Vaginal prolapse surgery with transvaginal mesh: results of the Austrian registry.

INTRODUCTION AND HYPOTHESIS: Several mesh repair systems for pelvic organ prolapse (POP) were introduced into clinical practice with limited data on safety, complications or success rates, and impact on sexual function. The Austrian Urogynecology Working Group initiated a registry to assess the use of transvaginal mesh devices for POP repair. We looked at perioperative data, as well as outcomes at 3 and 12 months. METHODS: Between 2006 and 2010 a total of 20 gynecology departments in Austria participated in the Transvaginal Mesh Registry. Case report forms were completed to gather data on operations, the postoperative course, and results at 3 and 12 months. RESULTS: A total of 726 transvaginal procedures with 10 different transvaginal kits were registered. Intra- and perioperative complications were reported in 6.8%. The most common complication was increased intraoperative bleeding (2.2%). Bladder and bowel perforation occurred in 6 (0.8%) and 2 (0.3%) cases. Mesh exposure was seen in 11% at 3 and in 12% at 12 months. 24 (10%) previously asymptomatic patients developed bowel symptoms by 1 year. De novo bladder symptoms were reported in 39 (10%) at 3 and in 26 (11%) at 12 months. Dyspareunia was reported by 7% and 10% of 265 and 181 sexually active patients at 3 and 12 months postoperatively respectively. CONCLUSIONS: The 6.8% rate of intra- and perioperative complications is in line with previous reports. Visceral injury was rare. The 12% rate of mesh exposure is consistent with previous series.

A new role for the neuronal ubiquitin C-terminal hydrolase-L1 (UCH-L1) in podocyte process formation and podocyte injury in human glomerulopathies.

Glomerular epithelial cell (podocyte) injury is characterized by foot process retraction, slit diaphragm reorganization, and degradation of podocyte-specific proteins. However, the mechanisms underlying podocyte injury are largely unknown. The ubiquitin C-terminal hydrolase-L1 (UCH-L1) is a key modulator of ubiquitin modification in neurons. Like neurons, UCH-L1 expression was associated with an undifferentiated status in cultured human podocytes, whereas differentiation and arborization decreased UCH-L1 and monoUb expression. Inhibition of UCH-L1 induced time and concentration-dependent process formation with alpha-actinin-4 distribution to the cell membrane and processes. An immunohistochemical approach was used to evaluate whether UCH-L1 expression was associated with podocyte injury in 15 different human glomerular diseases. Whereas normal kidneys expressed no UCH-L1 and little ubiquitin, a subset of human glomerulopathies associated with podocyte foot process effacement (membranous nephropathy, SLE class V, FSGS) de novo expressed UCH-L1 in podocyte cell bodies, nuclei, and processes. Interestingly, UCH-L1 expression correlated with podocyte ubiquitin content and internalization of the podocyte-specific proteins nephrin and alpha-actinin-4. In contrast, minimal change glomerulonephritis, a reversible disease, demonstrated minimal UCH-L1 and ubiquitin expression with intact alpha-actinin-4 but internalized nephrin. Glomerular kidney diseases typically not associated with foot process effacement (SLE class IV, ANCA+ necrotizing GN, amyloidosis, IgA nephritis) expressed intermediate to no UCH-L1 and ubiquitin. These studies show a role for UCH-L1 and ubiquitin modification in podocyte differentiation and injury.

[International interhospital transfer by scheduled airline]. / Internationaler Interhospitaltransfer mit dem Linienflugzeug.

BACKGROUND AND OBJECTIVE: International long-distance travel increasingly takes elderly and sometimes already ill persons to foreign countries. In case of illness it is usually best, for both medical and social reasons, that the person return home. This study was undertaken to assess possibilities and limits of bringing such patients home by scheduled airline. PATIENT AND METHODS: The transportation reports and case notes of 95 patients who had been repatriated to Germany in 1995 and 1996 for medical reasons were analysed retrospectively. The mean age was 56 (16-94) years. 50% of the patients had medical, 23% surgical, 19% neurological and 8% psychiatric illnesses. RESULTS: None of the patients died during transport. The NACA score (National Advisory Committee for Aeronautics, USA) for determining the degree of severity of an illness (point scale 1-7) in this group of patients was between 1 and 4, median of 3. Five patients with a score of 5 or higher were judged not to be fit for transport. Two were repatriated by ambulance plane, in three transport was postponed by a few days. No invasive procedures, other than providing intravenous access, were necessary. CONCLUSIONS: Patients who fall ill abroad can be safely and carefully brought home by scheduled airliner over great distances without additional risk caused by the transport. Ambulance planes are needed only in illnesses with an NACA score of 4 or higher.

Mortality in sickle cell disease. Life expectancy and risk factors for early death.

BACKGROUND: Information on life expectancy and risk factors for early death among patients with sickle cell disease (sickle cell anemia, sickle cell-hemoglobin C disease, and the sickle cell-beta-thalassemias) is needed to counsel patients, target therapy, and design clinical trials. METHODS: We followed 3764 patients who ranged from birth to 66 years of age at enrollment to determine the life expectancy and calculate the median age at death. In addition, we investigated the circumstances of death for all 209 adult patients who died during the study, and used proportional-hazards regression analysis to identify risk factors for early death among 964 adults with sickle cell anemia who were followed for at least two years. RESULTS: Among children and adults with sickle cell anemia (homozygous for sickle hemoglobin), the median age at death was 42 years for males and 48 years for females. Among those with sickle cell-hemoglobin C disease, the median age at death was 60 years for males and 68 years for females. Among adults with sickle cell disease, 18 percent of the deaths occurred in patients with overt organ failure, predominantly renal. Thirty-three percent were clinically free of organ failure but died during an acute sickle crisis (78 percent had pain, the chest syndrome, or both; 22 percent had stroke). Modeling revealed that in patients with sickle cell anemia, the acute chest syndrome, renal failure, seizures, a base-line white-cell count above 15,000 cells per cubic millimeter, and a low level of fetal hemoglobin were associated with an increased risk of early death. CONCLUSIONS: Fifty percent of patients with sickle cell anemia survived beyond the fifth decade. A large proportion of those who died had no overt chronic organ failure but died during an acute episode of pain, chest syndrome, or stroke. Early mortality was highest among patients whose disease was symptomatic. A high level of fetal hemoglobin predicted improved survival and is probably a reliable childhood forecaster of adult life expectancy.

[Vaginal sonographic contrast imaging of the endometrium with gel]. / Die vaginalsonographische Kontrastdarstellung des Endometriums mit Gel.

In many cases, the sonography of the endometrium requires an exact pre-therapeutical interpretation. Apart from a hysteroscopy, this can take place by means of an improved version of a contrast hysterosonography, i.e. the Gel-KHSG. The technique and examination results are described here. This simple examination method can--like hysteroscopy--precisely define or exclude anomalies of the endometrium, and, beyond that, it has the advantage of the sono-tomographic depiction of the uterine wall. Moreover, it can be taken assumed, that the vagino-sonomorphological diagnostics at the endometrium could--for instance, analogous to the colposcopy of the uterine portion--become part of a system of preventive diagnostics for the cavum uteri. However, such a system has not been set up to date.

[Rare pelvic tumors. A case report]. / Seltene Unterbauchtumoren. Ein kasuistischer Beitrag.

Two cases of rare pelvic masses of obscure origin are presented. The first was a giant pyometra, simulating an ovarian cyst, detected accidentally 13 years after conisation. The second was hematoma of lower parts of rectus muscles, also detected accidentally. The woman had a history of long-lasting anticoagulation, but couldn't remember any trauma. The difficulties of differential diagnosis are discussed.

[Role of vaginal sonography in the assessment of adnexa tumors]. / Zur Rolle der Vaginalsonografie bei der Beurteilung von Adnextumoren.

Ultrasound has for a long time been established as an essential part of the gynecological examination. Vaginal Ultrasound, which was introduced some years ago, renders more precise pictures as well as better diagnostic results in comparison to abdominal ultrasound. This is especially true for obese and/or old patients. We expected, therefore, that the vaginal ultrasound method would not only lead to a better and more precise structure-analysis but also to a better evaluation and characterization of findings, especially concerning pelvic masses. Our expectations that we would be able to make a diagnosis which would be very close to the findings of histology or to make prognoses on the basis of the sonographic results of 125 female patients with pelvic masses were, however, largely disappointed. Although its application is simpler and it produces pictures of a better quality, the variety of morphological symptoms of adnexal masses remains the limiting factor, which makes it impossible in most cases to predict the histologic findings. Pelvic masses must still be evaluated--in spite of the better quality of the pictures--through a synopsis of clinical, chemical and picture-giving methods.

[Treatment of primary cancer of the fallopian tube]. / Die Behandlung des primären Karzinoms der Tuba Fallopii.

33 patients treated since 1970 at the Medical School of the University of Graz, were classified using the FIGO system for ovarian carcinoma, fourteen were in stage I, 8 stage II, 8 stage III and 3 stage IV. In 17 patients, surgery consisted of total abdominal or vaginal hysterectomy with bilateral salpingo-oophorectomy; 12 patients underwent additional pelvic +/- paraaortic lymph node extirpation and in 4 the tumour excision was incomplete. Treatment in 6 patients was surgery alone (2/stage I, 4 with advanced disease) (Group A). Adjuvant radiotherapy was performed in 14 patients (Group B); the remaining patients were treated with single (2/13) or multiple agent chemotherapy (11/13) (Group C). The 3-year survival rate was 55% for stage I, 42% for stage II; 10/11 of the stage III/IV patients died within 26 months. The 4-year actuarial survival rate for group B was 68%, for group C 11%. There was no difference between the short-time results of stage II tumours when comparing radiotherapy against chemotherapy. The tumour progression rate was 60%, indicating the need for radical surgery as well as for more aggressive adjuvant treatment. Surgery alone is recommended for stage I disease confined to the mucosa. More advanced disease (extension to the serosa, stage Ic, stage II) requires whole abdominal irradiation with a boost to the pelvic lymph nodes. For stage III/IV tumours a multi-modality treatment is recommended. Chemotherapy (cis-platinum, cyclophosphamide) for recurrent disease resulted in remission in some cases.

Effectiveness of the cryosupernatant fraction of plasma in the treatment of refractory thrombotic thrombocytopenic purpura.

Many patients with thrombotic thrombocytopenic purpura (TTP) satisfactorily respond to plasma therapy (plasmapheresis and/or plasma infusion). Some, however, respond either not at all or only transiently and incompletely. Evidence indicates that platelets and endothelial cell-derived unusually large von Willebrand factor (ULvWF) multimers, as well as the largest vWF multimers in plasma, form thrombi which are deposited in the microvascular circulation. Accordingly, platelet transfusions are avoided unless there is intra-cranial or other life-threatening hemorrhage. The largest plasma multimers of vWF are, however, replenished by the infusion of large volumes of whole plasma. We postulated that under conditions of massive plasma replacement, plasma depleted of the largest multimers of vWF might be preferable for the treatment of TTP episodes. The largest vWF multimers sediment in the cryoprecipitate, and the cryoprecipitate-poor fraction of plasma (cryosupernatant) is depleted of these forms. Seven patients responding inadequately to intensive plasma therapy were switched to receive cryosupernatant in place of whole plasma. All patients improved quickly following this change in therapy, and the TTP syndrome resolved in all seven.

[Differential diagnosis of pelvic tumors. Abscess forming ileovesical fistula in Crohn's disease. A case report]. / Zur Differentialdiagnose von Unterbauchtumoren. Abszedierende Ileovesikalfistel bei M. Crohn.Kasuistik.

A report is given about a case of preoperatively unrecognized ileovesical-fistula caused by Crohn's-disease. Despite of uncharacteristic symptoms a more extensive medical history might have brought to also more extensive diagnostic methods and to suspicion of the intestinal disease.

[Pathologic changes in fetal brain ventricles and their prognostic significance. Case reports]. / Pathologische Erscheinungen fetaler Hirnventrikel und ihre prognostische Bedeutung. Falldarstellungen.

Enlargement of fetal ventricular system is found accidentally in most cases. The significance of the sonographic findings must be assessed with regard to the extent and progress of the lesion and to the presence of concomitant malformations. The decision to terminate the pregnancy must be considered carefully and in accord with the full informed parents.

Mortality in children and adolescents with sickle cell disease. Cooperative Study of Sickle Cell Disease.

A study of the natural history of sickle hemoglobinopathies was begun in March 1979. By August 1987, a total of 2824 patients less than 20 years of age were enrolled. There have been 14,670 person-years of follow-up. Seventy-three deaths have occurred. Most of the deaths were in patients with hemoglobin SS. The peak incidence of death was between 1 and 3 years of age, and the major cause in these young patients was infection. Cerebrovascular accidents and traumatic events exceeded infections as a cause of death in patients greater than 10 years of age. There was limited success in identifying risk factors for death. Comparison of this study's overall mortality of 2.6% (0.5 deaths per 100 person-years) with previous reports indicates improvement of survival in US patients less than 20 years of age with sickle hemoglobinopathies. This improvement is most likely due to parental education and counseling about the illness and the early institution of antibiotics in suspected infections.

[Comparison of vaginal ultrasound and histologic findings of the endometrium]. / Die Gegenüberstellung vaginalsonographischer und histologischer Befunde am Endometrium.

Transvaginal ultrasound makes it possible to show pelvic structures much more precisely than the abdominal method. As a consequence structures, which have hardly been seen so far, especially in the uterine cavity and the adnexal region, can be seen and analysed more distinctly. This is of vital importance for women of advanced age. We examined 450 women in pre- and postmenopause and studied in detail the structures of the endometrium shown by transvaginal ultrasound according to their respective shapes. In 215 cases they were compared with histological findings. It became evident that the size and structure of the endometrium can indicate its histological state. Premalignant or malignant formations of tissue occurred almost only in an endometrium with a thickness of more than 10 mm or in polyp-like structures. We conclude that in case of thick or extraordinarily structured endometrium - even without any symptoms of bleeding - a curettage should be performed. Vaginal ultrasound, which is, compared to other methods of examining the endometrium, very simple and non-invasive, can be applied any time. For these reasons it represents, in our opinion, another step towards improving the possibilities of diagnosing carcinoma of the endometrium at an early stage.

[Prenatal diagnosis of complex abnormality syndromes. A case report]. / Pränatale Diagnostik komplexer Missbildungssyndrome. Ein kasuistischer Beitrag.

Two cases of complex and serious fetal malformations are presented, which have only been diagnosed in a relatively late stage of pregnancy. In both cases unspecific difficulties had already arisen during ultrasound screening, but they were not considered to be of any vital importance. The problems of diagnosing malformations by ultrasound and the serious consecutive consequences are discussed.

[Prevention of postoperative complications following vaginal hysterectomy]. / Zur Verhütung postoperativer Komplikationen nach vaginalen Hysterektomien.

In a prospective study on infectious morbidity after vaginal hysterectomy we examined the clinical symptoms of an infection and partly also the microbial conditions of the vaginal wound. With a group of 49 patients without antibiotic prophylaxis we tried to find out if the type of vaginal occlusion might have any influence on the microbial situation and the healing process. The results of this first group were compared to those of a second group consisting of 31 patients, who had received antibiotic prophylaxis before the operation with a cephalosporin. Though it was not possible to make any microbial analyses in the second group, the clinical evaluation showed distinctly that antibiotic prophylaxis is an important contribution to the prevention of infections after vaginal hysterectomy. The careful consideration of septic-surgical precautions, however, and this was proved by the first part of the study, contributes as well to the prevention of infections.

[Primary diagnosis in acute adnexitis]. / Zur Frage der Primärdiagnostik bei der akuten Adnexitis.

Though acute salpingitis is the most frequent gynecological illness of a young woman, it occurs nevertheless less frequently than it is diagnosed. The reason for this is to be found above all in the fact, that the criteria of the findings are judged too superficially. If simple anamnestic, clinical or biochemical parameters such as the characteristics and duration of the pain, the findings of gynecological examination, BSR and considerations about differential diagnosis were rated more precisely, considerably fewer cases would have to be assigned to laparoscopy and the elucidation of the indistinct abdominal pains could be started more efficiently.

[Assessment by sonography and palpation of the cervical closure system]. / Die sonographische und palpatorische Beurteilung des zervikalen Verschluss-apparates.

Sonography or palpation alone are inadequate procedures in evaluating cervical function. Only by combining both methods cervical incompetence can be detected at an early stage, adequate therapy instituted and unnecessary cerclage operations prevented. The value of sonography lies in the possibility of studying the functional changes of the cervix in premature labour.