[Topicality of the fundamental and determining importance of chronic critical ischemia of the extremities and its restorative treatment using crural/pedal bypasses in Germany and in Saxony-Anhalt]

INTRODUCTION

Currently, there is an increase in severe stages of peripheral arterial occlusive disease (PAOD) with critical ischemia. This seems to correspond to the general demographic change as well as a consequence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic of the last 3 years. The now established and accepted interventional/endovascular approach for severe lower leg PAOD in experienced hands is still considered the first-line treatment but from the authors' perspective crural/pedal venous bypass is experiencing a renaissance.

MATERIAL AND METHODS

Compact narrative review of the current state of crural/pedal bypass surgery in Germany and Saxony-Anhalt (SA) combined with selective references from the current scientific medical literature and own clinical experiences.

RESULTS

The current statistics of case-related diagnosis-related groups (DRG) data show that, especially with the occurrence of the corona pandemic, a decrease in inpatient case numbers of patients with PAOD stage IIB can be observed nationwide and also in SA. The severe PAOD stages have remained approximately the same in case numbers but increased in SA. The risk stratification based on the wound, ischemia and foot infection (WIFI) classification offers the possibility to be able to make statements about the risk of amputation, benefits and type of revascularization measures. The length of the occlusion, occlusion site of the affected vessels and degree of calcification are taken into account in the global limb anatomic staging system (GLASS) to assess the prognosis. The evaluation of the case-based hospital statistics from 2015 to 2020 showed a constant use of femorocrural/femoropedal bypass surgery in Germany as well as a slight increase in reconstruction using femorocrural bypasses in SA, which seems to correlate with the tendency for an increase in the number of cases of severe PAOD. Parameter-based objectification of the severity of critical limb ischemia should be included in the indications for placement of a crural/pedal bypass. The WIFI classification and GLASS are suitable for this purpose as a relative prognosis of success is also possible. The treatment of critical limb ischemia by crural/pedal bypass surgery continues to find a constant application in Germany and SA.

[Statutory provisions, aims, motives, attitudes and thinking on the outpatient operation profile of general and abdominal surgery]

AIM

The aim of the manuscript is to discuss and assess the implications and opportunities as well as dangers of "outpatientization" of surgical and inpatient services for general and abdominal surgery.

METHOD

Narrative overview with literature reference based on a PubMed search with the search terms: outpatient operations and inpatient interventions, AOP catalog, hybrid DRG, outpatient hernia surgery, outpatient proctological surgery, selective sector-equal reimbursement and day-care forms of care. RESULTS (KEY POINTS): - In the Anglo-American area, the treatment of inguinal hernias is predominantly carried out on an outpatient clinic basis. In the USA, Sweden and Denmark, for example, over 70% of all hernias are treated in an outpatient clinic setting, in Germany it is only 20%. In Germany, the catalog of operations that can be performed on an outpatient basis and other department-replacing interventions in hospitals defines outpatient interventions in accordance with § 115b Social Security Code (SGB) V (Germany). - The conversion from inpatient to outpatient hernia surgery has also failed so far due to an enormous difference in revenues. According to the will of the Federal Ministry of Health, the planned forms of semistationary care are intended to relieve the nursing staff in the hospitals and thus relieve the tense situation of nursing professionals. By the end of March 2023, a special industry-specific reimbursement, so-called hybrid DRGs, is to be agreed, which applies regardless of whether a paid service is provided on an outpatient or inpatient basis. - According to § 115b SGB V, whether a hernia can be performed under inpatient or outpatient conditions is also decided according to the location of the hernia. In the new AOP catalog, frailty is operationalized in the context factors via the degree of care and the Barthel index. If one compares the number of encryption procedures for the 5‑530 procedure (closure of an inguinal hernia) in 2005 (184,679) with the pre-corona year 2019 (179,851), it can be seen that the proportion of hernias treated in hospital remained approximately the same over a period of 14 years. - Most elective proctological procedures can be performed on an outpatient basis. For reasons of safety (bleeding) and practicality (pain management, dressing change of large abscesses), inpatient surgery is preferred: extensive hemorrhoidectomy in the case of massive findings, large abscesses, extensive perianal fistula corrections, particularly high transsphincteric or suprasphincteric fistulas. - Guidelines based on the British Guidelines for Ambulant Surgery should be required for comprehensive outpatient treatment in surgery. The introduction of corresponding hybrid DRGs seems to be the right way to cover the costs of outpatient surgery in hospitals.

CONCLUSION

The restructuring of the hospital landscape and the nationwide expansion of outpatient operations is an unavoidable requirement in view of rising costs in the healthcare system and impending financing bottlenecks, which will pose challenges for the surgical disciplines in the years to come. Outpatient surgery is already practiced in many areas but has not become established due to the different remuneration. The flat rates for the same branches can be a starting point here. Furthermore, evidence-based framework conditions must be created along the lines of the British Guidelines for Ambulant Surgery.

The effect of an abdominal binder on postoperative outcome after open incisional hernia repair in sublay technique: a multicenter, randomized pilot trial (ABIHR-II)

INTRODUCTION

Although the evidence is minimal, an abdominal binder is commonly prescribed after open incisional hernia repair (IHR) to reduce pain. This study aimed to investigate this common postoperative treatment.

METHODS

The ABIHR-II trial was a national prospective, randomized, multicenter non-AMG/MPG pilot study with two groups of patients (wearing an abdominal binder (AB) for 2 weeks during daytime vs. not wearing an AB following open IHR with the sublay technique). Patient enrollment took place from July 2020 to February 2022. The primary endpoint was pain at rest on the 14th postoperative day (POD) using the visual analog scale (VAS). The use of analgesics was not systematically recorded. Mixed-effects linear regression models were used.

RESULTS

A total of 51 individuals were recruited (25 women, 26 men; mean age 61.4 years; mean body mass index 30.65 kg/m2). The per-protocol analysis included 40 cases (AB group, n = 21; No-AB group, n = 19). Neither group showed a significant difference in terms of pain at rest, limited mobility, general well-being, and seroma formation and rate. Patients among the AB group had a significantly lower rate of surgical site infection (SSI) on the 14th POD (AB group 4.8% (n = 1) vs. No-AB group 27.8% (n = 5), p = 0.004).

CONCLUSION

Wearing an AB did not have an impact on pain and seroma formation rate but it may reduce the rate of postoperative SSI within the first 14 days after surgery. Further trials are mandatory to confirm these findings.

[Lack of experienced surgeons in vascular surgery-A joint task]

INTRODUCTION

An increasing shortage of specialists and training assistants is also being lamented in vascular surgery. Despite a continuous increase in the number of physicians and medical students in Germany in recent years, the need for specialists and training assistants in vascular surgery is enormous in a sustained manner.

METHODS

Professional policy analysis from a medical vascular surgery perspective including currently available statistics, especially from the Federal Statistical Office, the Federal Medical Association, the Saxony-Anhalt (SA) State Medical Association and selective references from current medical scientific literature on epidemiological topics.

RESULTS

In 2022, according to the basic data of the Federal Statistical Office 200 vascular surgery departments provided a total of 5706 beds for care. In 2021, 1574 physicians with the regional and specialist title in vascular surgery were registered by the medical associations. In the following years, there was an increase of 404 vascular surgeons. The recognition of the specialist title for vascular surgery fell from 166 in 2018 to 143 in 2021. There are 23 vascular surgery care units in Saxony-Anhalt (SA). At the SA Medical Association, there were 52 registered doctors with the specialist title in vascular surgery in the inpatient sector in 2021. In comparison, at the North Rhine Medical Association in 2021 there were 362 registered doctors with regional and specialist titles in vascular surgery overall and 292 in the inpatient sector. The age-standardized hospital incidence of peripheral arterial occlusive disease (PAOD) rose from approximately 190 to over 250 per 100,000 inhabitants in Germany between 2005 and 2016 and plateaued at this level. This corresponded to a relative increase of 33%. During the same observational period, the number of procedures performed doubled, mainly due to a strong increase in the number of endovascular interventions (approximately 140% increase) and interventions for arterial embolism/thrombosis (approximately + 80%). A research report commissioned by the German Hospital Society (DKG) in 2010 predicted a replacement requirement for physicians of approximately 108,000 by 2019 and an additional requirement of almost 31,000 physicians. While 14.6-27.2% of those employed in 2008 will have retired by 2020, between 45.6% and 68.5% will retire by 2030. Despite the statistically verifiable improvement in the staffing situation of specialists in vascular surgery in the inpatient and outpatient sectors in Germany, it can be assumed that there is a problem in recruiting young specialists. In order to target the recruitment of junior staff, it is first necessary to comprehensively record basic data on the staff situation and staff development in the area of residents in vascular surgery. In addition, further work should be done on implementing the recommendations for action already put forward years ago by scientific reports at state and federal levels.

Vegan shrimp alternative made with pink oyster and lion's mane mushrooms: Nutritional profiles, presence of conjugated phenolic acids, and prototyping

The increasing demand for seafood is responsible for many environmental impacts, especially caused by aquaculture. Shrimp accounts for a substantial part of seafood production and therefore also for negative effects associated with it. This work aimed to develop a mushroom-based shrimp analogue with a texture similar to shrimp using the fruiting bodies of pink oyster mushroom (Pleurotus djamor) and lion's mane (Hericium erinaceus). Three flushes of pink oyster mushrooms and a first flush of lion's mane mushroom were analysed regarding their nutritional composition and whether they are suitable shrimp alternatives. The two mushrooms are rich in proteins (∼32% and ∼26% w/w for the first flush of pink oyster and lion's mane, respectively). The protein content of pink oyster mushroom decreased and the dietary fibre content increased across the different flushes. The antioxidants in the mushrooms were extracted using different methods, whereby aqueous extracts mostly excelled in terms of antioxidant activity. Hydrolysis confirmed the presence of conjugated p-coumaric acid in both mushrooms and possibly conjugated caffeic acid in pink oyster. Texture analysis results of the prototypes were close to the values of fried shrimp. However, although the sensory qualities of the final prototypes were perceived as similar to shrimp, further improvements in the recipe are necessary to make the prototypes indistinguishable from shrimp.

Manifestation of acute appendicitis as known but paradox visceral side effect of ulcerative colitis anti-inflammatory therapy with januskinase-inhibitor Tofacitinib (Xeljanz™)

BACKGROUND

The etiopathogenesis of accompanying inflammatory phenomena and consequences of immunomodulation constitute a challenging and innovative field in the medical treatment of patients with autoimmune diseases.

AIM

Based on i) clinical management experience gained from this challenging clinical case and ii) selective references of reports published in the scientific medical literature, we present an unusual counterfactual scientific case report. A patient diagnosed with ulcerative colitis undergoing januskinase (JAK)-inhibitor therapy developed acuteappendicitis as an unusual complication or as a visceral side effect of immunosuppressive/anti-inflammatory therapy.

METHOD

Scientific case report.

RESULTS

(case description): Medical history: A 52-year-old male presented with spasmodic pain in the right lower abdomen lasting for two days (no fever, no bowel movement changes (no stool irregularities), no vomiting).

MEDICATION USED TO DATE

Steroid-resistant ulcerative colitis treated with immunosuppressive therapy (Adalimumab administered for 10 months [next generation anti-TNFα mAb], Vendolizumab for 9 months [α4β7 integrin antagonist], Tofacitinib for 6 months); fructose intolerance, no previous abdominal surgery; medication: XeljanzTM (Tofacitinib, 5 mg 2x1; JAK-inhibitor; PFIZER PHARMA GmbH, Berlin,Germany); MutaflorTM (1x1; Ardeypharm GmbH, Herdecke, Germany).

CLINICAL FINDINGS

Pressure pain in the right lower abdomen with local muscular defense (Mc-Burney's/Lanz's point positive), no peritonism, Psoas-muscle sign positive.

DIAGNOSTIC MEASURES

Laboratory parameters: standard value of white blood cell count, CrP: 25 mg/l.-Transabdominal ultrasound revealed hypertrophic 'appendix vermiformis' with detectable target-phenomenon and surrounding fluid.

DECISION-MAKING

Indication for laparoscopic exploration.

THERAPY

Under perioperative single-shot antibiotic administration with UnacidTM, the patient underwent emergency laparoscopic appendectomy due to confirmed acute appendicitis with additional lavage and placement of local drainage.

CLINICAL COURSE

The postoperative phase was uneventful (sufficient analgetic therapy, removal of local drainage on the 2nd postoperative day). The patient was discharged four days after surgery. Histopathology confirmed ulcero-phlegmonous, acute purulent appendicitis with fibrinous purulent mesenteriolitis.

FURTHER MEASURES

Immunosuppressive therapy was continued.

CONCLUSION

Based on the paradoxon of an acute inflammatory disease (acute appendicitis) seen in the case of a patient undergoing immunosuppressive/anti-inflammatory treatment using a JAK-Inhibitor for ulcerative colitis, we consider this case worthy of publication although this side effect has previously been described in patients with rheumatoid arthritis. This might be the manifestation of i) an immunomodulatory effect that reduced or at least altered mucosal defense, including an increased risk of opportunistic infections, presenting as a specific visceral 'side effect' of the JAK-Inhibitor and/or as a consequence; ii) an induced alternative inflammatory mechanism/proinflammatory signal transduction and - theoretically - an intestinal drainage defect in the segment of right colic artery with consecutive collection of necrotic cells and activation of inflammatory mediators.

[Traumatic injuries of the kidney and the urinary tract in blunt abdominal trauma]

BACKGROUND

In the context of blunt abdominal trauma, injuries to the urinary tracts often occur, especially in polytrauma patients. Urotrauma is rarely immediately life-threatening but can lead to serious complications and chronic functional limitations during treatment. Therefore early urological involvement is crucial for adequate interdisciplinary treatment.

METHODS

The most important facts for the clinical routine on the consultant urological management of urogenital injuries in blunt abdominal trauma are discussed according to the European "EAU guidelines on Urological Trauma" and the German "S3 guidelines on Polytrauma/Treatment of Severely Injured Patients" as well as the relevant literature.

RESULTS

Urinary tract injuries can occur even with an initially inconspicuous status and always require explicit exclusion diagnostics by means of contrast medium tomography of the entire urinary tract and, if necessary, by means of urographic and endoscopic examinations. The most common urological intervention is catheterization of the urinary tract which is often required. Less common is urological surgery, which should be coordinated interdisciplinarily with visceral and trauma surgery. More than 90% of vitally threatening kidney injuries (usually up to the American Association for the Surgery of Trauma (AAST) grades 4-5) are now treated by interventional radiology.

CONCLUSION

Due to possible complex injury patterns in blunt abdominal trauma, these patients should ideally be directed to (certified) trauma centers with subspecialized or maximum care from the departments of visceral and vascular surgery, trauma surgery, interventional radiology and urology.

[Consultations by senior physicians in general and abdominal surgery for other medical disciplines over 10 years at a tertiary center-Is a fast time-consuming processing necessary? : Spectrum of clinical findings, diagnoses and treatment decision making]

BACKGROUND

The challenges of an adequate, efficient and rational medical treatment and care of patients are always associated with an interprofessional activity of several specialist disciplines.

AIM

The spectrum of variable diagnoses and the profile of surgical decision-making with further surgical measures within the framework of senior physician consultation in general and visceral surgery for neighboring medical disciplines were analyzed on a representative patient cohort over a defined observational time period.

PATIENTS AND METHODS

All consecutive patients (n = 549 cases) were documented as part of a clinical systematic prospective single center observational study at a tertiary center using a computer-based patient registry over 10 years (1 October 2006-30 September 2016). The data were analyzed with respect to the spectrum of clinical findings, diagnoses, treatment decisions and the influencing factors as well as gender and age differences and time-dependent developmental trends using χ2-tests and U‑tests.

RESULTS (KEY POINTS)

The predominant discipline for requests for surgical consultation was cardiology (19.9%) followed by surgical disciplines (11.8%) and gastroenterology (11.3%). Disorders of wound healing (7.1%) and acute abdomen (7.1%) were predominant in the diagnostic profile. In 11.7% of the patients the indications for immediate surgery were derived, whereas in 12.9% elective surgery was recommended. The conformity rate of suspected and definitive diagnoses was only 58.4%.

CONCLUSION

The surgical consultation work is an important mainstay of a sufficient and especially timely clarification of surgically relevant questions in nearly all medical institutions and especially in a center. This serves i) the quality assurance of surgery in the clinical care of patients with need of additional interdisciplinary needs for surgical treatment in the daily practice of general and abdominal surgery in research on clinical care, ii) clinical marketing and monetary aspects in the sense of patient recruitment and iii) last but not least to provide emergency care of patients. Due to the high proportion of 12% of subsequent emergency operations, which were derived from requests for general and visceral surgical consultations, such requests must be processed promptly during working hours.

Introduction of laparoscopic nephrectomy for autosomal dominant polycystic kidney disease as the standard procedure

PURPOSE

Autosomal dominant polycystic kidney disease (ADPKD) is a common hereditary disorder and accounts for 5-10% of all cases of kidney failure. 50% of ADPKD patients reach kidney failure by the age of 58 years requiring dialysis or transplantation. Nephrectomy is performed in up to 20% of patients due to compressive symptoms, renal-related complications or in preparation for kidney transplantation. However, due to the large kidney size in ADPKD, nephrectomy can come with a considerable burden. Here we evaluate our institution's experience of laparoscopic nephrectomy (LN) as an alternative to open nephrectomy (ON) for ADPKD patients.

MATERIALS AND METHODS

We report the results of the first 12 consecutive LN for ADPKD from August 2020 to August 2021 in our institution. These results were compared with the 12 most recent performed ON for ADPKD at the same institution (09/2017 to 07/2020). Intra- and postoperative parameters were collected and analyzed. Health related quality of life (HRQoL) was assessed using the SF36 questionnaire.

RESULTS

Age, sex, and median preoperative kidney volumes were not significantly different between the two analyzed groups. Intraoperative estimated blood loss was significantly less in the laparoscopic group (33 ml (0-200 ml)) in comparison to the open group (186 ml (0-800 ml)) and postoperative need for blood transfusion was significantly reduced in the laparoscopic group (p = 0.0462). Operative time was significantly longer if LN was performed (158 min (85-227 min)) compared to the open procedure (107 min (56-174 min)) (p = 0.0079). In both groups one postoperative complication Clavien Dindo ≥ 3 occurred with the need of revision surgery. SF36 HRQol questionnaire revealed excellent postoperative quality of life after LN.

CONCLUSION

LN in ADPKD patients is a safe and effective operative procedure independent of kidney size with excellent postoperative outcomes and benefits of minimally invasive surgery. Compared with the open procedure patients profit from significantly less need for transfusion with comparable postoperative complication rates. However significant longer operation times need to be taken in account.

Patients with carotid intraplaque hemorrhage have higher incidence of cerebral microbleeds

Background

Carotid intraplaque hemorrhage (IPH) is considered a strong marker of histologically defined plaque vulnerability leading to cerebrovascular ischemic events. Cerebral microbleeds (CMBs) represent hemorrhage-prone small vessel disease and they are a common finding on brain MRI in patients with cerebrovascular disease. However, the potential mechanism and the risk for CMBs are not clear. The characteristics of carotid lesions have been considered relevant in the relationship between carotid artery atherosclerosis and the presence of CMBs. The potential association between carotid IPH histologically defined and CMBs has not been investigated yet.

Purpose

We have previously reported the prevalence of IPH in patients with non-obstructive carotid disease in patients who underwent carotid endarterectomy (CEA). In this study, we aimed to investigate whether the presence and the extent of carotid IPH are related to the existence of CMBs. We hypothesized that patients with carotid IPH would have a higher risk of CMBs.

Methods

This retrospective study enrolled 101 consecutive patients undergoing CEA with symptomatic (including ischemic stroke, TIA, and amaurosis fugax) or asymptomatic ipsilateral carotid artery disease. Carotid plaque specimens were collected at CEA from all the patients and stained with Movat Pentachrome to identify the presence and the extent (%) of IPH. Neck CTA was obtained to measure the degree of carotid stenosis. Brain MRI was pre-surgically performed and CMBs were studied using T2*-weighted gradient-recalled echo (GRE) or susceptibility-weighted imaging (SWI) sequence. The CMBs were counted and localized. Clinical and biochemical data, comorbidities, and medications were recorded. The association between carotid IPH and CMBs was examined adjusted for other risk factors.

Results

The presence of carotid IPH was in 57 (56.4%) patients. CMBs were more observed in patients with carotid IPH compared to those without IPH [19 (33.3%) vs 5 (11.4%); p=0.010]. Logistic regression analysis demonstrated an association between the extent of IPH in the carotid atheroma and the presence of CMBs [OR 1.051 (95% CI 1.012–1.090); p=0.009]. Moreover, the carotid IPH extent was associated with the number of CMBs (p=0.004). In patients with CMBs, the median degree of ipsilateral carotid stenosis was 40% (35–65%) and it was 70% (50–80%) in those without CMBs, with a significant difference between the two groups (p=0.049).

Conclusions

In patients undergoing CEA, the histologically defined presence of carotid IPH and its extent are associated with CMBs on brain MR imaging. CMBs may be a potential mechanism for cerebrovascular events in patients with carotid atherosclerotic IPH and they may be an imaging marker that can distinguish the severity of the carotid artery disease.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Mayo Clinic Foundation

Solitary colorectal liver metastasis: overview of treatment strategies and role of prognostic factors

The following is an overview of the treatment strategies and the prognostic factors to consider in the therapeutic choice of patients characterized by solitary colorectal liver metastasis. Liver resection is the only potential curative option; nevertheless, only 25% of the patients are considered to be eligible for surgery. To expand the potentially resectable pool of patients, surgeons developed multidisciplinary techniques like portal vein embolization, two-stage hepatectomy or associating liver partition and portal vein ligation for staged hepatectomy. Moreover, mini-invasive surgery is gaining support, since it offers lower post-operative complication rates and shorter hospital stay with no differences in long-term outcomes. In case of unresectable disease, various techniques of local ablation have been developed. Radiofrequency ablation is the most commonly used form of thermal ablation: it is widely used for unresectable patients and is trying to find its role in patients with small resectable metastasis. The identification of prognostic factors is crucial in the choice of the treatment strategy. Previous works that focused on patients with solitary colorectal liver metastasis obtained trustable negative predictive factors such as presence of lymph-node metastasis in the primary tumour, synchronous metastasis, R status, right-sided primary colon tumor, and additional presence of extrahepatic tumour lesion. Even the time factor could turn into a predictor of tumour biology as well as further clinical course, and could be helpful to discern patients with worse prognosis.

2021 opinion from the CUROPF on THE efficacy and safety of mid-urethral slings used in women WITH urinary stress incontinence

OBJECTIVE

To determine the usefulness of mid-urethral slings (MUS) in the surgical management of women presenting with urinary stress incontinence (USI) METHOD: A consensus committee of multidisciplinary experts (CUROPF) was convened and focused on PICO questions concerning the efficacy and safety of MUS surgery compared to other procedures and concerning which approach (retropubic (RP) vs transobturator (TO)) should be proposed as a first-line MUS surgery for specific subpopulations (obese; intrinsic sphincteric deficiency (ISD); elderly) RESULTS: As compared to other procedures (urethral bulking agents, traditional slings and open colposuspension), the MUS procedure should be proposed as the first-line surgical therapy (strong agreement). MUS surgery can be associated with complications and proper pre-operative informed consent is mandatory (strong agreement). Mini-slings (SIS/SIMS) should only be proposed in clinical trials (strong agreement). Both RP and TO approaches may be proposed for the insertion of MUS (strong agreement). However, if the woman is willing to accept a moderate increase in per-operative risk, the RP approach should be preferred (strong agreement) since it is associated with higher very long-term cure rates and as it is possible to completely remove the sling surgically if a severe complication occurs. The RP approach should be used for the insertion of MUS in a woman presenting with ISD (strong agreement). Either the RP or TO approach should be used for the insertion of MUS in an obese woman presenting with USI (strong agreement). In very obese women (BMI ≥35-40kg/m²), weight loss should be preferred prior to MUS surgery and bariatric surgery should be discussed (strong agreement) CONCLUSION: The current Opinion provides an appropriate strategy for both the selection of patients and the best therapeutic approach in women presenting with USI.

[Complications of mid-urethral sling - A review from the Committee for Female Urology and Pelviperineology for the French Association of Urology]

INTRODUCTION

Placement of a mid-urethral sling is the gold standard in the surgical management of stress urinary incontinence in women in France. The cure rate of this material is no longer to be demonstrated, but the per- and post-operative complications are currently the subject of a growing controversy not only in Europe but also across the Channel and across the Atlantic, having led to the modification of operative indications. In France, recommendations are also evolving with a stricter framework for indications for surgery by multidisciplinary consultation meeting and an obligation for postoperative follow-up in the short and long term.

OBJECTIVES

In this context, CUROPF realized a review of the literature bringing together the available scientific evidence concerning the occurrence of per- and post-operative complications relating to the installation of mid urethral sling. The bibliographic search was carried out using the Medline database and 123 articles were selected.

RESULTS

Analysis of the data highlights various complications, depending on the implanted material, the patient and the indication for surgery. The retro-pubic mid urethral sling provides more bladder erosion during surgery (up to 14%), more suprapubic pain (up to 4%) and more acute urinary retention (up to 19,7%) and postoperative dysuria (up to 26%). The trans obturator mid-urethral sling is responsible for more vaginal erosion during the operation (up to 10,9%), more lower limb pain of neurological origin (up to 26,7%). The risk of developing over active bladder is similar in both procedures (up to 33%). But these risks of complications must be balanced by the strong impact of urinary incontinence surgery on the overall quality of life of these women.

CONCLUSION

Thus, surgical failure and long term complications exist but should not limit the surgical management of stress urinary incontinence with mid urethral tape. Women should be treated with individualized decision-making process and long-term follow -up is necessary.

Temporal and kinematic patterns distinguishing the G2 from the G4 skating sub-technique

In cross-country ski skating, both the G2 and G4 sub-techniques involve one pole push for every second ski push but are used at largely different speed-slope ranges. The aim of this study was to compare temporal and kinematic patterns between G2 and G4 at both identical and different speed-slope conditions. A mixed model was used to analyse spatio-temporal parameters, while a combination of dynamic time warping and statistical parametric mapping was used to compare time traces. Main spatio-temporal parameters, such as cycle time, ski contact time and swing time, differed between G2 and G4 (all p < 0.01). Moreover, two forward and more pronounced acceleration phases of the centre of mass (CoM) were visible in G4 while only one acceleration phase was present in G2. The more continuous propulsion in G2 allows for maintaining a more constant speed at steep slopes and low speeds where this sub-technique is preferred. In contrast, the achievement of high speeds while skiing on flatter terrain seem to require more dynamic motion with shorter, more explosive propulsion periods allowed for in G4. In conclusion, G2 and G4 are two unique movements as characterised by fundamentally different CoM motion and should be denoted as two different sub-techniques.

Home vision monitoring in patients with maculopathy: Real-life study of the OdySight application

INTRODUCTION

The goal of the present study was to analyze the implementation and clinical efficacy of OdySight, a mobile medical application for the remote monitoring of patients with maculopathy.

MATERIALS AND METHODS

In all, 60 patients with edematous maculopathies receiving traditional clinical treatment (PRN or Treat & Extend) were provided with OdySight to detect changes in visual acuity from home. To determine both the feasibility and reliability of the application, its use by patients (both testing and game play), as well as the processing of alerts by the clinical team, were analyzed during the first year.

RESULTS

The female-to-male ratio was 3:2, with a mean age of 64 years. 52% of patients presented with age-related macular degeneration, 31% with high myopia, 11% with retinal vein occlusion, and 6% with diabetic maculopathy. The conversion rate (defined as the percentage of patients completing at least one test following prescription) and the nine-month retention rate (percentage of active patients) were 61% and 24% respectively. Patients aged 50 to 70 years and those whose use of the app included game play represent 75% of active patients at 9 months. The 22 active patients performed 483 visual acuity tests, completed 1,667 game sessions, and underwent 77 in-person consultations. During the trial period, the clinical team processed 19 alerts, on average in fewer than 6 days. Decreases in visual acuity were detected with a sensitivity of 92% and specificity of 99%.

DISCUSSION

The use of connected and mobile devices today is widespread, as is interest in mobile medical applications. Long-term treatments for maculopathies can be a difficult burden to bear, both for patients and healthcare practitioners. Overcoming the challenges associated with the successful remote detection of recurrences thus represents a significant opportunity for improving patient care. The implementation of novel digital tools requires the cooperation of the clinical team as a whole, to both inform and motivate patients. OdySight demonstrates satisfactory detection rates, thanks to reliable and reproducible home testing, and can thus serve as a supplementary tool for patients whose consultations are often spaced several months apart. Implementation can be nonetheless improved by facilitating alert processing, a goal which necessitates active adaptation of clinical practices. In general, active patients were very satisfied with this personalized service.

CONCLUSION

Improved medical support, plus the amusing nature of the tests and games, both bolster long-term use of the OdySight app. The application allows for the remote monitoring of changes in visual acuity and affords patients and practitioners an added level of protection, particularly during long intervals between treatments and at the end of a treatment course. To ensure proper implementation, clinics should focus on reinforcing and modernizing the clinical pathway, from patient intake to the injection room.

Which experimental models and explorations to use in regenerative endodontics? A comprehensive review on standard practices

Since the discovery of dental pulp stem cells, a lot of teams have expressed an interest in dental pulp regeneration. Many approaches, experimental models and biological explorations have been developed, each including the use of stem cells and scaffolds with the final goal being clinical application in humans. In this review, the authors' objective was to compare the experimental models and strategies used for the development of biomaterials for tissue engineering of dental pulp with stem cells. Electronic queries were conducted on PubMed using the following terms: pulp regeneration, scaffold, stem cells, tissue engineering and biomaterial. The extracted data included the following information: the strategy envisaged, the type of stem cells, the experimental models, the exploration or analysis methods, the cytotoxicity or viability or proliferation cellular tests, the tests of scaffold antibacterial properties and take into account the vascularization of the regenerated dental pulp. From the 71 selected articles, 59% focused on the "cell-transplantation" strategy, 82% used in vitro experimentation, 58% in vivo animal models and only one described an in vivo in situ human clinical study. 87% used dental pulp stem cells. A majority of the studies reported histology (75%) and immunohistochemistry explorations (66%). 73% mentioned the use of cytotoxicity, proliferation or viability tests. 48% took vascularization into account but only 6% studied the antibacterial properties of the scaffolds. This article gives an overview of the methods used to regenerate dental pulp from stem cells and should help researchers create the best development strategies for research in this field.

Integrated bioelectronic proton-gated logic elements utilizing nanoscale patterned Nafion

A central endeavour in bioelectronics is the development of logic elements to transduce and process ionic to electronic signals. Motivated by this challenge, we report fully monolithic, nanoscale logic elements featuring n- and p-type nanowires as electronic channels that are proton-gated by electron-beam patterned Nafion. We demonstrate inverter circuits with state-of-the-art ion-to-electron transduction performance giving DC gain exceeding 5 and frequency response up to 2 kHz. A key innovation facilitating the logic integration is a new electron-beam process for patterning Nafion with linewidths down to 125 nm. This process delivers feature sizes compatible with low voltage, fast switching elements. This expands the scope for Nafion as a versatile patternable high-proton-conductivity element for bioelectronics and other applications requiring nanoengineered protonic membranes and electrodes.

Prognostic Assessment of Non-functioning Neuroendocrine Pancreatic Neoplasms as a Basis for Risk-Adapted Resection Strategies

BACKGROUND

In contrast to exocrine pancreatic carcinomas, prognosis and treatment of pancreatic neuroendocrine neoplasms (PNEN) are significantly different. The variable growth pattern and associated clinical situation of functioning and non-functioning PNEN demand an individualized surgical approach. However, due to the scarce evidence associated with the rare disease, guidelines lack detailed recommendations for indication and for the required extent of surgical resection.

METHODS

In a retrospective single-center study from 1990 to 2018, 239 patients with PNEN were identified. Clinical data were collected in the MaDoc database of the University Medical Center Mainz. A total of 155 non-functional PNEN were selected for further analysis.

RESULTS

According to the classification of NET by the WHO in 2017, 28.8% (n = 40) of the tumors were G1, 61.9% (n = 86) G2, and 9.4% (n = 13) G3. In 73 patients, hepatic metastases were present. Sixty patients had lymph node metastasis. An R0 resection was achieved in 98 cases, an R1 situation in 10 cases. Five times, a tumor debulking was carried out (R2) and 5 times the operation was aborted without any resection because of the advanced tumor stage. A relapse occurred in 29 patients. Different prognostic factors (grade, tumor size, age) were analyzed. Grade-dependent 10-year overall survival rates were 79.5% (grade 1) and 60.1% (grade 2), respectively. The survival rate of grade 3 patients was limited to 66.7% after 13 months.

CONCLUSION

In our study, patients with non-functioning PNEN had a longer overall survival after successful R0 resection. The risk analysis confirmed a Ki-67 cutoff value of 5%, which divided a high- and low-risk group. Patients with a PNEC G3 (Ki-67 index > 50%) had a very poor prognosis.

UEFA expert group statement on nutrition in elite football. Current evidence to inform practical recommendations and guide future research

Football is a global game which is constantly evolving, showing substantial increases in physical and technical demands. Nutrition plays a valuable integrated role in optimising performance of elite players during training and match-play, and maintaining their overall health throughout the season. An evidence-based approach to nutrition emphasising, a 'food first' philosophy (ie, food over supplements), is fundamental to ensure effective player support. This requires relevant scientific evidence to be applied according to the constraints of what is practical and feasible in the football setting. The science underpinning sports nutrition is evolving fast, and practitioners must be alert to new developments. In response to these developments, the Union of European Football Associations (UEFA) has gathered experts in applied sports nutrition research as well as practitioners working with elite football clubs and national associations/federations to issue an expert statement on a range of topics relevant to elite football nutrition: (1) match day nutrition, (2) training day nutrition, (3) body composition, (4) stressful environments and travel, (5) cultural diversity and dietary considerations, (6) dietary supplements, (7) rehabilitation, (8) referees and (9) junior high-level players. The expert group provide a narrative synthesis of the scientific background relating to these topics based on their knowledge and experience of the scientific research literature, as well as practical experience of applying knowledge within an elite sports setting. Our intention is to provide readers with content to help drive their own practical recommendations. In addition, to provide guidance to applied researchers where to focus future efforts.

Thermoregulatory and perceptual responses of lean and obese fit and unfit girls exercising in the heat

OBJECTIVE

To verify the thermoregulatory and perceptual responses of obese and lean girls, either fit or unfit, exercising in the heat at a similar rate of metabolic heat production per unit body mass.

METHODS

A total of 34 pubescent girls were allocated in four groups: 12 obese fit, 9 obese unfit, 5 lean fit, and 8 lean unfit. The obese groups (13.2±1.4 years, 40.5%±5.8% fat by DXA) differed in their aerobic fitness (V˙O_2peak 76.0±8.1 vs. 56.6±5.8mL.kgmusclemass^-1.min^-1), as well as the lean groups (13.1±1.6 years, 24.0%±4.8% fat) (V˙O_2peak 74.5±2.9 vs. 56.2±5.0mL.kgmuscle mass^-1min^-1). Girls cycled two bouts of 25min with a 10min rest in between, at ∼5.4W.kg^-1 in the heat (36°C and 40% relative humidity) and they were kept euhydrated. Rectal and skin temperatures and heart rate were measured every 5min. Perceptual responses were evaluated throughout the exercise.

RESULTS

Initial rectal temperature was higher in the obese subjects compared to the lean subjects (37.5±0.3 and 37.2±0.3°C). No difference was observed among the girls whom were obese (eight fit or unfit) and lean (also fit or unfit) throughout the exercise in rectal temperature (37.6±0.2, 37.5±0.3, 37.5±0.3, 37.4±0.3°C, respectively), skin temperature (34.8±0.8, 35.1±1.0, 34.4±0.9, 35.2±0.9°C), and heart rate (128±18; 118±12, 130±16, 119±16beatsmin^-1). No differences were observed in perceptual responses among groups.

CONCLUSION

Regardless of the adiposity or aerobic fitness, pubescent girls had similar thermoregulatory and perceptual responses while cycling in the heat at similar metabolic heat production.

AB0067 CHONDROCALCINOSIS IS ASSOCIATED WITH A SPECIFIC EFFECT ON THE CHONDROCYTE PHENOTYPE THAT MARKEDLY DIFFERS FROM OA

Background:

Calcification of cartilage with BCP crystals is a common finding during osteoarthritis (OA) and is directly linked to the severity of the disease and hypertrophic differentiation of chondrocytes. Chondrocalcinosis (CC) is associated with CPPD crystal formation. There is only little knowledge about the effect of CPPD crystals on chondrocytes.

Objectives:

The aim of this study was to investigate the chondrocyte phenotype in CC cartilage and the effect of CPPD crystals on chondrocytes.

Methods:

Cartilage samples of patients with CC were used and compared with samples of severe OA patients without chondrocalcinosis and healthy cartilage samples served as control. Radiological presence of chondrocalcinosis was evaluated using standard X-ray pictures, as well as macroscopically inspection. The cartilage samples were stained using von Kossa/Safranin-orange staining. These stainings were used for OA severity scoring using the Chambers-Score. FTIR analyses was performed to distinguish CPPD and BCP crystals in cartilage. Chondrocyte differentiation markers were evaluated using Collagen 2 and X, as well as Sox9 and aggrecan as markers for chondrocyte hypertrophic differentiation in immunohistochemistry and qRT-PCR. TUNEL staining was performed to investigate cell death. In vivo results were validated using qRT-PCR for the expression of the respective genes after stimulation of C28 chondrocytes with CPPD and BCP crystals.

Results:

Radiologically detectable cartilage calcifications were evident in chondrocalcinosis patients, but absent in OA patients without CC. CPPD crystals were detected on the cartilage surface, whereas BCP crystals were detected in the pericellular matrix of hypertrophic chondrocytes. CC cartilage exhibited an increased collagen X expression compared to healthy cartilage, as well as to severe OA cartilage containing BCP calcification. Interestingly, aggrecan and collagen 2 were not reduced in CC cartilage, but markedly reduced in OA cartilage. TUNEL positive cells were significantly increased in CPPD cartilage compared to OA cartilage, although the histological OA severity was lower. qRT-PCR indicated no relevant influence of CPPD crystals on hypertrophic marker genes, whereas BCP crystals significantly induced hypertrophic differentiation.

Conclusion:

BCP and CPPD crystals seem to trigger differential effects on the chondrocyte phenotype. BCP crystals induce hypertrophic differentiation, which is not induced by CPPD crystals.

Acknowledgments:

The project was funded by theDeutsche Rheumastifung by the sponsor Dr. Sigrid Schuler.

Disclosure of Interests:

Franziska Meyer: None declared, Miriam Bollmann: None declared, Uwe Kornak: None declared, Jessica Bertrand Grant/research support from: Pfizer, Speakers bureau: Pfizer

Single-cycle, MHz repetition rate THz source with 66 mW of average power

We demonstrate terahertz (THz) generation using the tilted pulse front method in lithium niobate, driven at an unprecedented high average power of more than 100 W and at a 13.3 MHz repetition rate, provided by a compact amplifier-free mode-locked thin-disk oscillator. The conversion efficiency was optimized with respect to the pump spot size and pump pulse duration, enabling us to generate a maximum THz average power of 66 mW, which is, to the best of our knowledge, the highest reported to date from a laser-driven, few-cycle THz source. Furthermore, we identify beam walk-off as the main obstacle that currently limits the conversion efficiency in this excitation regime (with moderate pulse energies and small spot sizes). Further upscaling to the watt level and beyond is within reach, paving the way for linear and nonlinear high average power THz spectroscopy experiments with an exceptional signal-to-noise ratio at megahertz repetition rates.

Correction to: Prognostic Assessment of Non-functioning Neuroendocrine Pancreatic Neoplasms as a Basis for Risk-Adapted Resection Strategies

This article contains parts of the doctoral thesis of F. Meyer.