaraldehyde glue), were evaluated in this study. Primary study endpoints were tissue integration, dislocation, and adhesion formation. Foreign-body reaction formed the secondary study endpoint. METHODS: Twenty-four polypropylene meshes (VM, Vitamesh®) were randomized to four groups (n = 6): two groups of onlay hernia repair (two meshes per animal) with mesh fixation by FS (O-FS) or by AGG (O-AGG), and two groups of IPOM repair (one mesh per animal) with mesh fixation by four sutures and FS (I-FS) or AGG (I-AGG). Eighteen rats underwent surgery. Follow-up was 30 days. Tissue integration, dislocation, seroma formation, inflammation, adhesion formation, and foreign-body reaction were assessed. RESULTS: Meshes fixed with FS (O-FS, I-FS) showed good tissue integration. No dislocation, seroma formation, or macroscopic signs of inflammation were detectable. Adhesion formation of I-FS was significantly milder compared with I-AGG (P = 0.024). A moderate foreign-body reaction without active inflammation was seen histologically in O-FS and I-FS groups. Samples fixed with AGG (O-AGG, I-AGG) showed extensive scar formation. No dislocation and no seroma formation were observed. All of these samples showed moderate to severe signs of inflammation with abscess formation in the six meshes of O-AGG. Histology underlined these findings. CONCLUSIONS: The fibrin sealant adhesive showed very good overall results of the primary and secondary outcome parameters. FS is a recommendable atraumatic fixation tool for the surgical onlay technique. AGG provides high adhesive strength, but shows low biocompatibility. Persisting active inflammation was seen in both the O-AGG and I-AGG groups, not favoring its use for these indications.

The effect of RANKL and OPG on bone mineral density in pre-dialysis chronic renal failure.

AIMS: The influence of pre-dialysis chronic kidney disease (CKD) on bone is ill defined. Isolation of specific pathogenic mechanisms would improve the understanding and therapeutic options. We therefore investigated whether parathyroid dysfunction, altered vitamin D and hormonal status, or RANKL and OPG have an influence on bone mineral density (BMD) in patients with pre-dialysis renal failure. MATERIAL: 132 patients with chronic renal failure stage 1 - 5 (not yet on dialysis) were investigated in a cross sectional study. Osteoprotegerin (OPG), receptor activator of nuclear factor kB ligand (RANKL), parathyroid hormone (whole, intact and 7-84 fragment), bone markers, sex hormones, and vitamin D status were assessed together with femoral neck and trochanter z-score. Correlation and multivariate analyses were performed between the different parameters and BMD. RESULTS: In the multivariate analysis a significant association was found between the femoral neck z-score and sRANKL (B = -0.45; p < 0.001), and OPG (B = 0.20; p < 0.05). A significant negative association was also found between the trochanter z-score and sRANKL (B = -0.32; p < 0.001). No associations were found between the trochanter z-score and OPG or the sRANKL/OPG ratio. The body mass index was the only additional marker associated with both FN z-score (B = 0.20, p < 0.05) and TR z-score (B = 0.20, p < 0.05). Neither markers of osteoblast nor osteoclast activity, or intact PTH, whole PTH, the PTH 7-84 fragment or vitamin D status were related to bone mineral density. CONCLUSION: Our results demonstrate that the RANKL/RANK/OPG system is associated with bone mineral density in pre-dialysis chronic renal failure.

Effect of teriparatide on early bone loss after kidney transplantation.

Kidney transplantation is associated with bone loss and a high risk of fractures. Prophylactic treatment of bone is therefore recommended in the early posttransplant period. As a large number of transplant recipients develop adynamic renal osteodystrophy, recombinant parathyroid hormone (rPTH) could be a promising therapeutic option. In a 6-month double-blind, randomized trial, 26 kidney transplant recipients were treated with daily subcutaneous injections of 20 microg teriparatide (PTH 1-34) or placebo. Bone mineral density (BMD) of the femoral neck, lumbar spine and radial bone was measured at transplantation and after 6 months. Paired bone biopsies for histomorphometric analysis were obtained in six, and for measurement of bone matrix mineralization in five patients of each group. Serologic bone markers were measured at baseline and every 3 months. A total of 24 out of 26 patients completed the study. Femoral neck BMD was stable in the teriparatide group, but decreased significantly in the placebo group. Lumbar spine and radial BMD, histomorphometric bone volume and bone matrix mineralization status remained unchanged in both groups. Serologic bone markers were similarly reduced in both groups throughout the study. We conclude that teriparatide does not improve BMD early after kidney transplantation. Neither histological analysis nor bone markers provide evidence of improved bone turnover or mineralization.

The desmopressin stimulation test in dogs with Cushing's syndrome.

Desmopressin is a synthetic analogue of the hypothalamic peptide vasopressin and binds to specific pituitary vasopressin (V3) receptors. The V3-receptor is overexpressed in pituitary corticotrope tumors and the injection of desmopressin induces a marked ACTH and cortisol release in human patients with pituitary- (PDH), but not adrenal tumor (AT) dependent hyperadrenocorticism. In this prospective study, we investigated the effects of desmopressin on serum cortisol levels in 80 dogs suspected of Cushing's syndrome. The aim was to find a sensitive and specific test to exclude AT. According to standard tests the dogs were divided into 3 groups (group 1=other disease, n=27; group 2=PDH, n=46; group 3=AT, n=7). Desmopressin was injected as an i.v. bolus of 4microg and serial blood samples were collected before and after 30, 60 and 90min. Desmopressin significantly stimulated cortisol release in dogs with PDH (median 51%, range -24 to 563%; p<0.0001), whereas no increase was seen in dogs with AT (median -12%, range -44 to 5%; p=0.063) and in controls (median +7%, range -36 to 196%; p=0.131). Using a cut off value of 10% increase over baseline, it was possible to exclude AT in 75% of patients. The results of this study suggest that the desmopressin test could be a useful tool in differentiating pituitary from adrenal dependent Cushing's syndromes. Additional dogs with adrenocortical tumor must be tested in order to recommend its use in clinical practice.

Venous reflux surgery promotes venous leg ulcer healing despite reduced ankle brachial pressure index.

AIM: The aim of this study was to demonstrate that venous surgery promotes ulcer healing, even in the presence of peripheral arterial disease. METHODS: In this retrospective study, 33 patients (49 legs) with venous leg ulcers and reduced arterial ankle brachial pressure index (< or = 0.8) were followed up 3 months to 7 years (median: 3.11 years) after venous surgery (group I). Venous reflux was considered to be the main cause of ulceration, and no attempt was made to restore the arterial circulation. The results were compared with those of patients with ulcers without arterial occlusive disease (n=190) who were treated following the same principles (group II). The surgical procedure consisted of interruption of reflux in the superficial and/or perforating veins. Additionally, shaving, fasciectomy, and mesh grafting was performed in 36 cases. RESULTS: In group I, 21 legs were lost to follow-up, 16 due to death. The mortality rate was three times higher in group I than in group II. From 28 legs of group I seen after 0.4-6.7 years (median: 2.9 years), 19/28 legs (68%) were healed compared with 123/145 (85%) in group II after 0.2-7.2 years (median: 3.2 years) (not significant [NS]). Group I showed a significantly longer healing time than group II (P<0.05) (P<0.001). Recurrence was observed in 3/28 (11%) from group I and in 6/145 (4%) from group II (NS). The time course of recurrence showed no statistically significant difference between the groups. CONCLUSION: Venous surgery produces beneficial results not only in pure venous ulcerations, but also in patients with accompanying arterial disease.

[The role of Stratus OCT in anti-VEGF therapy. Qualitative and quantitative assessment of neovascular AMD]. / Die Rolle des Stratus-OCT bei der Anti-VEGF-Therapie : Qualitative und quantitative Beurteilung bei neovaskulärer AMD.

BACKGROUND: The evaluation of OCT3 during anti-VEGF therapy. METHODS: A total of 29 patients with choroidal neovascularization secondary to AMD received 3 intravitreal injections of ranibizumab. OCT examination and visual acuity testing (ETDRS) were performed before therapy onset, after 1 week and after 1, 2 and 3 months. RESULTS: The central retinal thickness (CRT) was assessed correctly by OCT in 128 out of 145 measurements. There was a distinct (84%) but not significant correlation between decrease in central retinal thickness and increase in visual acuity. Incorrect retinal layer segmentation and inadequate CRT measurements were a significant technical limitation. CONCLUSION: During anti-VEGF therapy, OCT allows documentation and quantification of morphologic retinal changes and in most cases also for an estimation of functional improvement.

Anemia in patients with Wegener's granulomatosis.

AIMS: Anemia is commonly observed among patients with chronic kidney disease (CKD). No such information is available for patients with a history of systemic vasculitis. METHODS: We examined the prevalence of anemia, the response to therapy with erythropoiesis-stimulating agents (ESA), and the association of anemia with the kidney function in clinically stable patients with Wegener's granulomatosis in a retrospective, single-center study. RESULTS: The mean hemoglobin concentration of 36 patients (mean age: 58 years; 15 female, 21 male; mean duration of disease: 4.6 years) was 13.0+/-2.1 g/dl, and the mean estimated glomerular filtration rate (eGFR) was 41+/-21 ml/min/1.73 m(2). 14 of 36 patients (38.8%) presented with anemia (hemoglobin concentration < 12 g/dl in women, < 13 g/dl in men, or ESA therapy). In patients with a CKD Stage 3 or 4, anemia was present about twice as much as compared to the Third National Health and Nutrition Examination Survey (NHANES III) population. The hemoglobin concentration, however, was not associated with a change of kidney function (p = 0.1578). CONCLUSIONS: We found a higher prevalence of anemia in patients with Wegener's granulomatosis, as compared to the NHANES III population. The hemoglobin concentrations showed no association with changes of kidney function.

Encouraging treatment algorithm for computer-assisted navigated total knee arthroplasty (TKA): A retrospective cohort analysis.

OBJECTIVE: Navigated computer-assisted total knee arthroplasty (TKA) shows inconclusive mid- to long-term outcome results and is limited by increased costs, surgery-time and an additional learning curve. We introduced a treatment algorithm preserving computer-assisted TKA for patients with adipositas-per-magna, posttraumatic leg-deformities, osteosynthetic material in-situ or reduced preoperative X-ray quality. METHODS: 237 primary unilateral TKA were allocated based on the treatment concept described above. A retrospective pre- and postoperative radiological analysis was performed. RESULTS: 222 TKA (93.7%) were within 3° varus/valgus of mechanical-lower-limb axis (mean absolute deviation: 1.8° ± 1.3°). CONCLUSION: This algorithm showed an excellent postoperative implantation-accuracy based on an accurate preoperative surgery-planning.

Structural and serum surrogate markers of cerebrovascular disease in obstructive sleep apnea (OSA): association of mild OSA with early atherosclerosis.

There is increasing evidence of a causal interaction between obstructive sleep apnea (OSA) and cerebrovascular disease. The aim of the study was to elucidate the relationship between the polysomnographically (PSG) measured severity of OSA and carotid atherosclerosis determined by ultrasonography and serum surrogate markers. 147 patients (102 males, 45 females) referred to our sleep laboratory for evaluation of snoring and sleep-disordered breathing were investigated. Carotid atherosclerosis was evaluated by serum analysis of high-sensitivity C-reactive protein (hs-CRP) and fibrinogen and four sonographic indices: intima-media thickness (IMT) of the common carotid artery (CCA), IMT from bulb to internal carotid artery (Bulb-ICA), combined IMT measurements from all segments and a plaque score (PlaS). Pearson correlation analysis, intergroup comparison (ANOVA), covariance analysis and a multiple regression were performed to assess the association between surrogate markers and respiratory variables. 44 patients had no OSA (apnea-hypopnea index AHI < 5/h), 27 mild (AHI 5-15), 25 moderate (AHI 15-30) and 51 severe OSA (AHI > 30). After adjusting for potential confounders, significant differences between the controls and all three OSA groups were observed in the CCA-IMT (p = 0.032) and in the PlaS between the controls and the severe group (p = 0.034). Multiple regression revealed the AHI as an independent predictor of CCA-IMT (p = 0.001) and combined IMT (p = 0.001), whereas the percentage of total sleep time with an oxygen saturation below 90 % was associated with Bulb-ICA IMT (p = 0.018) and hs-CRP (p = 0.015). OSA is associated with higher surrogate levels of cerebrovascular disease. Even mild OSA seems to predispose to early atherosclerosis.

Investigation of food contamination since the Chernobyl fallout in Austria.

In a large-scale investigation the decrease of the activity concentration of 137Cs in foodstuffs after the widespread Chernobyl fallout was determined. At different times after the deposition in 1986 more than 1000 samples of various foodstuffs in Austria were taken and investigated with regard to their activity concentration. The investigation showed that in the first year after deposition, the activity concentration decreased to about 6-10% (milk, fruit), and 3-6%, respectively (grain, potatoes, vegetables) of the values in the fallout maximum. The calculated effective half-lives are significantly shorter than observed after nuclear weapon test series and result in a smaller long-term exposure than estimated before. The effective ingestion dose in the 50 years following of a one-time nuclear fallout amounts to about 1.3 times of the first year ingestion dose. In 2002, the ingestion dose in Austria amounts to 2.24 microSv (adult), or 0.88 microSv (5-year infant) respectively, which is less than 0.5% of the ingestion dose of the first year and amounts to 0.7% of the ingestion dose from natural radionuclides.

The impact of the social network, stigma and empowerment on the quality of life in patients with schizophrenia.

OBJECTIVE: The quality of life (QOL) of patients with schizophrenia has been found to be positively correlated with the social network and empowerment, and negatively correlated with stigma and depression. However, little is known about the way these variables impact on the QOL. The study aims to test the hypothesis that the social network, stigma and empowerment directly and indirectly by contributing to depression influence the QOL in patients with schizophrenia and schizoaffective disorders. METHOD: Data were collected on demographic and clinical variables, internalized stigma, perceived devaluation and discrimination, empowerment, control convictions, depression and QOL. Structural equation modelling (SEM) was applied to examine the impact of the above-mentioned constructs on QOL. RESULTS: The influences of the social network, stigma, empowerment and depression on QOL were supported by the SEM. A poor social network contributed to a lack of empowerment and stigma, which resulted in depression and, in turn, in poor QOL. Interestingly, however, the social network and stigma did not show a direct effect on QOL. CONCLUSION: Following a recovery approach in mental health services by focusing on the improvement of the social network, stigma reduction and especially on the development of personal strength has the potential to reduce depression in patients with psychosis and improving their QOL.

Individual and workplace monitoring measurements made after a 240Pu incident and during the clean-up operations.

On 3 August 2008, five glass vials containing around 7 GBq of (240)Pu in nitric acid solution burst in a laboratory operated by the IAEA in Seibersdorf, Austria. The vials were located in a fire-proof safe in the IAEA Safeguards Analytical Laboratory, and the release of the (240)Pu caused an air contamination in the room and in adjoining rooms. Immediate emergency work was carried out, which was then followed by a long period of clean-up operations. A large number of conventional individual and workplace monitoring measurements were carried out immediately after the incident and during the clean-up work. In addition, due to the fact that (240)Pu has a very low background presence in the environment, and that the IAEA laboratories operate an inductively coupled plasma mass spectrometry system capable of very low levels of detection of this radionuclide, a number of non-conventional measurements were made to detect (240)Pu on, for example, the photographic camera used to document the incident, on nasal swabs from the first responders, etc. Plastic beakers were left in the corridor of the controlled area to accumulate (240)Pu from precipitation to see whether it was possible to detect traces of the radionuclide. This paper presents the measurements obtained, and discusses their relevance to occupational radiation protection.

Morphological and functional analysis of the loading regimen with intravitreal ranibizumab in neovascular age-related macular degeneration.

AIM: To quantify and correlate the morphological and functional effects of the recommended loading regimen with intravitreal ranibizumab in neovascular age-related macular degeneration (AMD). METHODS: In a prospective, interventional clinical trial, 29 consecutive patients (29 eyes) with choroidal neovascularisation secondary to AMD received three initial monthly intravitreal injections of ranibizumab. During this loading regimen, best corrected visual acuity (BCVA) and microperimetry (MP) testing, as well as optical coherence tomography and fluorescein angiography (FA), were performed using a standardised protocol and the results correlated. RESULTS: Significant morphological and functional therapeutic effects were observed as early as 1 week following the first treatment. Throughout the loading-dose period, central retinal thickness, including intraretinal cysts and subretinal fluid, decreased fast and significantly (p<0.01); pigment epithelial detachment resolved less rapidly. The mean leakage area by FA decreased (p<0.01) and retinal function (BCVA and MP) increased significantly (both p<0.01). However, the change in morphology and function was only significant between baseline and week 1. There was no significant additional morphological or functional benefit following the second and third injection. CONCLUSION: The initial administration of intravitreal ranibizumab in neovascular AMD induced a significant effect on intra- and subretinal fluid and visual function; subsequent injections had a less pronounced effect. It remains to be determined whether this loading regimen should be mandatory in all patients or if a single dose regimen would lead to a comparable functional and morphological retinal improvement.

Low-turnover bone disease in hypercalcemic hyperparathyroidism after kidney transplantation.

Hypercalcemia in persistent secondary hyperparathyroidism after kidney transplantation is considered to result from increased bone resorption. Bone biopsies' studies, however, have never been performed in these patients. Bone biopsies after double tetracycline labeling were obtained from 17 patients with hypercalcemic hyperparathyroidism and an estimated glomerular filtration rate > 30 mL/min/1.73 m2. Serologic bone markers, calcitriol, intact fibroblast growth factor-23 (iFGF-23), and serum and 24h urine concentration of calcium and phosphate were measured in all patients. Tubular maximum for phosphate corrected for GFR (TmP/GFR), and the fractional excretion of calcium (FeCa) were calculated. High-turnover renal osteodystrophy (ROD) was present in nine and low-turnover ROD in eight patients. The bone formation rate was significantly associated with bone alkaline phosphatase, c-telopeptide and osteocalcin. In patients with high turnover ROD, osteocalcin was also significantly higher than in patients with decreased bone formation. The FeCa was normal or below normal in 14/17 patients. TmP/GFR was below normal in all patients. Neither intact PTH nor iFGF-23 was associated with TmP/GFR, FeCa or any histomorphometric bone parameter. We conclude that hypercalcemia of posttransplant hyperparathyroidism can be associated with high or low turnover bone disease. Decreased calcium excretion suggests an additive tubular effect on hypercalcemia.

Lip piercing: prevalence of associated gingival recession and contributing factors. A cross-sectional study.

BACKGROUND AND OBJECTIVE: Body piercings have increased tremendously in popularity in recent years. For oral piercing, late complications include gingival trauma and localized periodontitis. The purpose of this cross-sectional study was to investigate the prevalence and contributing factors of gingival recession associated with labial piercing. MATERIAL AND METHODS: The test group included 50 subjects with lower-lip studs. Nonpierced controls were matched according to gender, age and smoking status. Clinical examination included plaque and bleeding indices, probing depth, recession, clinical attachment level, width of keratinized gingiva, periodontal biotype, insertion of frenula, evaluation of hard tissues, trauma of occlusion, characteristics of the stud, radiographs and photographs. RESULTS: Gingival recessions were noted on teeth opposite the stud in 68% of the test group compared with 4% of the controls. Localized periodontitis was recorded in 4% of test subjects. Time since piercing and the position of the stud in relation to the cemento-enamel junction were significantly associated with the prevalence of buccal recessions. There were no significant associations between piercing and abnormal tooth wear. CONCLUSION: The prevalence of gingival recessions is associated with labial piercing. The position of the intra-oral disc and time since piercing are associated with a greater prevalence of gingival recession. A narrow width of keratinized gingiva is associated with increased buccal recessions.

Interfragmentary compression forces of scaphoid screws in a sawbone cylinder model.

Various screws have been developed to stabilise fractures of the scaphoid. Commonly used are the Herbert, the HBS, the 3-mm AO and the Acutrak screws. Not long ago a new screw, the Twin Fix, was introduced. This is cannulated and similar in shape and appearance to the classical Herbert screw. In our test series we compared the maximum achievable compression forces of the Twin Fix screw with that of three other screws (AO, HBS and Acutrak screws). To avoid the variations of density, stiffness and rigidity in natural bone, a polyurethane sawbone-based test setup was used. The test series included 10 screws of each type. The compression force was measured using a special strain gauge. The mean compression force was significantly higher for the Twin Fix screw (8+/-1N) and the Acutrak screw (7.6+/-0.4/0.6N) in relation to the AO screw (6.8+/-1.0/1.4N) and HBS screw (2+/-1N). We found the Twin Fix and Acutrak screws to be promising in the treatment of scaphoid fractures.