Perioperative outcome of unilateral versus bilateral inguinal hernia repairs in TAPP technique: analysis of 15,176 cases from the Herniamed Registry.

INTRODUCTION: Following repair of a unilateral inguinal hernia, there is a risk of 1% per year of onset of an inguinal hernia on the other side. Comparison of bilateral with unilateral TAPP operation in a high-volume center found that morbidity and reoperation rates were only marginally higher for bilateral TAPP operation. Some authors are calling for prophylactic operation of the contralateral side. METHODS: Between September 2009 and April 2013, data were entered into the Herniamed Registry on 15,176 patients who had undergone TAPP operation. Of these patients, 10,887 had been operated on because of a unilateral (71.7%) and 4289 because of a bilateral (28.3%) inguinal hernia. RESULTS: A significant difference was noted in the rate of postoperative complications occurring within 30 days, which was 4.9% for bilateral compared with 3.9% for unilateral inguinal hernia (p = 0.009). The postoperative complications necessitated reoperation in 0.9% of patients after unilateral and in 1.9% of patients after bilateral inguinal hernia repair, thus attesting to the significantly higher risk presented by bilateral inguinal hernia repair (p = <0.001).Multivariate analysis confirmed the highly significant influence of bilateral TAPP on increased reoperation rates due to complications (p > 0.0001). The odds ratio was 2.13 (95% CI 1.58-2.86). Comparison of the results from a high-volume center with those from the Herniamed Registry showed that perioperative complication rates were markedly higher. CONCLUSION: Perioperative outcome of bilateral TAPP operation demonstrates significantly worse postoperative complication and reoperation rates compared with unilateral TAPP. Likewise, the results were markedly unfavorable compared with those of a high-volume center. If a bilateral hernia repair should be attempted in those patients with only a unilateral hernia, these data give the surgeon more information on how to better prepare a patient and obtain consent preoperatively.

[Effects of calorie information and nutrition traffic light on alimentation behaviour in public catering]. / Auswirkungen von Kalorienangaben und Ernährungsampel auf das Ernährungsverhalten in der Gemeinschaftsverpflegung.

BACKGROUND: Due to the significant increase in overweight and obese people, action is needed to raise eating behaviour awareness. A significant main meal (lunch) is witnessing a growing trend in the catering (part of the out-of-home nutrition). The aim of this study is to determine whether the selection of lunch menus is affected through the display of nutritional information in the form of number of calories or a traffic light model. METHODS: In this exploratory study, quantitative data were collected in a cross-sectional design. In addition to the established measurement instruments, socio-demographic and socio-economic information of the subjects based on the study were evaluated. The survey took place in 2008 in 2 passes (time t A/t B). The identical lunch menu of a catering company was applied twice respectively for 4 weeks. In the second run (t B) the lunch menu contained additional nutritional information (big 4 instructions) in the form of calories or a traffic light nutrition. The test of group differences was based on scientific statistical analysis in SPSS. RESULTS: The overall results for the illustration of kilocalories or traffic light do not have a unique significance in the direction of a low average number of calories at the time t B in comparison to the time t A. The food participants, on average, choose a lower calorie-containing menu, when a combination of traffic light and calories is given. CONCLUSION: The nutrition behaviour is accompanied by an oversupply of unhealthy foods. Lunch participants are sensitised for the selection of healthier lunch menus by a traffic light nutrition information or calories information. Nutrition labelling for lunch menus in the form of calories nutrition information or a coloured traffic light could trigger preventive effects.

The International Endometriosis Evaluation Program (IEEP Study) - A Systematic Study for Physicians, Researchers and Patients.

INTRODUCTION: Endometriosis is a heterogeneous disease characterized by a range of different presentations. It is usually diagnosed when patients present with pain and/or infertility, but it has also been diagnosed in asymptomatic patients. Because of the different diagnostic approaches and diverse therapies, time to diagnosis can vary considerably and the definitive diagnosis may be delayed, with some cases not being diagnosed for several years. Endometriosis patients have many unmet needs. A systematic registration and follow-up of endometriosis patients could be useful to obtain an insight into the course of the disease. The validation of biomarkers could contribute to the development of diagnostic and predictive tests which could help select patients for surgical assessment earlier and offer better predictions about patients who might benefit from medical, surgical or other interventions. The aim is also to obtain a better understanding of the etiology, pathogenesis and progression of the disease. MATERIAL AND METHODS: To do this, an online multicenter documentation system was introduced to facilitate the establishment of a prospective multicenter case-control study, the IEEP (International Endometriosis Evaluation Program) study. We report here on the first 696 patients with endometriosis included in the program between June 2013 and June 2015. RESULTS: A documentation system was created, and the structure and course of the study were mapped out with regard to data collection and the collection of biomaterials. CONCLUSION: The documentation system permits the history and clinical data of patients with endometriosis to be recorded. The IEEP combines this information with biomaterials and uses it for scientific studies. The recorded data can also be used to evaluate clinical quality control measures such as the certification parameters used by the EEL (European Endometriosis League) to assess certified endometriosis centers.

Induction of Labour: Change of Method and its Effects.

Aim: The combination of mechanical and drug procedures for the induction of labour seems to be beneficial. Accordingly, the normal procedure in clinical routine has been changed and induction of labour by means of a balloon catheter has been implemented. The aim of this study was to find out if this procedural change has resulted in a more effective induction of labour. Materials and Method: In this historical cohort study 230 inductions of labour at term in the year 2012 were compared with 291 inductions of labour in the year 2013, all at the University of Erlangen Perinatal Centre. Exclusion criteria were, among others, a multiple pregnancy, a premature rupture of membranes and a prior Caesarean section. In 2012 births were induced solely by use of the drugs dinoprostone and misoprostol, in 2013 not only with misoprostol but also mainly by use of a balloon catheter. The primary target parameter was the rate of failed labour inductions, defined as "no birth within 72 hours". Results: Altogether 521 inductions of labour were analysed. The rate of failed inductions of labour could be reduced by the changes in induction method (first-time mothers: 23 vs. 9 %, p = 0.0059; multiparous women: 10 vs. 1 %, p = 0.0204). Furthermore, the rate of primary Caesarean sections due to failed induction of labour (5.7 vs. 1.4 %, p = 0.0064), that of the observation of green amniotic fluid (first-time mothers: 23 vs. 9 %, p = 0.0059; multiparous women: 10 vs. 1 %, p = 0.0204) and of infantile infections (first-time mothers: 23 vs. 9 %, p = 0.0059; multiparous women: 10 vs. 1 %, p = 0.0204) were all reduced as well. Conclusion: The routine use of a balloon catheter for induction of labour has markedly improved the procedure. There were fewer failed labour inductions and fewer Caesarean sections due to failed induction of labour.

Noise in the ICU.

OBJECTIVE: The growing number of technical devices in ICUs makes noise exposure a major stressor. The purpose of this study was to assess noise levels during routine operation in our ICU. DESIGN: Our ICU is an open ward with four rooms, constructed in the 1960s. During the study period, 4 patients were in the controlled room and were treated by 4 nurses during the day and by 2 at night. A-weighted sound pressure levels (SPL) were measured continuously for 2 days and nights. Also measured were the alarms of various appliances. For gross overall evaluation it is customary to state the Leq, i.e. the energy-averaged level during measurement. The annoyance caused by noise depends more on rare events of high intensity. Therefore, the distribution of SPL values (Ln) over time was also analysed. RESULTS: SPL was roughly the same during the day and at night, with Leq between 60-65 dB(A) and peaks up to 96 dB(A). Most alarms reach an SPL of 60-70 dB(A), but some exceed 80 dB(A). During teaching rounds Leq exceeds 65 dB(A). CONCLUSION: During the day and at night SPL always surpasses the permissible noise exposure for 24 h of 45 db(A) recommended by the US Environmental Protection Agency. Alarms cause the most irritating noise. Hospital management should pay attention to internal noise, and SPL should be measured routinely.

Sodium balance and osmolarity in burn patients.

In 12 severely burned patients the input of fluid and sodium, as well as sodium concentration in plasma and urine, was studied. The osmolarity in plasma and 24-h urine was measured. The high initial sodium input is noted. Plasma sodium levels stay within the normal range when the amount of sodium given during the further treatment is reduced. The importance of urea production in affecting plasma osmolarity is demonstrated.

Endocrine abnormalities in severe traumatic brain injury--a cue to prognosis in severe craniocerebral trauma?

Patients with severe craniocerebral trauma (sCCT) display metabolic and endocrine changes. The question is raised whether hormonal patterns give cues to the prognosis of outcome or not. In 21 patients the function of the adrenocortical, gonadal, thyroid and human growth hormone (hGH)-insulin system was assessed. LH, FSH, TSH, prolactin and hGH were stimulated. 3 groups of patients were formed. Group I: patients in acute phase with a Glasgow Coma Score (GCS) more than 6 (group Ia) and less than 6 (group Ib). Group II: patients in transition to traumatic apallic syndrome (TAS). Group III: patients with full-blown or resolving TAS. The values of group Ia comprised low T3, T4 and testosterone, elevated insulin, normal hGH. Group Ib had hypothyroid T3 and T4 and an attenuated response of LH, TSH, prolactin and hGH to stimulation. Group III: there was seen an endocrine normalisation with elevated T4 and TBG and an altered response of hGH and prolactin to stimulation. Endocrine abnormalities were not helpful in predicting which course, either to better or to worse, a given patient would follow.

The activity of the sympathetic nervous system following severe head injury.

The activity of the sympathetic nervous system during the course of severe closed head injury has been evaluated in 15 patients by measuring plasma levels of epinephrine and norepinephrine. With the onset of the transition stage from midbrain syndrome to the apallic syndrome the plasma levels mainly of norepinephrine started to increase and remained high during the further course of the disease. During the remission from the apallic syndrome the elevated norepinephrine levels started to decline. The data indicate that a longlasting overactivity of the sympathetic nervous system is a characteristic feature in the course of severe head injury. As a rational therapy to protect the peripheral tissues against the consequences of a longlasting sympathetic overactivity we suggest the use of beta-adrenergic blocking agents and adrenergic neuron blocking drugs.

The secretion of human growth hormone stimulated by human growth hormone releasing factor following severe cranio-cerebral trauma.

Patients suffering from severe cranio-cerebral trauma show alterations of the secretory patterns of thyroid stimulating hormone (TSH) and human growth hormone (HGH) which may be of prognostic significance. We studied 10 patients following severe brain injury and prospectively compared a new synthetic human growth hormone releasing factor (HGHRF) test with the thyrotropin releasing hormone (TRH) test. On admission, all patients had a Glasgow Coma Scale score of 3 or 4. All patients had a low T3 syndrome. In the patients who died the TSH response after stimulation with TRH was also absent. In the patients who survived a significant TSH increase was observed (p less than 0.05). In comparison to the patients who died those who survived showed a significant (p less than 0.001) HGH increase after HGHRF stimulation. This test might be useful as an additional tool in establishing early prognosis in patients with severe brain injury.

Factors influencing transcutaneous oxygen and carbon dioxide measurements in adult intensive care patients.

Transcutaneous PO2 (PtcO2) is suggested to reflect tissue oxygenation in intensive care patients, whereas transcutaneous PCO2 (PtcCO2) is advocated as a noninvasive method for assessing PaCO2. In 24 critically ill adult patients (mean Apache II score 14.2, SD 4.7) we investigated the impact of variables that are commonly thought to determine PtcO2 and PtcCO2 measurements. A linear correlation was found between PtcO2 and PaO2 (r = 0.6; p less than or equal to 0.0001) and between PtcO2 and mean arterial blood pressure (MAP; r = 0.42; p less than or equal to 0.003). Cardiac index (CI) correlated with tc-index (PtcO2/PaO2; r = 0.31; p less than or equal to 0.03). There was no relationship between PtcO2 and hemoglobin concentration (Hb) and the position of the oxygen dissociation curve (ODC). Stepwise multiple regression analysis demonstrated a significant influence of PaO2 and MAP on PtcO2. The contribution of CI, Hb and the ODC was not significant. Only 40% of the variability of a single PtcO2 measurement could be explained by PaO2 and MAP. A significant linear correlation was demonstrated between PtcCO2 and PaCO2 (r = 0.76; p less than or equal to 0.0001) but not between PtcCO2 and CI, MAP and arterial base excess (BEa). Stepwise multiple regression analysis revealed an influence of PaCO2 and of CI on PtcCO2; 66% of the variability of a single PtcCO2-value could be explained by PaCO2 and CI. Our data demonstrate that transcutaneous derived gas tensions result from complex interaction between hemodynamic, respiratory and local factors, which can hardly be defined in ICU-patients.

Treatment of Guillain-Barré syndrome by plasma exchange.

Plasma exchange has been used for therapy in eight patients with the Guillain-Barré syndrome. All patients were severely ill. They became tetraplegic and showed cranial nerve involvement. Five patients received assisted respiration, but the others were also at risk of ventilatory insufficiency. Recovery was abrupt in all cases after the first plasma exchanges. Improvement was more marked when plasmapheresis was done on three successive days with plasma exchanges of 2.0-3.01 each in the initial progressive stage of the disease. A considerable advantage of this therapy is the avoidance of continued artificial respiration and nutrition, which both carry the risk of further complications.

Central somatosensory conduction time and acoustic brainstem transmission time in post-traumatic coma.

Short-latency evoked potentials (SEPs) of the scalp and neck after median nerve stimulation and acoustic brainstem evoked potentials (BAEPs) were recorded in 85 patients in post-traumatic coma with clinical signs of brainstem impairment between days 2 and 6 after trauma. The central somatosensory conduction time (CCT), the amplitude ratio (AR) N20:N13, the interpeak latencies (IPL) I-III, III-V, I-V, and the ARs between waves I and V (I:V) and between wave I and the wave IV/V complex (I:IV/V) were calculated and related to the outcome of the patients. In cases of coma due to supratentorial lesions, CCT and ARs of SEPs were close to normal in patients with good outcome: CCT increased and ARs decreased with worsening of outcome. In cases of primary brainstem injury, a significant prolongation of CCT was also seen in patients with good recovery, whereas normal CCTs could be found in patients with severe disability and death outcome. In this case, unilateral absent scalp SEPs were frequently found. The IPLs I-III, III-V, I-V, and the ARs of BAEPs increased with worsening of outcome. Significant differences of IPL I-V and III-V (brainstem transmission time) were seen between patients with good recovery or moderate disability outcome and the patients with severe disability or death outcome. There was no difference in BAEPs between patients with primary brainstem lesion and patients with secondary brainstem lesion. Patients with bilateral absent SEPs and bilateral absent BAEPs not related to traumatic or preexisting hearing disorders died or survived severely disabled. Unilateral absence of scalp SEPs and unilateral absence of BAEPs were frequently found in patients who died or who had severe disability. Asymmetries in scalp SEPs appeared to be distributed equally to all outcome categories, but asymmetries in BAEPs increased with worsening of outcome too. In most of the patients who died or survived disabled, both SEPs and BAEPs were abnormal.

[Five cases of lactic acidosis (author's transl)]. / Fünf Fälle von Laktatazidose.

Five cases of non-biguanide-induced lactic acidoses are reported. The key role of the liver and kidneys in lactate metabolism is stressed. The patients at risk are enumerated and the particular stress in connexion with surgical procedures and the dangers of fructose infusions are pointed out. The coagulation disturbances due to lactic acidosis are discussed. The different operative procedures and their effectiveness are discussed.

[Differential diagnosis between skeletal muscle lesions and myocardial damage in multiple injury by determination of myocardial-specific creatine phosphokinase (CK-MB) (author's transl)]. / Differentialdiagnose von Skelettmuskel- und Herzmuskeltrauma bei polytraumatischen Verletzungen durch Bestimmung der herzspezifischen Kreatinphosphokinase (CKMB).

The serum level of the myocardial-specific isoenzyme of creatine phosphokinase, CK-MB was determined in 50 patients with severe multiple injuries or following extensive surgery. It is concluded that whenever the proportion of CK-MB exceeds 10% of the total creatine phosphokinase activity myocardial damage has occurred, especially since equivalent ECG changes were registered in this group of patients.

[Plasma catecholamines in accidental hypothermia (author's transl)]. / Das Verhalten der Plasmakatecholamine bei akzidenteller Hypothermie.

The plasma levels of adrenaline and noradrenaline were measured by a radioenzymatic method in 3 patients with accidental hypothermia and followed up until normal body temperature was achieved. In all 3 patients the hypothermia was accompanied by markedly elevated levels of noradrenaline, whereas adrenaline increased considerably only in one of the 3 patients. During normalization of body temperature the elevated catecholamine levels started to decrease. In 2 of the 3 patients nearly normal catecholamine levels were measured, when body temperature had normalized. In spite of the high levels of catecholamines in plasma the heart rate was strikingly low at the lowest temperature. During the increase of the lowered body temperature the heart rate increased in contrast to the decreasing catecholamine levels. The increase of the catecholamine levels in plasma in patients with accidental hypothermia can be explained either by an augmented stimulation of the sympathetic nervous system or by a decreased metabolism. On the basis of the high endogeneous catecholamine levels the use of beta-sympathomimetics appears contraindicated in case a haemodynamic insufficiency develops during the course of accidental hypothermia.

[Intraoperative and postoperative course of enzyme activities in patients with angiographically closed and open aortocoronary bypass grafts]. / Intraoperativer und postoperativer Verlauf von Enzymaktivitäten bei Patienten mit angiographisch verschlossenen und offenen aortokoronaren Bypassgrafts.

30 patients who consecutively underwent cardiac surgery with extracorporeal circulation were investigated with regard to preoperative, intraoperative and postoperative activities of creatine kinase (CK) and CKMB isoenzyme (CK-MB), as well as myoglobin concentrations in the blood. 12 lead electrocardiograms were taken before and after the operation. At subsequent control angiography, of 18 patients with coronary heart disease 10 showed patent bypass grafts, whilst the remaining 8 patients had at least one occluded graft. 12 patients served as a control group, half of them undergoing mitral valve replacement and the other half aortic valve replacement. There was no significant difference in enzyme activity patterns between the groups. Specific determinations together with ECG monitoring can be of diagnostic help in perioperative control of these patients.

[Postoperative fructose infusion in a case of presumed hereditary fructose intolerance (author's transl)]. / Postoperative Fruktoseinfusion bei wahrscheinlich hereditärer Fruktoseintoleranz.

Hereditary fructose intolerance (HFI) was diagnosed in a 61 year-old male patient on account of liver dysfunction followed by prolonged shock immediately after the administration of a fructose and lactose infusion postoperatively. The diagnosis of HFI was based on an increased value of fructose, hypoglycaemia, lactic acidosis and diminution of the phosphate level in combination with the typical family history. The patient's children showed a normal reaction to fructose administration. The therapy included glucose, insulin and heparin administration, balance of acidosis and partial exchange of blood, which resulted in improvement in the glucose level, coagulation factors and acidosis, but could not prevent further liver damage and uraemia with a fatal outcome.

[Possible malignant hyperthermia as reaction to an overdose of myotonolytic, antidepressive and sedative drugs (author's transl)]. / Fragliche maligne Hyperthermiekrise bei Medikamentenintoxikation.

A 51-year-old male patient with no history of musculo-skeletal or myopathic abnormalities, but suffering from manic-depressive psychosis, attempted suicide with an overdose of dolpersin hydrochloride (Mydocalm), dipenzepine hydrochloride (Noveril), meprobamate (Mepronox) and nitrazepam (Mogadon). He developed high fever, muscle rigidity, tachycardia, arrhythmias, hypotension and mottled cyanosis, symptoms well-known in persons with malignant hyperthermia, an autosomally inherited disease of skeletal muscle. There is also discussed the manifestation and the symptoms of an acute rhabdomyolysis. The diagnosis was confirmed by chemical pathological laboratory findings, including respiratory and metabolic acidosis, myoglobinaemia accompanied by myoglobin diuresis, and elevated creatine phosphokinase (CPK values up to 2790 U/l). Electron microscopic examination of muscle tissue revealed signs of myolysis and mitochondrial reactions with pleoconic hyperplasia. No inhalation anaesthetics or skeletal muscle relaxants, such as succinyl choline, were used in this case. Therefore, malignant hyperthermia might have been induced by a combination of drugs which were not known to induce this abnormal muscular reaction. However, the muscle relaxant effect of dolpersin hydrochloride may have acted as a possible inducer of the attack.

[On the topic of do not resuscitate (DNR) orders on intensive care units: an evaluation of the present status on intensive care units of the Innsbruck University clinics]. / Die Problematik des Do Not Resuscitate (DNR)-Vermerks an Intensivmedizinischen Stationen: Eine Evaluierung des Ist-Zustandes an den Intensivmedizinischen Abteilungen der Universitätskliniken Innsbruck.

INTRODUCTION: Intensive care physicians are frequently called upon to decide whether intensive care treatment is justified. Critically ill patients with a poor prognosis receive "Do Not Resuscitate (DNR) Orders", which entitles the physician in charge to withhold cardiopulmonary resuscitation in case of cardiac arrest. Guidelines concerning the implementation of DNR orders do not exist for Austrian intensive care units. The aim of this study was to evaluate the different practices of issuing a DNR order in the departments of intensive care medicine at the University Hospital of Innsbruck. METHODS: Forty-nine physicians working in intensive care units were interviewed about the different procedures in the management of a DNR order. Furthermore, the various answers of senior physicians and assistant physicians were evaluated. RESULTS: Thirty-nine per cent of the interviewed physicians reported that DNR orders were always issued in writing. According to the answers of 63% of intensive care physicians, the decision to issue a DNR order is usually made by senior physicians. Twenty-nine per cent mentioned that nurses are never included in the decision making process and 6%, that the family is not included in the decision making process. According to 29%, the family is regularly informed about a written DNR order. Twenty per cent of the interviewed physicians reported that the quality of the administration of a written DNR order is very good, 6% that the quality is poor. CONCLUSION: We believe that the unsatisfactory situation in regard of DNR orders is not due to inactivity on the part of physicians, but is more likely a result of the inconclusive and, in part, contradictory legal situation. The physician is compelled to take a major decision within a poorly defined legal situation.

[Implementing limited therapy methods in intensive care units: discontinuing therapy, reducing therapy and withholding therapy in intensive care units of the Innsbruck University Clinics]. / Durchführung therapielimitierender Massnahmen an Intensivmedizinischen Stationen: Therapieabbruch, Therapiereduktion und Therapieverzicht an den Intensivmedizinischen Abteilungen der Universitätskliniken Innsbruck.

INTRODUCTION: The intensive care physician is frequently confronted with the decision to withhold or withdraw therapy in patients with a poor prognosis. Apart from the legal implications, the practical management of withholding or withdrawing intensive care treatment continues to be indistinct. The subject has not been investigated in Austria or Germany. The aim of the study was to examine the different points of view of intensive care physicians and the various procedures to limit therapy in patients with a poor prognosis. METHODS: We interviewed physicians working at different intensive care departments of the University Hospital of Innsbruck from March to April 1998. RESULTS: Withholding treatment was given preference over withdrawing treatment. In regard of withdrawing treatment, 64% of the interviewed physicians felt more uncertain. In the decision making process the potential reversibility of disease was estimated to be more important than the wish of the patient. Hemofiltration and antibiotics were mentioned as the first measures the physicians would withdraw. The last measure that would be withheld was ventilatory support. Sixty-three per cent of the physicians felt that sedation and analgesia should be continued. In regard of withholding or withdrawing treatment 83% voted for an obligatory DNR order. CONCLUSION: Before withholding or withdrawing intensive care therapy, a medical specialist must determine and document the futile prognosis of the patient. If the patient's wish is unknown, all further decisions should be made in agreement with all participants. The goal of the therapy is to provide the patient maximum comfort under minimal intensive care treatment.