[Inguinal hernia repair in TAPP technique in a day-case surgery setting - at what price?] / Ambulanter transabdomineller präperitonealer Leistenhernienverschluss (TAPP) ­ um welchen Preis?

BACKGROUND: TAPP surgery can be considered as a gold standard in inguinal hernia repair. Patients benefit of a faster reconvalescence and less pain compared to other techniques. TAPP surgery in Germany is performed in an in-patient setting routinely. However, according to European guidelines, inguinal hernia surgery should be considered as day-case surgery whenever possible. OBJECTIVES: The safety of day-case surgery was examined in relation to postoperative pain, complications, comorbidities, recurrent inguinal hernia and bilateral procedures. MATERIAL AND METHODS: In a retrospective, monocentric study we analyzed 522 elective inguinal hernia repairs using TAPP technique in a specialized hernia center. Supplemental data from Herniamed registry is analyzed. RESULTS: Parts of the procedures should be performed in an in-patient setting, whereas a much larger number of cases should be carried out as day-case surgeries. Logistic regression analyses show that "age", "bilateral procedures" and "comorbidities" affect the complication rate. "Age" and "recurrent inguinal hernia" are risk factors for an increased need for analgetic medication. Furthermore, we present an actual distribution of day-case vs. in-patient surgeries in inguinal hernia repair based on data from the Herniamed registry. CONCLUSION: A much larger part of procedures could safely be carried out as day-case surgeries. Based on a false incentive there is an incorrect steering in the German health system. These procedures cannot be carried out covering the costs as day-surgery cases. If there is no reevaluation of the proceeds of these procedures in a day-case surgery setting, the reasonable quality in treatment is compromised especially in inguinal hernia surgery.

Isotope-tagged cross-linking reagents. A new tool in mass spectrometric protein interaction analysis.

In protein interaction analysis, one promising method to identify the involved proteins and to characterize interacting sites at the same time is the mass spectrometric analysis of enzymatic hydrolysates of covalently cross-linked complexes. While protein identification can be accomplished by the methodology developed for proteome analysis, the unequivocal detection and characterization of cross-linked sites remained involved without selection criteria for linked peptides in addition to mass. To provide such criteria, we incorporated cross-links with a distinct isotope pattern into the microtubule-destabilizing protein Op18/stathmin (Op18) and into complexes formed by Op18 with tubulin. The deuterium-labeled cross-linking reagents bis(sulfosuccinimidyl)-glutarate-d4, -pimelate-d4, and -sebacate-d4 were prepared together with their undeuterated counterparts and applied as a 1:1 mixture of the respective d0 and d4 isotopomers. The resulting d0/d4 isotope tags allowed a straightforward mass spectrometric detection of peptides carrying the linker even in complex enzymatic protein hydrolysates. In the structure elucidation of the linked peptides by MS/MS, the assignment of the linked amino acids was again greatly facilitated by the d0/d4 tag. By applying two cross-linkers with similar reactivity but different spacer length in parallel, even doublets with very low intensity could be assigned with high confidence in MS and MS/MS spectra. Since in the Op18-tubulin complexes only a limited number of peptides carried the linker, the identification of the involved proteins per se was not impeded, thus accomplishing both protein identification and characterization of interacting sites in the same experiment. This novel methodology allowed us to significantly refine the current view of the complex between Op18 and tubulin corroborating the tubulin "capping" activity of the N-terminal domain of Op18.

[Ovarian activity, cycle behavior and tolerance of low dosage oral contraceptives: a comparative study]. / Ovarielle Aktivität, Zyklusverhalten und Verträglichkeit bei niedrigdosierten oralen Kontrazeptiva: Eine Vergleichsstudie.

In a double-blind randomized study, the suppression of ovarian activity, the effects on the cervix and endometrium, menstrual bleeding patterns and overall tolerance were assessed during administration of two low-dose oral contraceptives (20 micrograms ethinylestradiol EE, 500 micrograms norethisterone--Eve 20, Grünenthal, Aachen; 20 micrograms EE, 150 micrograms Desogestrel--Lovelle, Organon, Munich), 118 healthy women (ages: 18 to 35 years) with comparable bioprofiles (height, weight, menstrual cycle patterns) were studied in 10 investigation centres during medication with either Eve 20 (n = 59) or Lovelle (n = 59). During 3 treatment cycles, ovarian activity was evaluated by sonographic determination of follicular size and by simultaneous assessment of serum endocrine profiles (gonadotropins LH and FSH, ovarian steroids estradiol [E2] and progesterone [P]). Treatment cycles 4 to 6 served to evaluate the patterns of menstrual bleeding and the overall subjective tolerance on each contraceptive. While on the preparations, no ovarian activity (as judged by a lack of follicular growth and suppressed sex steroid levels) was found in over 90% of all investigated cycles. Follicular activity and/or cyst formation were detected in 18 of 173 cycles (Eve 20) and in 5 of 175 cycles (Lovelle) respectively. Gonadotropin levels were suppressed (LH < 6 IU/l, FSH < 8 IU/l) in most treatment cycles (Eve 20: 76.6% vs. Lovelle: 84.8%). Serum E2 concentrations exceeding 0.1 nmol/l indicated residual follicular activity in 19.3% (Eve 20) vs. 12.2% (Lovelle) of all cycles. As estimated by serum P levels over 5 nmol/l, ovulation had presumably occurred in 4.1% (Eve 20) vs. 2.9% (Lovelle) of treatments respectively. However, when the sonographic and endocrinological data were combined, no ovulation was documented in any treatment cycle. In addition, the quality of the cervical mucus was minimal and a low endometrial thickness was found in the majority of women, indicating strong progestogen effects of both contraceptives. Menstrual irregularities (intermenstrual spotting, break-through bleeding) occurred initially on each preparation, but were mostly resolved when the pills were continued. The acceptance of each investigated drug was rated as very good or good by most subjects. These observations allow us to conclude that the rate of ovarian suppression with inhibition of follicular activity is high under low-dose oral contraceptives. The different progestogens as components of these contraceptive pills display equally good anti-conceptive effects on both the cervix and the endometrium. Furthermore, the rate of irregular menstrual bleeding is acceptable for these low-dose contraceptives. The high acceptance of each preparation suggests that such agents will have a high rate of acceptability in clinical use.

Does the gonadotropin pulsatility of postmenopausal women represent the unrestrained hypothalamic-pituitary activity?

Ovarian sex steroids profoundly modulate the gonadotropin pulsatile secretion in women. A gonadotropin pulsatility determined in the absence of any considerable ovarian sex steroid feedback, as in postmenopausal women (PMW), may thus represent the unrestrained activity of the hypothalamic-pituitary axis. We hypothesized that increases in the gonadotropin pulse frequencies and amplitudes during sex steroid replacements may be limited by those determined in the hypogonadal state of PMW. To address this assumption, we investigated the unstimulated the gonadotropin-releasing hormone (GnRH)-stimulated release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in PMW before and during sequential ovarian sex steroid treatments. Seven PMW (mean age 59.4 years) were studied initially during unreplaced conditions (control studies), then on the last day of a 21-day course of oral estradiol valeriate (E2) administrations (2 mg daily) and, finally, on the last day of a 21-day course of oral estradiol-progesterone (E2/P4) replacements (2 mg of E2 and 200 mg of micronized P4 daily). On all study occasions, blood was drawn at 10-min intervals for 10 h and GnRH (25 micrograms iv) was administered 8 h after initiation of blood collections. Compared to control conditions, the basal serum estrogen (estrone and E2) and progesterone (P4) concentrations markedly increased (p < 0.001) following oral E2 or E2/P4 treatments. As determined by Cluster pulse algorithm, LH and FSH were found to be released episodically during each study condition. Mean LH and FSH release rates declined (P < 0.05 or less) during E2 and E2/P4 regimens.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effects of sleep on gonadotropin secretion]. / Einflüsse des Schlafes auf die Gonadotropinsekretion.

Comparable to the period of adolescence in puberty, sleep exerts profound effects on the gonadotropin secretion in adult women. During the early follicular phase of the menstrual cycle, a slowing of the luteinising hormone (LH) pulse frequencies is concomitant with a rise in LH pulse amplitudes during sleep. A selective sleep-associated increase in opioidergic, but not in dopaminergic activity, may account for the decline in the LH pulse frequencies. Since pituitary gonadotropin responsiveness is virtually unchanged during sleep, the reasons for the enhanced LH pulse amplitudes remain unknown. Although the physiological meaning of this neuroendocrine manifestation is unexplained at present, the observed changes in the LH secretory profiles during sleep may represent close functional links between the endocrine secretion and the rest-activity cycle of the brain.

Immediate-early RNA 2.9 and early RNA 2.6 of bovine herpesvirus 1 are 3' coterminal and encode a putative zinc finger transactivator protein.

Bovine herpesvirus 1 (BHV-1) contains three major immediate-early (IE) genes involved in regulation of the productive cycle of replication. Two spliced IE RNAs, IER4.2 (4.2 kb) and IER2.9 (2.9 kb), are under the control of a single promoter; IER1.7 (1.7 kb) is transcribed from a different promoter in the opposite direction. Examining the kinetics of transcription, we found that the IER4.2/2.9 promoter was turned off at the end of the IE period. An alternative promoter became active, directing synthesis of an unspliced early RNA, ER2.6 (2.6 kb), which was colinear with the second exon of IER2.9 except for its 5' end in the intron about 10 bases upstream of the splice site. Sequence analysis revealed a single open reading frame common to IER2.9 and ER2.6 with a coding potential of 676 amino acids. The putative protein, named p135, contained a cysteine-rich zinc finger domain near the N terminus with homology to ICP0 of herpes simplex virus type 1, to protein 61 of varicella-zoster virus, to early protein 0 of pseudorabies virus, and to other viral and cellular proteins. The remaining parts of p135 exhibited only limited homology, mainly with pseudorabies virus protein 0, but the entire sequence was highly conserved between two strains of BHV-1 (K22 and Jura). The latency-related antisense transcript covered a large portion of ER2.6 excluding the zinc finger coding region. In transient expression assays, p135 activated a variety of promoters, including that for ER2.6, but repressed the IER1.7 promoter. Thus, p135 combines functional characteristics of ICP0, a strong transactivator, and of protein 61, a repressor. BHV-1 seems to have evolved a subtle mechanism to ensure the continued synthesis of p135 while turning off IER4.2, which encodes p180, the herpes simplex virus type 1 ICP4 homolog.

Spatial and temporal distribution of bovine herpesvirus 1 transcripts.

Northern (RNA) blot analysis was used to determine the spatial and temporal distribution of bovine herpesvirus 1 (BHV-1) transcripts. Total RNA was isolated from Madin-Darby bovine kidney cells which had been infected with BHV-1.2b strain K22 or BHV-1.1 strain Jura in the presence or absence of metabolic inhibitors. Cloned restriction fragments representing the entire genome of strain K22 were labeled with 32P and hybridized to immobilized RNA. A total of 54 BHV-1 transcripts were found, ranging in size from 0.4 to larger than 8 kilobases (kb). The inverted repeat regions and an adjacent segment of the unique large part of the BHV-1 genome encoded three major immediate-early (IE) transcripts and one minor IE transcript enriched after cycloheximide treatment of infected cells. Late transcripts were identified by drastically reduced abundance after cytosine arabinoside (araC) treatment. Twelve late transcripts were encoded mainly by the unique long genome region, with a cluster of four transcripts located on HindIII fragment K (map units 0.677 to 0.733). The 21 transcripts unaffected by araC treatment were defined as early; they showed dispersed locations over the whole genome, with a cluster on the unique short sequence. The 17 remaining transcripts could not be classified unambiguously as early or late by these techniques. The IE transcript with a size of 4.2 kb exhibited homology with the single IE gene of pseudorabies virus, and the IE transcript with a size of 2.9 kb was encoded in part by the genome region known to be transcriptionally active during latency.

Does prolonged dopaminergic blockade alter the LH pulsatile secretion in normal cycling and postmenopausal women?

To investigate effects of prolonged dopaminergic antagonism on LH pulsatile secretion, 22 normal cycling women (10 in the early follicular phase (days 3 and 4), 6 in the late follicular phase (days 10 to 13), 6 in the midluteal phase (days 6 to 8 after ovulations) and 8 postmenopausal women were studied before and during 8-h dopamine receptor blockade imposed by metoclopramide. Sequential 8-h infusions of either saline (50 ml/h) or metoclopramide (30 micrograms . kg-1 . h-1) were conducted on two consecutive days. LH pulsatile activity was assessed in blood samples obtained at 15 min intervals during these 8-h infusion periods. Based estradiol and progesterone concentrations were lowest (p. less than 0.001) in postmenopausal and highest (p less than 0.001) in the midluteal phase women, 8-h metoclopramide infusions evoked prompt (within 90 min, p less than 0.001) and sustained (greater than 70 micrograms/l, p less than 0.001) increases of PRL, similar (p = 0.78) in magnitude for normal cycling and postmenopausal women. Metoclopramide infusions failed to significantly modify the LH pulsatile activity during the menstrual cycles and in hypogonadal women. These observations suggest that even in the presence of high circulating estradiol and progesterone concentrations the dopaminergic inhibition may not be operating. However, any possible stimulatory effect on LH secretion by dopamine receptor blockade may be confounded by the concomitant metoclopramide-induced hyperprolactinemia.

The effects of prolonged opioidergic blockade on LH pulsatile secretion during the menstrual cycle.

Although considerable evidence points towards a pivotal role for the endogenous opioid peptides (EOP) in the neuroendocrine regulation of GnRH-LH secretion, the effects of prolonged opioidergic blockade on LH pulsatile activity during the menstrual cycle have not been thoroughly investigated. Accordingly, 10 women in the early follicular phase (EFP, days 3 and 4), 10 women in the late follicular phase (LFP, days 9 to 13) and 7 women in the midluteal phase (MLP, days 6 to 8 after LH surge) were studied on two consecutive days before and during opioidergic blockade imposed by an opiate receptor antagonist, naloxone. Blood samples were obtained at 15 min intervals for 8 h during saline (150 mmol/l at 50 ml/h) or naloxone (30 micrograms/kg/h) infusions. Furthermore, sequential 24-h infusions of saline or naloxone (30 micrograms/kg/h) were performed in 6 other women (two each in the EFP, LFP, and MLP). LH hormone series were analyzed for significant pulses by the Cluster pulse algorithm. While 8-h naloxone infusions did not change any of the LH pulse characteristics (frequency, amplitude, transverse mean, duration) in the EFP, they elevated significantly (p less than 0.05) the LH pulse frequencies, pulse amplitudes and transverse mean levels in the LFP. In the MLP, the LH pulse amplitudes were significantly (p less than 0.05) increased, but pulse frequencies and transverse mean levels remained unchanged. While the 24-h naloxone infusions did not alter any of the pulse characteristics in the EFP, they elicited a robust increase in LH pulsatile activity in the LFP, composed of a progressive rise in LH pulse amplitudes and transverse mean levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Endocrine dynamics during pulsatile GnRH administration in patients with hypothalamic amenorrhea and polycystic ovarian disease.

The LH secretory patterns and ovarian endocrine responses have been determined during pulsatile gonadotropin-releasing hormone (GnRH) administration for induction of ovulation in patients with hypothalamic amenorrhea (HA). However, until now these endocrine dynamics during GnRH therapy have not been thoroughly investigated in patients with polycystic ovarian disease (PCOD). Seven patients with HA and 4 patients with PCOD have therefore been studied to determine changes in LH pulsatile activity and in serum sex steroid levels in response to chronic intermittent GnRH stimulation. GnRH was administered intravenously (5-10 micrograms/90 minutes) by means of a portable infusion pump. Blood samples were obtained at 15-minute intervals for 4 hours on the day before the start of GnRH stimulation (control day) and on treatment days 5, 10 and 15. LH was determined in all samples and FSH, serum androgens and estrogens were measured in baseline samples by RIA. While 8 (62%) ovulations and 5 conceptions were observed in 13 treatment cycles in patients with HA, no ovulations were achieved during 9 treatment cycles in patients with PCOD. On the control day significantly (p less than 0.05) higher basal LH and testosterone (T) levels and significantly (p less than 0.05) lower FSH levels were found in the PCOD patients. The LH pulsatile profiles of the PCOD patients showed significantly (p less than 0.05) higher pulse amplitudes and areas under the curve (integrated responses). Pulsatile GnRH administration induced a significant (p less than 0.05) increase in LH pulse amplitudes in both HA and PCOD patients, and also increased (p less than 0.05) the integrated responses in patients with HA. During the GnRH stimulation, the LH interpulse intervals of both HA and PCOD patients were found to be similar to the frequency in which exogenous GnRH was administered. FSH levels rose continuously (p less than 0.001) during stimulation in patients with HA, but remained unchanged in patients with PCOD. In HA patients, T, androstenedione (AD) and estrone (E1) did not change during the GnRH treatment, but estradiol (E2) rose so that the ratios of aromatized estrogens to non-aromatized androgens (E1/AD, E2/T) increased. In contrast, T and AD increased significantly (p less than 0.05 or less) and E2 remained unchanged during stimulations in PCOD patients, which resulted in decreasing ratios of estrogens to androgens. These observations confirm that pulsatile GnRH administration can successfully induce ovulation in patients with HA by restoring the ovarian physiology. The data also demonstrate that pulsatile GnRH administration can influence the LH secretory patterns in PCOD patients.(ABSTRACT TRUNCATED AT 400 WORDS)