European Hernia Society classification of parastomal hernias

Purpose

A classification of parastomal hernias (PH) is needed to compare different populations described in various trials and cohort studies, complete the previous inguinal and ventral hernia classifications of the European Hernia Society (EHS) and will be integrated into the EuraHS database (European Registry of Abdominal Wall Hernias).

Methods

Several members of the EHS board and invited experts gathered for 2 days to discuss the development of an EHS classification of PH. The discussions were based on a literature review and critical appraisal of existing classifications.

Results

The classification proposal is based on the PH defect size (small is ≤5 cm) and the presence of a concomitant incisional hernia (cIH). Four types were defined: Type I, small PH without cIH; Type II, small PH with cIH; Type III, large PH without cIH; and Type IV, large PH with cIH. In addition, the classification grid includes details about whether the hernia recurs after a previous PH repair or whether it is a primary PH. Clinical validation is needed in the future to assess if the classification allows us to differentiate the treatment strategy and if the classification impacts outcome in these different subgroups.

Conclusion

A classification of PH divided into subgroups according to size and cIH was formulated with the aim of improving the ability to compare different studies and their results.

Morphological and molecular characterization of an undifferentiated soft tissue sarcoma cell line and derivative clones

From an undifferentiated soft tissue sarcoma (STS) a cell line designated US8-93 has been established. At subcloning the cell line US8-93 three different lines (US8-93A, B and C) could be set up. In a subsequent study characteristics for ultrastructure, growth, cell cycle distribution, karyotype, protein overexpression detected by immunohistochemistry (IHC) and p53 mutational status were determined. The cell line US8-93 as well as subclones contain mainly bipolar spindle-shaped cells and additionally some polygonal and multinucleated cells. Cells possess the characteristics of primitive mesenchymal cells based on their positive reactions with anti-vimentin and negative reactions for desmin, cytokeratin, myoglobin, S100, and NSE, implying a classification as an undifferentiated STS. Cytogenetic analysis revealed nearly diploid cells with several structural and numerical aberrations for chromosomes 1, 3, 4, 6, 9, 10, 12, 13, 15 and 18. IHC positivity was found for the tumor suppressor proteins p53 and Rb, the oncogene products Bcl-2, K-ras, N-ras, P-glycoprotein Mdr-1 and MDM-2. In the p53 gene a nonsense mutation in exon 4 was detected, that was confirmed in the original primary tumor and in three derivative clonal lines. The described STS cell line represents a valuable supplementation to the relatively small number of human STS cell lines currently available and may also provide a good in vitro model for studies of STS tumorigenesis in respect to a mutated p53 gene.

The evolution of alternative developmental pathways: footprints of selection on life-history traits in a butterfly

Developmental pathways may evolve to optimize alternative phenotypes across environments. However, the maintenance of such adaptive plasticity under relaxed selection has received little study. We compare the expression of life-history traits across two developmental pathways in two populations of the butterfly Pararge aegeria where both populations express a diapause pathway but one never expresses direct development in nature. In the population with ongoing selection on both pathways, the difference between pathways in development time and growth rate was larger, whereas the difference in body size was smaller compared with the population experiencing relaxed selection on one pathway. This indicates that relaxed selection on the direct pathway has allowed life-history traits to drift towards values associated with lower fitness when following this pathway. Relaxed selection on direct development was also associated with a higher degree of genetic variation for protandry expressed as within-family sexual dimorphism in growth rate. Genetic correlations for larval growth rate across sexes and pathways were generally positive, with the notable exception of correlation estimates that involved directly developing males of the population that experienced relaxed selection on this pathway. We conclude that relaxed selection on one developmental pathway appears to have partly disrupted the developmental regulation of life-history trait expression. This in turn suggests that ongoing selection may be responsible for maintaining adaptive developmental regulation along alternative developmental pathways in these populations.

[Laparoscopic repair of parastomal hernia]

Parastomal hernias are a common complication after stoma formation. An exact evaluation of the history of the patients reveals clinically impairing symptoms in the majority of patients. The surgical treatment should generally be based on the augmentation or even replacement of the abdominal wall by non-resorbable meshes. The laparoscopic repair can be performed using the intraperitoneal placement of a mesh according to Sugarbaker with a wide lateralization of the stoma loop, the keyhole-technique, which means an incised mesh placed around the stoma loop, or the combination of both techniques (sandwich-technique). By far the best results can be achieved with the sandwich-technique. The recurrence rate in our series is less than 3% with an acceptable complication rate. The literature demonstrates high recurrence rates after keyhole-repair and the Sugarbaker-technique was also shown to be ineffective by our own data. In summary the laparoscopic sandwich-technique is a technically challenging but very successful method for long-lasting repair of parastomal hernias leading to an astonishingly low recurrence rate.

Self-reported psychological distress associated with steroid therapy for HIV

Anabolic androgenic steroid (AAS) replacement therapy is standard care for patients with low testosterone, including HIV-related conditions. These medications have been associated with development of aggressiveness, anxiety disorders, and depression, but only in short-term clinical trials. We conducted an anonymous street survey at a gay and lesbian community event and a survey in a clinic-based setting to study the wider prevalence of psychiatric side-effects associated with androgenic steroids. In the street-based survey, almost half of those prescribed AAS reported psychological side-effects, most commonly aggression (29%) followed by depression (21%). In the clinic survey of mostly HIV+ male patients, changes in sex drive were the most commonly reported effect of treatment while impulsive aggression, anxiety and depression were reported at levels similar to those in the street fair survey. These findings suggest that AAS therapy may be more frequently associated with distress than has been reported in the clinical literature.

Peritoneal resorption capacity for lipopolysaccharide and interleukin-6 in acute zymosan-induced chemical peritonitis

AIM

To evaluate peritoneal resorption capacity for lipopolysaccharide (LPS) and interleukin-6 (IL-6) in a model of chemical peritonitis.

METHODS

Zymosan peritonitis was induced in anesthetized rats. LPS was injected intraperitoneally to different groups at 4 h (n = 10), 8 h (n = 9), 12 h (n = 9), and 24 h (n = 9) after peritonitis and to a control group (n = 8). Similarly, IL-6 was injected intraperitoneally to different groups at 4 h (n = 9), 8 h (n = 10), 12 h (n = 10), and 24 h (n = 10) after peritonitis, and to a control group (n = 10). Plasma levels of LPS or IL-6 were measured immediately after intraperitoneal injections of LPS or IL-6, respectively, and at 5, 15, 30, 45, and 60 min later.

RESULTS

There was no change over time in plasma LPS levels in the groups receiving LPS intraperitoneally (p = 0.4). There was highly significant change over time in the IL-6 level in the studied time periods in the groups receiving IL-6 intraperitoneally (p < 0.0001). There was an increase in the plasma IL-6 level when sampled at 4 h after peritonitis.

CONCLUSION

There was a reduction of resorption capacity of inflamed peritoneum for inflammatory mediators in acute chemical peritonitis.

The diapause decision as a cascade switch for adaptive developmental plasticity in body mass in a butterfly

Switch-induced developmental plasticity, such as the diapause decision in insects, is a major form of adaptation to variable environments. As individuals that follow alternative developmental pathways will experience different selective environments the diapause decision may evolve to a cascade switch that induces additional adaptive developmental differences downstream of the diapause decision. Here, we show that individuals following alternative developmental pathways in a Swedish population of the butterfly, Pararge aegeria, display differential optimization of adult body mass as a likely response to predictable differences in thermal conditions during reproduction. In a more northern population where this type of selection is absent no similar difference in adult mass among pathways was found. We conclude that the diapause decision in the southern population appears to act as a cascade switch, coordinating development downstream of the diapause decision, to produce adult phenotypes adapted to the typical thermal conditions of their expected reproductive period.

Echinacea/sage or chlorhexidine/lidocaine for treating acute sore throats: a randomized double-blind trial

Background

The aim of this trial was to assess the relative efficacy of a sage/echinacea spray and a chlorhexidine/lidocaine spray in the treatment of acute sore throats.

Methods

This was a multicenter, randomized, double-blind, double-dummy controlled trial carried out in eleven general practices in Switzerland. A total of 154 patients (133 analyzed in per protocol collective) at least 12 years old with acute sore throat present for not more than 72 hours prior to inclusion and with a throat score ≥6 participated in the study. They used either an echinacea/sage spray or a chlorhexidine/lidocaine spray with two puffs every 2 hours, in a double-dummy blinded manner, up to 10 times daily until they were symptom-free, for a maximum of 5 days. The main outcome measures was the comparison of response rates during the first three days. A response was defined as a decrease of at least 50% of the total symptoms compared to baseline.

Results

The echinacea/sage treatment exhibited similar efficacy to the chlorhexidine/lidocaine treatment in reducing sore throat symptoms during the first 3 days (P(x < Y) = .5083). Response rates after 3 days were 63.8% in the echinacea/sage group and 57.8% in the chlorhexidine/lidocaine group. For all secondary parameters, such as time to becoming symptom free, throat pain, and global assessments of efficacy by the physician and patient, no difference between the two treatments was seen. They were both very well tolerated.

Conclusion

An echinacea/sage preparation is as efficacious and well tolerated as a chlorhexidine/lidocaine spray in the treatment of acute sore throats.

A phase I/II study of bevacizumab (beva), erlotinib (erl), and 5-fluorouracil (5-FU) with concurrent external beam radiation therapy (RT) in locally advanced rectal cancer (LARC)

4106

Background: The German Rectal Cancer Study Group established neoadjuvant therapy as a standard of care in patients with T3/T4 rectal cancer. Beva, a vascular endothelial growth factor (VEGF) inhibitor with demonstrated activity in colorectal cancer, and erl, an epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor may both serve as radiation sensitizers. Methods: Twenty one pts with LARC, defined as T3 or T4 disease by MRI or endorectal ultrasound, were enrolled from May 2006-December 2008. Pts had adequate hepatic, renal and hematopoietic function, and an ECOG performance status of ≤2. Treatment consisted of 5-FU 225 mg/M2/day by continuous infusion for the duration of radiation (50.4 Gy). Beva 5 mg/kg was administered on days 1, 15 and 29. The first cohort received erl 50 mg, the second cohort 100 mg, and third cohort 150 mg daily until completion of radiation. Pts underwent surgery 6–9 weeks following the radiation. The primary endpoints were determination of the maximally tolerated dose (MTD) and pathologic complete response (pCR). Secondary endpoints included toxicity (TOX), local control (LC), progression free survival and median survival. A total of 25 pts will be treated at the MTD. Results: Twenty-one pts began study therapy: 2 withdrew consent prior to completing study therapy, and 2 pts were removed prior to completion for clostridium difficile colitis and cardiac ischemia. No dose limiting toxicities were achieved. Erl 100 mg was chosen as the MTD. Two pts have not yet completed study treatment. Fifteen pts have completed study therapy and have undergone surgery, of whom 7 (47%) have demonstrated a pCR. At a median follow-up of 7 months, there have been no local recurrences in patients who completed study therapy. Grade 3–4 treatment related TOX included: lymphopenia 6 (59%), diarrhea 4 (24%), rash 2(12%), cardiac ischemia 1(6%), transaminitis 1(6%), mucositis 1(6%). One pt developed an anastomotic leak. Conclusions: Beva and erl in combination with infusional 5-FU and RT appears to be a highly active preoperative regimen for locally advanced rectal cancer.

[Table: see text]

Subcutaneous or intravenous administration of romiplostim in thrombocytopenic patients with myelodysplastic syndrome (MDS)

7009

Background: Thrombocytopenia is common in patients (pts) with MDS, and treatment options are currently limited to platelet (plt) transfusions. Romiplostim is an Fc-peptide fusion protein (peptibody) that stimulates plt production by the same mechanism as thrombopoietin. Methods: This was a phase II, multicenter, single arm, open-label study. Eligibility criteria included IPSS low or intermediate-1 risk MDS and a mean baseline plt count ≤50x109/L. Safety and efficacy of romiplostim were evaluated in pts receiving 750μg romiplostim according to one of 3 schedules: weekly or biweekly subcutaneous injections (QWSC or Q2WSC), or biweekly intravenous injections (Q2WIV). Plt responses were measured per IWG 2006 criteria. Results: Of the 28 pts enrolled, 17 (61%) completed the study; 22 (79%) were male and the mean (±SD) baseline plt count was 29 (±10) x 109/L. The mean age was 71 years and 19 pts (68%) had received plt transfusions in the past year. Mean duration of exposure to romiplostim was 12 (±8) weeks. The most common adverse events (AEs) were fatigue and headache (both 18%). Five pts experienced serious AEs, and there were 2 cases of disease progression to AML: one pt in the QWSC cohort who received romiplostim for 4 weeks and one in the Q2WSC cohort who received romiplostim for 20 weeks. For pts who completed 8 weeks treatment, 15/23 (65%) achieved a plt response, defined by IWG 2006 criteria, and 14/23 (61%) did not require a plt transfusion during this period. The small number of pts limited the ability to compare administration schedules; minor differences were observed in plt responses and plt transfusions, and the incidence of AEs appeared similar among cohorts. Conclusions: IV and SC romiplostim appeared well-tolerated and effective in raising plt counts and avoiding plt transfusions in low and intermediate-1 risk MDS pts. The dose recommendation for future studies is 750μg, given QW or Q2W SC.

[Table: see text]

[Table: see text]

[Atypical case of bronchus carcinoma]

Bronchuscarcinoma ist the most frequent death cause with tumor patients. At time of diagnosis the stadium is often already advanced, the patient is inoperable. We present a patient (non-smoker) with polydipsia, visual troubles and polyuria. The lab results confirmed diabetes insipidus, but the following x-rays proved multiple intracerebral spots. And also multiple spots in the lungs, the mediastinum, in the liver, the coloumn and the adrenals. Histological diagnosis was non small cell lung cancer (NSCLC).

Polyvinylidene fluoride: a suitable mesh material for laparoscopic incisional and parastomal hernia repair! A prospective, observational study with 344 patients

BACKGROUND

Today, the laparoscopic approach is a standard procedure for the repair of incisional hernias. However, the direct contact of visceral organs with mesh material is a major issue.

PATIENTS AND METHODS

This prospective observational study presents the data of 344 patients treated for incisional and parastomal hernias with a new mesh made of polyvinylidene fluoride (PVDF; Dynamesh IPOM) between May 2004 and January 2008 with a minimum follow-up of 6 months. The median follow-up of 297 patients after incisional hernias totaled 24 months and 20 months for 47 patients with parastomal hernias. Incisional hernias were repaired using an IPOM technique. For parastomal hernias, a recently described sandwich technique was used with two meshes implanted in an intraperitoneal onlay position.

RESULTS

The recurrence rate for incisional hernias was 2/297 = 0.6% and 1/47 = 2% for parastomal hernias. Three patients developed a secondary infection after surgical revision or puncture of a seroma. One patient had a bowel fistula through the mesh, with an abscess in the hernia sac. In all cases, the infection healed and the mesh could be preserved. No long-term mesh-related complications have been observed.

CONCLUSION

The laparoscopic repair of incisional and parastomal hernias with meshes made of PVDF (Dynamesh IPOM) revealed low recurrence and, overall, low complication rates. Especially in cases of infection, the material proved to be resistant without clinical signs of persistent bacterial contamination. Mesh-related complications did not occur during the follow-up.

[Fever, pneumonia and eosinophilia]

We present the case of a 71-year old man with acute eosinophilic pneumonia. By ruling out other common etiologies and by a positive lymphocyte transformation test the non-steroidal anti-inflammatory drug mefenamic acid was identified as the possible causative agent or this potentially life threatening lung disease. The clinical presentation, diagnosis, and treatment of acute eosinophilic pneumonia as a pulmonary manifestation of a drug-induced allergic reaction are discussed.

Imaging the Surface of Altair

Spatially resolving the surfaces of nearby stars promises to advance our knowledge of stellar physics. Using optical long-baseline interferometry, we constructed a near-infrared image of the rapidly rotating hot star Altair with a resolution of <1 milliarcsecond. The image clearly reveals the strong effect of gravity darkening on the highly distorted stellar photosphere. Standard models for a uniformly rotating star cannot explain our findings, which appear to result from differential rotation, alternative gravity-darkening laws, or both.

Immediate and late outcomes of transarterial coil occlusion of patent ductus arteriosus in dogs

Records from dogs (n = 125) that underwent attempted transarterial coil occlusion of patent ductus arteriosus (PDA) at the University of California, Davis, between 1998 and 2003, were reviewed, and a subset of these dogs (n = 31) in which the procedure was performed at least 12 months earlier were reexamined to determine long-term outcome. Coil implantation was achieved in 108 dogs (86%). Despite immediate complete ductal closure in only 34% of dogs, the procedure was hemodynamically successful as evidenced by a reduction in indexed left ventricular internal diameter in diastole (LVIDd; P < .0001), fractional shortening (P < .0001), and left atrial to aortic ratio (LA: Ao; P = .022) within 24 hours. Complete ductal closure was documented in 61% of dogs examined 12 to 63 months after coil occlusion. Long-standing residual ductal flow in the other 39% of dogs was not associated with increased indexed LVIDd or LA: Ao and was not hemodynamically relevant. Repeat intervention was deemed advisable in only 4 dogs with persistent (n = 1) or recurrent (n = 3) ductal flow. Complications included aberrant embolization (n = 27), death (n = 3), ductal reopening (n = 3), transient hemoglobinuria (n = 2), hemorrhage (n = 1), aberrant coil placement (n = 1), pulmonary hypertension (n = 1), and skin abscessation (n = 1). Serious infectious complications did not occur despite antibiotic administration to only 40% of these dogs. Transarterial coil occlusion was not possible in 14 dogs (11%) because of coil instability in the PDA and was associated with increased indexed minimum ductal diameter (P = .03), LVIDd (P = .0002), LVIDs (P = 0.001), and congestive left heart failure (P = .03) reflecting a relatively large shunt volume.

Hypophosphataemia in old patients is associated with the refeeding syndrome and reduced survival

OBJECTIVES

Previous studies found that hypophosphataemia (HP) a common finding in hospitalised patients associated with unfavourable outcome, but they did not focus on old patients. The aim of the current study was to determine the prevalence, associated risk factors and potential clinical consequences of HP detected during hospitalisation in a geriatric medical centre.

DESIGN

Case-control study.

SETTING

A total of 312-bed geriatric division.

SUBJECTS

We compared 325 patients aged >or=65 years with at least one episode of HP-group defined by serum phosphate <or=0.77 mmol L(-1) with 326 patients without HP (non-HP group).

MEASUREMENTS

Evaluation included baseline anamnesis, demographic and laboratory data. Patients in both groups were followed up to 2.7 years and clinical outcome recorded included length of hospitalisation, in-hospital and long-term survival.

RESULTS

About 14.1% of 2307 elderly had HP. Patients in the HP-group compared with the non-HP group had significantly more weight loss, lower albumin levels, more sepsis and received threefold more glucose-containing infusions and twofold more food supplementations (P < 0.0001). HP was detected on average on the 10.9 +/- 21.5 days of hospitalisation. Patients in the HP-group compared with the non-HP group, had significantly longer hospitalisation period (P < 0.0001) and reduced long-term survival (P = 0.003) with threefold increased mortality rates. In a multivariate analysis, HP was not found to be an independent predictor of mortality.

CONCLUSIONS

The HP was common among old hospitalised patients. Clinical characteristics of the HP-group, the time-course and strong association with glucose and food supplementation, are compatible with the refeeding syndrome, described previously in malnourished patients. HP was associated with significantly reduced survival.

Quantification of dose perturbation by plaque in vascular brachytherapy

BACKGROUND

Dose prescription and reporting in vascular brachytherapy (VBT) is based on the assumption that the vessel wall is water equivalent, which does not consider a possible dose perturbation by plaque. As the extent of this perturbation is unknown, we aimed to quantify dose attenuation by atherosclerotic plaque for beta- and gamma-radiation.

MATERIAL AND METHODS

The dose delivered from Strontium-90/Yttrium-90 ((90)Sr/Y) and Iridium-192 ((192)Ir) sources with and without human peripheral arteries ((90)Sr/Y: n = 38, (192)Ir: n = 7) surrounding the respective delivery catheter was determined with radiochromic films. Plaque and vessel wall thickness were measured using light microscopy. From the ratio-attenuated doseunattenuated dose (dose perturbation factor: DPF) we determined averaged attenuation coefficients for atherosclerotic plaque (micro(P)) and the residual part of the vessel wall (micro(W)) by regression analysis based on the function DPF = exp(-micro(P) * plaque thickness -micro(W) * residual wall thickness).

RESULTS

Attenuation in case of (192)Ir was less than the measurement uncertainties. For beta-radiation correlation was found by discrimination between calcified and noncalcified plaque. Classifying noncalcified plaque as normal arterial tissue, the regression coefficient was r = 0.845 at micro(P)= 0.5356 mm(-1) and micro(W) = 0.0663 mm(-1).

CONCLUSIONS

Vascular brachytherapy with beta radiation in calcified arteries results in significant dose attenuation within the vessel wall, which can be calculated on knowing the vascular morphometry. Thus, plaque thickness should be taken into account in treatment planning and retrospective analyses.