Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)): Part B.

In 2014 the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias". Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. METHODS: For the development of the original guidelines all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based-Medicine. For the present update all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne) the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. RESULTS: Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques-minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite still insufficient evidence with respect to these new techniques it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. CONCLUSION: Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initially guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-Part A.

In 2014, the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias." Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. METHODS: For the development of the original guidelines, all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based Medicine. For the present update, all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne), the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. RESULTS: Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques-minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite insufficient evidence with respect to these new techniques, it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. CONCLUSION: Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initial guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

Recurrent pleural effusion: who benefits from a tunneled pleural catheter?

Recurrent malignant pleural effusion (MPE) is a common concomitant phenomenon of malignant disease, which can worsen the patient's quality of life and lead to significant morbidity. Tunneled indwelling pleural catheters (TIPC) offer new modalities in patients with recurrent MPE and impaired dilatability of the lung. We report on our experience with 100 consecutive patients suffering from recurrent benign (n = 12) and malignant pleural effusion (n = 88) who were treated with TIPC. The catheter was placed during a VATS procedure or under local anesthesia in an open technique. The median residence time of the TIPC was 70 days; spontaneous pleurodesis was achieved in 29 patients. The rate of complications was low: pleura empyema (n = 4), accidental dislodgement (n = 2), malfunction of the drainage (n = 3). In conclusion, TIPC is a useful method for the palliative treatment of patients with recurrent malignant or nonmalignant pleural effusions and 3 groups of patients seem to benefit most: a) patients with the intraoperative finding of a trapped lung in diagnostic VATS procedure; b) patients after a history of repeated pleuracenteses or previously failed attempts at pleurodesis; c) patients in a reduced condition with a limited lifespan due to underlying disease.

Modulation of influenza virus replication by alteration of sodium ion transport and protein kinase C activity.

In recent years, increasing levels of resistance to the four FDA-approved anti-influenza virus drugs have been described and vaccine manufacturers have experienced demands that exceed their capacity. This situation underlines the urgent need for novel antivirals as well as innovations in vaccine production in preparation for the next influenza epidemic. Here we report the development of a cell-based high-throughput screen which we have used for the identification of compounds that modulate influenza virus growth either negatively or positively. We screened a library of compounds with known biological activity and identified distinct groups of inhibitors and enhancers that target sodium channels or protein kinase C (PKC). We confirmed these results in viral growth assays and find that treatment with a sodium channel opener or PKC inhibitor significantly reduces viral replication. In contrast, inhibition of sodium channels or activation of PKC leads to enhanced virus production in tissue culture. These diametrically opposing effects strongly support a role for PKC activity and the regulation of Na(+) currents in influenza virus replication and both may serve as targets for antiviral drugs. Furthermore, we raise the possibility that compounds that result in increased viral titers may be beneficial for boosting the production of tissue culture-grown influenza vaccines.

[Pulmonary nocardiosis with trimethoprime/sulphamethoxazole-resistant Nocardia paucivorans in a patient with no signs of immunosuppression]. / Pulmonale Nokardiose mit Trimethoprim/Sulfamethoxazol resistenter Nocardia paucivorans bei einem Patienten ohne Hinweise auf Immunsuppression.

This is so far the first published case report of a Nocardia paucivorans infection in an immunocompetent patient. A 54-year-old farmer was hospitalised with a history of coughing and fever for a period of five months. There was no indicator of either primary of secondary immunodeficiency in the prior medical history. A chest X-ray showed pneumonic infiltrates in the right middle und lower lobes, which progressed despite of antibiotic therapy with macrolides. A transbronchial biopsy revealed unspecific granulomatous inflammation of soft tissues. N. paucivorans - grew in cultures of sputum, bronchoalveolar lavage, and transbronchial biopsy. Oral antibiotic therapy was started with trimethoprime-sulphamethoxazole (TMP/SMX) and amoxicillin plus clavulanic acid. Susceptibility testing revealed high level resistance to TMP/SMX, which was consequently replaced by ciprofloxacin. Six months later, infiltrates had completely resolved and the patient did not report any residual clinical symptoms. The present case showed once again that nocardiosis is not limited to patients with immunodeficiencies. However, conservative combination therapy with oral antibiotics seems to be sufficiently effective for nocardiosis in the immunocompetent patient. For cases of suspected nocardiosis, a step-wise, risk-based diagnostic and therapeutic procedure is proposed.

Expression screening of factors binding to the osteocalcin bone-specific promoter element OC box I: isolation of a novel osteoblast differentiation-specific factor.

Contributing to bone-specific expression of the osteocalcin gene is the promoter element OC Box I (-99 to -76), which binds both Hox proteins and another nonhomeodomain factor (designated OCBP for osteocalcin-box binding protein) (Hoffmann et al. [1996] J Cell Biochem 61:310-324). OCBP correlates with increased promoter activity and may, therefore, be important to development or maintenance of the osteoblast phenotype. To identify OCBP candidates, we used a multimerized OC Box I sequence to screen a gammagt11 cDNA expression library, constructed from the rat osteosarcoma osteoblastic ROS 17/2.8 cell line, for cDNA clones encoding factors that recognize this element. Mutant OC Box I sequences that do not bind OCBP and/or homeodomain proteins were used to counterscreen the cDNA isolates. Clones showing binding specificity were sequenced and further characterized for patterns of expression in different tissues and cell lines. Among the characterized nonhomeodomain-related isolates, we identified a nucleolin, a clone encoding rCAP2 that is related to myogenic differentiation and more importantly, a cDNA clone containing a previously uncharacterized gene that has been designated as a cell differentiation-related factor (DRF). DRF mRNA is highly expressed in ROS 17/2.8 cells and in a developmentally regulated pattern during osteoblast differentiation, being upregulated at the postproliferative maturation transition and coinciding with the induction of osteocalcin gene expression. The 7.7-kb transcript encoded by clone 44 is abundantly expressed in osteoblasts, but the mRNA was not present at detectable levels in bone and soft tissues by Northern blot analysis. However, related expressed sequence tags were recently reported in cDNA libraries of rat lung and mouse sympathetic ganglion. The identification of DRF represents a novel osteoblast differentiation-specific marker related to osteocalcin expression. The identification of DRF may further facilitate definition of gene regulatory mechanisms mediating the final stages of bone cell differentiation

Predicting schizophrenic outpatients' behavior by symptomatology and social skills.

Though social skills have been identified as an independent construct, recent studies have revealed that schizophrenic symptomatology and social skills are interrelated. The nature and extent of this relationship, however, are far from clear. To address this issue, we examined 33 schizophrenic outpatients participating in a rehabilitation program for an average of 10 months. The object of this study was to investigate to what extent behavior can be predicted by symptomatology and social skills, and whether social skills have a significant effect on outpatients' behavior independently of schizophrenic symptoms and vice versa. Regression analyses revealed good prediction of outpatients' behavior by conceptual disorganization and disorder of relating from the PANSS and, to a lesser degree, social skills. After having eliminated the influence of psychopathology on social skills and behavior, social skills variables still had significant predictive value for social competence, social interest, and irritability. These findings imply specific contributions of both symptomatology and social skills to future behavior of chronic schizophrenic outpatients.

Relationships between social competence, psychopathology and work performance and their predictive value for vocational rehabilitation of schizophrenic outpatients.

Earlier studies suggest that social competence has a higher predictive value for vocational outcome than psychopathology. These studies, however, show methodological shortcomings, including the fact that the instruments used for assessing social competence, psychopathology and work performance are strongly interrelated. The present study, involving a population of 34 chronically schizophrenic outpatients enrolled in a vocational rehabilitation program, was conducted in order to determine: (1) how closely the Role Play Test, the Positive and Negative Syndrome Scale and the Work Behavior Assessment Scale are related to each other; and (2) whether social competence is a better predictor of work performance and outcome of vocational rehabilitation than psychopathology. Factor analysis has revealed that the instruments are interrelated, mainly in the dimensions of negative symptoms, social relationships, non-verbal measures of social competence and conceptual disorganization. In backward regression analyses, psychopathological indicators proved to be the best predictors of work performance both cross-sectionally as well as in the longterm course. In the traditional two-syndrome model of schizophrenic psychopathology only negative symptoms were left in the regression model. In a four-dimension model the disorder of relating and the conceptual disorganization dimension were the best predictors. Differences between disorder of relating and social competence, assessed by the Role Play Test, are discussed here as well as the implications of this study for rehabilitation.

Influence of age on antileukemic action, subacute toxicity and tissue distribution of ambazone in B6D2F1 mice.

The influence of age of experimental animals on the antileukemic activity, toxicity and distribution of ambazone, a new potential antineoplastic agent, was studied in 2- and 12-month-old B6D2F1 mice. The predominant effect observed was a significant reduction of the antileukemic action of this compound in old-aged mice. Together with a slight increase in several toxicity parameters this caused a marked reduction of the therapeutic index in 12-month-old mice compared to younger individuals. Furthermore, a general tendency to increased ambazone levels in liver, kidneys and thymus of old-aged mice was observed. Our data therefore provide further evidence that age has to be taken into consideration as one factor that may account for the variety of drug response frequently observed during clinical therapy with anticancer agents.

Primary structure and promoter analysis of leghemoglobin genes of the stem-nodulated tropical legume Sesbania rostrata: conserved coding sequences, cis-elements and trans-acting factors.

The primary structure of a leghemoglobin (lb) gene from the stem-nodulated, tropical legume Sesbania rostrata and two lb gene promoter regions was analysed. The S. rostrata lb gene structure and Lb amino acid composition were found to be highly conserved with previously described lb genes and Lb proteins. Distinct DNA elements were identified in the S. rostrata lb promoter regions, which share a high degree of homology with cis-active regulatory elements found in the soybean (Glycine max) lbc3 promoter. One conserved DNA element was found to interact specifically with an apparently universal, trans-acting factor present in nuclear extracts of nodules. These results suggest a conserved mechanism for nodule specific induction of lb genes in leguminous plants.

[Ciprofloxacin in Salmonella infection and abdominal typhoid]. / Ciprofloxacin bei Salmonelleninfektion und Typhus abdominalis.

Ten patients - two with Salmonella septicaemia associated with AIDS; one each Salmonella excretors in the convalescence stage and with Salmonella osteomyelitis; three with abdominal typhoid, and three with Salmonella enteritis - were treated with the gyrase inhibitor ciprofloxacin. The drug was given for 3-33 days, at a dosage of 250-750 mg orally in most cases. Clinical and bacteriological cure was achieved in nine patients. There were no significant side effects. One patient developed a macular rash, which is within the usual side-effect rate.

[Current aspects of pseudomonas meningitis]. / Aktuelle Aspekte der Pseudomonasmeningitis.

The article reports on the incidence, the conditions of occurrence, possibilities and successes of treatment with certain (combinations of) antibiotics, in dealing with cases of pseudomonas meningitis. The various possible substances used for treatment are discussed. Rates of penetration and CSF concentrations of azlocillin and cefsulodin are stated. Alternative possibilities for treatment are pointed out.

Hemodynamic and humoral effects of coffee after beta 1-selective and nonselective beta-blockade.

Several studies report a substantial rise in plasma catecholamines after caffeine. Epinephrine infusion induces a pressor response after nonselective beta-blockade. We studied the hemodynamic and humoral effects of drinking coffee after placebo and after both nonselective (propranolol) and beta 1-selective (metoprolol) blockade in 12 normotensive subjects. After placebo, coffee induced a rise in systolic and diastolic blood pressure and a fall in heart rate, whereas forearm blood flow did not change. Plasma catecholamines, especially epinephrine (+150%), rose and plasma renin activity, fell after drinking coffee. The effects of coffee on blood pressure, forearm blood flow, and all humoral parameters were not altered by pretreatment with propranolol or metoprolol. The fall in heart rate after coffee, however, seemed to be greater during propranolol. We conclude that the rise in plasma epinephrine after coffee was too small to reveal differences in reaction in propranolol- and metoprolol-pretreated subjects.

[A non-invasive stress test for fetal movement stimulation]. / Ein nicht invasiver Stresstest zur fetalen Bewegungsstimulation.

A method for foetal stimulation is required for both interpretation of external CTG and assessment of foetal mobility status. All methods so far described in the literature proved to be impracticable for their invasive nature or for insufficient controllability. An approximately unitised level of stimulation is necessary for proper assessment of mobility standards, and this has been achieved by means of sound stimulation. The latter is based on a body sound transmitter coupled to a sinus generator. Sensitivity of the method is 90 per cent. Preliminary comparison between quantity of movement and birth weight of examined foetuses has provided some clues to the effect that the responsiveness to external stimuli of newborns with low birth weight had been comparatively low, which was reflected in less movement activity.

Dietary influence on serum and urinary oxalate in healthy subjects and oxalate stone formers.

With a new enzymatic method, the dietary influence of oxalate, glycine, protein, and ascorbic acid on serum and urinary oxalate has been examined. Healthy and oxalate stone-forming subjects were compared. Two doses of sodium oxalate (130 and 400 mg daily) were administered. The high dose induced significant hyperoxaluria. No changes of serum oxalate were seen. Neither glycine (4.5 g daily) nor protein (50 g daily, 50% animal protein) had any effect on serum or urinary oxalate. Urinary oxalate excretion did not increase upon ingestion of large amounts of ascorbic acid (1--6 g daily), but serum oxalate levels were significantly elevated. The value of severe dietary restrictions concerning the compounds examined here seems to be questionable, as a significant increase of urinary oxalate excretion is lacking.

Interaction versus independence of startle-modification processes in the rat.

In a series of experiments it was found that the amount of inhibition produced by a weak acoustic stimulus occurring 64 msec prior to a startle-eliciting stimulus is unaffected by a second weak acoustic stimulus occurring 4 msec prior to the startle-eliciting stimulus. Likewise, the amount of latency reduction produced by an antecedent stimulus with a 4-msec lead time is unaffected by the presence of an antecedent stimulus with a 64-msec lead time. Finally, it was found that both the amount of inhibition produced by a prestimulus with a 64-msec lead time and the amount of latency reduction produced by a prestimulus with a 4-msec lead time are independent of the intensity of the startle-eliciting stimulus. These findings suggest that the inhibition effect is independent of the latency reduction effect and that both are independent of the absolute level of activation in the neural mechanisms responsible for the overt startle response.