Risk of conversion after intended total extraperitoneal hernia repair for inguinal hernia depends on type of previous abdominal surgery

PURPOSE

Risk of total extraperitoneal hernia repair (TEP) in patients with previous lower abdominal surgery (PLAS) is still debated. The present study was designed to assess the rate of conversion in TEP for inguinal hernia stratified by type of PLAS.

METHODS

Variables on patients undergoing TEP inguinal hernia repair at our center were prospectively collected between July 2012 and May 2018. Patients with PLAS were compared to patients without PLAS. Furthermore, the most frequent subtypes of PLAS were defined and TEP conversion rate was stratified according to type of PLAS.

RESULTS

A total of 1589 patients with TEP inguinal hernia repair were identified including 152 (9.6%) patients with PLAS. Operative time was increased in patients with PLAS (70 vs. 60 min, p < 0.001). Conversion from TEP to transabdominal preperitoneal patch plasty (TAPP) or Lichtenstein open inguinal hernia repair was eight-times more frequent after PLAS (8% vs. 1%, p < 0.001). Considering type of PLAS, open appendectomy was most frequently encountered, followed by multiple PLAS and surgery to the bladder and prostate (53%, 11% and 10%). After stratification for type of PLAS, conversions were most frequently found after previous surgery to the bladder or prostate and after multiple PLAS (conversion rate of 20% and 24%, p < 0.001). In contrast, conversion rate after open appendectomy was not increased.

CONCLUSION

PLAS to the bladder and prostate is associated with TEP conversion. Selected patients might profit from a different operative approach for inguinal hernia repair.

Cardio-oncology in Austria: cardiotoxicity and surveillance of anti-cancer therapies : Position paper of the Heart Failure Working Group of the Austrian Society of Cardiology

Survival in cancer is continuously improving due to evolving oncological treatment. Therefore, cardiovascular short-term and long-term side effects gain crucial importance for overall outcome. Cardiotoxicity not only presents as heart failure, but also as treatment-resistant hypertension, acute coronary ischemia with plaque rupture or vasospasm, thromboembolism, arrhythmia, pulmonary hypertension, diastolic dysfunction, acute myocarditis and others. Recent recommendations have proposed baseline cardiac risk assessment and surveillance strategies. Major challenges are the availability of monitoring and imaging resources, including echocardiography with speckle tracking longitudinal strain (GLS), serum biomarkers such as natriuretic peptides (NT-proBNP) and highly sensitive cardiac troponins. This Austrian consensus encompasses cardiotoxicity occurrence in frequent antiproliferative cancer drugs, radiotherapy, immune checkpoint inhibitors and cardiac follow-up considerations in cancer survivors in the context of the Austrian healthcare setting. It is important to optimize cardiovascular risk factors and pre-existing cardiac diseases without delaying oncological treatment. If left ventricular ejection fraction (LVEF) deteriorates during cancer treatment (from >10% to <50%), or myocardial strain decreases (>15% change in GLS), early initiation of cardioprotective therapies (angiotensin-converting enzyme inhibitors, angiotensin or beta receptor blockers) is recommended, and LVEF should be reassessed before discontinuation. Lower LVEF cut-offs were recently shown to be feasible in breast cancer patients to enable optimal anticancer treatment. Interdisciplinary cardio-oncology cooperation is pivotal for optimal management of cancer patients.

Effect of a dynamic seat pan design on spine biomechanics, calf circumference and perceived pain during prolonged sitting

This study investigates the effects of a dynamic seat pan design on sitting biomechanics, perceived pain and seat movement compared to a control. Thirty male participants were recruited for two experimental sessions consisting of a 2-h sitting exposure (standardized typing task). Spine angles, back muscle activity, perceived pain and calf circumference were measured pre and post exposure. Sitting in the dynamic condition resulted in lower pain ratings (p = 0.031), decreased calf circumference (p < 0.001), lower average seat pressure (p < 0.001), and greater seat contact area (p = 0.003) compared to the control. Spine angles and low back EMG for all 6 muscles showed no significant differences between chair conditions. These results suggest this dynamic seat pan design is effective at decreasing several negative components associated with sitting for the occupant. Future work should examine the longer-term effects of dynamic office chair features in the field setting with a more generalizable population.

[Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]

Long-term oxygen therapy is of great importance both for reducing mortality and for improving performance in patients with chronic lung diseases. The prerequisites for Long-term oxygen therapy are adequate diagnostics and clearly defined indication. A causal distinction into chronic hypoxaemic and hypercapnic respiratory failure is reasonable, from which the differential indication for non-invasive ventilation results.The revised guideline covers the diagnostics and indication of chronic lung and heart diseases, the role of oxygen in terminal illness and gives a detailed description of available oxygen devices. The guideline is intended to help avoid undersupply, oversupply and false prescriptions. Furthermore, the chapter "Postacute Oxygen Therapy" discusses the procedure, relevant in everyday life, but not yet clearly defined, for prescribing oxygen therapy for the home at the end of an inpatient stay. Another important point, the correct prescription of mobile oxygen systems, is also presented in the guideline. This document is a revised version of the guideline for longterm oxygen therapy and replaces the version of 2008.

Wave-Vector Dependence of the Dynamics in Supercooled Metallic Liquids

We present a detailed investigation of the wave-vector dependence of collective atomic motion in Au_{49}Cu_{26.9}Si_{16.3}Ag_{5.5}Pd_{2.3} and Pd_{42.5}Cu_{27}Ni_{9.5}P_{21} supercooled liquids close to the glass transition temperature. Using x-ray photon correlation spectroscopy in a previously uncovered spatial range of only a few interatomic distances, we show that the microscopic structural relaxation process mimics the structure and presents a marked slowing down at the main average interparticle distance. This behavior is accompanied by dramatic changes in the shape of the intermediate scattering functions, which suggest the presence of large dynamical heterogeneities at length scales corresponding to a few particle diameters. A ballisticlike mechanism of particle motion seems to govern the structural relaxation of the two systems in the highly viscous phase, likely associated with hopping of caged particles in agreement with theoretical studies.

5937Natural history of functional tricuspid regurgitation: implications of quantitative doppler assessment

Objectives

To establish the prognostic value of quantitative measures of functional tricuspid regurgitation (TR) severity i.e. effective regurgitant orifice area (EROA) and regurgitant volume.

Methods

382 patients with HFrEF on guideline-directed medical therapy were enrolled and TR EROA as well as regurgitant volume by Doppler/2D-echocardiography were assessed. All-cause mortality was defined as the primary study endpoint.

Results

Quantitative metrics of TR severity were consistently associated with mortality with a HR of 1.27 (95% CI 1.13–1.42, P<0.001) for the EROA and of 1.29 (95% CI 1.14–1.45, P<0.001) for the regurgitant volume (Figure 1, Panels A and B). Results remained unchanged after bootstrap- or clinical confounder-based adjustment. A spline curve pattern illustrates the association with mortality with thresholds for the EROA≥0.2cm2, and the regurgitant volume≥20ml with sustained excess mortality thereafter (Figure 1 Panels C-D).

Figure 1. Panels A–D

Conclusions

This large-scale study demonstrates the prognostic value of quantitative measures of TR severity in HFrEF. Thresholds for EROA and TR regurgitant volume associated with mortality fall within current ranges defining non-severe TR. This may potentially impact therapeutic decision making particularly timing of intervention.

Delignified Wood-Polymer Interpenetrating Composites Exceeding the Rule of Mixtures

Wood is increasingly considered in sustainable structural materials development due to its hierarchical structure, including an oriented reinforcing cellulose phase combined with carbon capturing and renewability. Top-down manufacturing techniques can provide direct access to this hierarchical cellulose scaffold for use in new functional materials. For high-performance load-bearing wood-based materials, the volume content of the reinforcing phase needs to be increased to much higher fiber volume contents (FVCs). This has been achieved by structure-retaining delignification followed by densification. The obtained matrix-free materials possess high tensile stiffness due to preservation of hierarchical fiber alignment; however, they demonstrate low mechanical properties in bending and cannot be used in moist conditions due to their propensity for water absorption. In order to address these two challenges, an interpenetrating wood polymer phase composite is developed using a delignified wood scaffold as a continuous reinforcing phase and epoxy resin as the interconnected matrix phase. We utilize the continuous flow channels in delignified wood for vacuum-assisted matrix infiltration in a condition of open continuous porosity in the wood scaffold. Prior to matrix curing, the material is densified in order to increase the FVC, decrease porosity, and reduce density variations in the wood scaffold. Due to the compressibility of delignified cellulose fibers, interpenetrating phase composites (IPCs) with very high FVCs of up to 80% could be produced, leading to exceptionally high tensile stiffness and strength of up to 70 GPa and 600 MPa. The obtained stiffness values far exceed the upper limit of the rule of mixtures due to an enhanced stress transfer through mechanically interlocked fiber-fiber interfaces combined with the stiffness providing matrix phase that further aids stress transfer between neighboring wood cells via their pits. This new approach paves the way for an efficient production of high-performance sustainable materials that can be used as alternative for glass fiber reinforced composites or natural fiber composites.

Carpal Tunnel Syndrome: A Question of Hand and Wrist Configurations?

This study investigated whether there is an association between hand and wrist configurations and the occurrence of carpal tunnel syndrome. The external hand and wrist dimensions of 50 subjects with carpal tunnel syndrome and 50 healthy volunteers were measured and compared. In addition carpal tunnel depth and width were determined with ultrasound. Our results showed that the hand length was significantly higher in the control group (hand length, 19.0; SD, 1.0 cm: patients’ hand length, 18.2; SD, 1.1 cm) and the palm width was significantly greater in the patients’ group (palm width, 9.1; SD, 0.7 cm: controls palm width, 8.6; SD, 0.6 cm). Carpal tunnel syndrome patients had a squarer wrist (wrist ratio, 0.72; SD, 0.1) and carpal tunnel (carpal tunnel ratio, 0.48; SD, 0.1) than the controls (wrist ratio, 0.68; SD, 0.1; carpal tunnel ratio, 0.42; SD, 0.1). These findings indicate that the anatomy of the hand, wrist and carpal tunnel may predispose to carpal tunnel syndrome.

Feelings of stigmatization in patients with rosacea

BACKGROUND

Rosacea is a chronic facial disease that may lead to feelings of stigmatization, which can negatively impact psychological and social well-being.

OBJECTIVE

The aim of this study was to evaluate different aspects of rosacea that could contribute to feelings of stigmatization.

METHODS

An online survey of a representative sample of the adult population in the UK, France, Germany and US was conducted to identify patients with rosacea based on presence of three or more clinical features.

RESULTS

Among the patients who completed the survey (n = 807), mean age at first sign/symptom of rosacea was 31.3 ± 14.5 years; mean duration of disease was 102 ± 119 months. One-third of patients reported feelings of stigmatization (FS; n = 275). Male patients were more likely to experience FS (49% vs. 37.2% in non-FS population; P = 0.0037). Those with FS were more likely to avoid social situations (54.2% vs. 2.0%, P < 1.00^E-10 ) and had a higher rate of depression (36.7% vs. 21.1%, P < 1.00^E-10 ).

CONCLUSIONS

Stigmatization is important in the daily lives of those with rosacea and should be taken into consideration in the management of these patients.

Depletion of naive T cells using clinical grade magnetic CD45RA beads: a new approach for GVHD prophylaxis

Depletion of naive T cells from donor leukapheresis products (LPs) aims at the reduction of alloreactivity, while preserving memory T-cell reactivity (for example, to pathogens). This study established the immunomagnetic depletion procedure under clean room conditions using CD45RA beads and analyzed LPs of six donors for cell composition and functional immune responses. CD45RA depletion resulted in 3.4-4.7 log (median 4.4) reduction of CD45RA(+) T cells, thereby eliminating naive and late effector T cells. B cells were also completely removed, whereas significant proportions of NK cells, monocytes and granulocytes persisted. CD45RA-depleted LPs contained effector and central memory CD4(+) and CD8(+) T cells that showed sustained IFN-γ secretion to CMV, EBV, Aspergillus and Candida Ags. Alloreactivity was measured in MLRs between donors with complete HLA-mismatch. Alloreactive CD8(+) T cells were strongly reduced (median >1-log) upon CD45RA depletion, whereas alloreactive CD4(+) T cells persisted in significant numbers. In conclusion, clinical grade depletion of CD45RA(+) naive T cells from donor LPs is feasible and highly efficient. The depleted products show sustained CD4(+) and CD8(+) T-cell reactivity to pathogens and effectively reduced CD8-mediated alloreactivity. Prophylactic and preemptive infusions after allogeneic SCT may improve T-cell reconstitution and pathogen-specific immunosurveillance, along with lower risk of inducing GVHD.

Diagnosis and management of chronic obstructive pulmonary disease: the Swiss guidelines. Official guidelines of the Swiss Respiratory Society

The new Swiss Chronic Obstructive Pulmonary Disease (COPD) Guidelines are based on a previous version, which was published 10 years ago. The Swiss Respiratory Society felt the need to update the previous document due to new knowledge and novel therapeutic developments about this prevalent and important disease. The recommendations and statements are based on the available literature, on other national guidelines and, in particular, on the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. Our aim is to advise pulmonary physicians, general practitioners and other health care workers on the early detection and diagnosis, prevention, best symptomatic control, and avoidance of COPD as well as its complications and deterioration.

[Squamous cell carcinoma in Dupuytren's disease--a case report]

Squamous cell carcinoma in the palm is an extremely rare entity. In the following case report we describe the occurrence of a squamous cell carcinoma in the presence of Dupuytren's disease. A 49-year-old man was operated on the right hand for ulcerating Dupuytren's disease. A squamous cell carcinoma was diagnosed by performing obtaining a fast section intraoperatively. The patient had an invasive, highly differentiated keratinizing squamous cell carcinoma. The lesion was resected together with the Dupuytren lesion and the defect covered with a full-thickness graft. Postoperatively the patient was irradiated. He is free of recurrence for three years now. To our knowledge, this is the first published report of a squamous cell carcinoma in the presence of Dupuytren's disease.

[Treatment of painful neuromas via end-to-side neurorraphy]

INTRODUCTION

Management of the painful neuroma has been subject to controversy since the earliest descriptions of this disabling problem. Today, treatment is limited to resection of the neuroma and implantation of the nerve in a muscle at a location where it is safe from irritation and trauma. This however is not attainable in many cases and it is our clinical experience, that nerves without a target remain a source of constant discomfort and pain. Recently we reported of the feasibility of neuroma prevention through end-to-side neurorraphy into adjacent sensory and/or motor nerves to provide a target for axons deprived of their endorgan. Here we report of our first clinical experience with this method in sixteen patients with longstanding upper and lower extremity neuromas.

PATIENTS AND METHODS

16 patients were included in this study. All had neuromas of different sensory nerves of both the upper and lower extremity. 11 were of iatrogenic origin, 5 were caused by different traumas. 8 had previous attempts to surgically treat the neuroma. Finally, all were treated by end-to-side neurorraphy into adjacent nerves. Postoperatively quantitative sensorymotor testing was performed to evaluate possible changes of nerve function of the recipient nerves. Pain was evaluated by visual analogue score and changes in pain medication.

RESULTS

In no patient a sensory or motor deficit or painful sensations were induced in the target area of the recipient nerve. Some had dysaesthesias for about 6 months, which finally subsided. All but 1 patient improved in their symptoms at a follow-up of more than 2 years.

CONCLUSION

Previous experimental work and present clinical results suggest that axons of a severed peripheral nerve that are provided with a pathway and target through an end-to-side coaptation will either be pruned or establish some type of end-organ contact so that a neuroma can be prevented without inducing sensory or motor dysfunctions in the recipient nerve.

Emotional associations with skin: differences between burned and non-burned individuals

INTRODUCTION

The appearance of skin is crucial for our physical and psychological integrity, and is strongly associated with our emotional self-awareness. Burn victims have to cope with negative and even threatening sensations resulting from the changed appearance of their skin after injury and also linked to experiences during the treatment. The aim of this study was to analyse differences regarding the emotional associations with skin in burn victims (burn group) to persons not having subdued any burn (control group).

METHODS

In the first instance over 960 volunteers were recruited for the rating of emotional associations with skin in the control group and thereby a representative profile for non-injured individuals. In the second part, 44 burn patients of the Vienna Burn Center answered the same questionnaire. The quantitative rating of emotional associations with skin was performed with a newly designed questionnaire using a semantic differential on eight dimensions with a 5-point scale system.

RESULTS

Both groups have positive associations with skin. One significant difference (p=0.0090, Chi-square test for trend) was the overall rating of the item "importance": for burn victims skin is more "important" than for controls. Patients with visible burns tended to put more emphasize on the possible exposure to danger ("threatened") of skin, and patients with >/=20% TBSA rated skin as more "noticeable" and "strong" as compared to small burns (<20% TBSA). Patients with burns to the face, hands and neck ("visible burns") were more likely to judge skin as threatened item.

DISCUSSION

Our poll suggests that despite long treatment, rehabilitation and even near-death experiences burn patients continue to have positive associations with skin. This in turn, should encourage all specialists dealing with burns to engage in a continuous follow-up as well as enhance psychological and social support.

Determinants of change in airway reactivity over 11 years in the SAPALDIA population study

We investigated determinants of change in bronchial reactivity in the Swiss Cohort Study on Air Pollution and Lung Diseases in Adults (SAPALDIA), a population-based cohort with wide age range (29-72 yrs at follow-up). The role of sex, age, atopic status, smoking and body mass index (BMI) on percentage change in bronchial reactivity slope from the baseline value was analysed in 3,005 participants with methacholine tests in 1991 and 2002, and complete covariate data. Slope was defined as percentage decline in forced expiratory volume in 1 s from its maximal value per micromole of methacholine. Bronchial hyperreactivity prevalence fell from 14.3 to 12.5% during follow-up. Baseline age was nonlinearly associated with change in reactivity slope: participants aged <50 yrs experienced a decline and those above an increase during follow-up. Atopy was not associated with change, but accentuated the age pattern (p-value for interaction = 0.038). Smoking significantly increased slope by 21.2%, as did weight gain (2.7% increase per BMI unit). Compared with persistent smokers, those who ceased smoking before baseline or during follow-up experienced a significant decrease in slope (-27.7 and -23.9%, respectively). Differing, but not statistically different, age relationships and effect sizes for smoking and BMI between sexes were found. Mean bronchial reactivity increases after 50 yrs of age, possibly due to airway remodelling or ventilation-perfusion disturbances related to cumulative lifetime exposures.

Prevalence of airflow obstruction in smokers and never-smokers in Switzerland

The aim of the present study was to measure age-specific prevalence of airflow obstruction in Switzerland in smokers and never-smokers using pulmonary function tests and respiratory symptoms from 6,126 subjects participating in the Swiss Cohort Study on Air Pollution and Lung Diseases in Adults. The lower limit of normal of the forced expiratory volume in 1 s/forced vital capacity ratio was used to define airflow obstruction. Severity of airflow obstruction was graded according to the recommendations of the Global Initiative for Chronic Obstructive Lung Disease. Prevalence of airflow obstruction ranged from 2.5% in subjects aged 30-39 yrs to 8.0% in those aged ≥ 70 yrs. In multivariate analysis, age (OR 2.8, ≥ 70 yrs versus 30-39 yrs), smoking (OR 1.8) and asthma (OR 6.7) were associated with airflow obstruction. Never-smokers constituted 29.3% of subjects with airflow obstruction. Never-smokers with airflow obstruction were younger, more likely to be male and reported asthma more frequently than obstructive smokers. Obstructive smokers and never-smokers had similar level of symptoms and quality of life impairment. The prevalence of airflow obstruction in Switzerland is similar to other developed countries. Never-smokers account for a third of the prevalence, which is higher proportion than elsewhere. Airflow obstruction in never-smokers deserves attention because of its frequency and its similar health impact to that in smokers.

[Conservative treatment and rehabilitation in peripheral facial palsy]

Facial paralysis may be treated by physical therapies with different therapeutic strategies and devices. Exercise therapy, electrotherapy, massage, lymph-drainage, biofeedback therapy are applied. Therapeutic strategies are based on the course of disease. It may be assumed that paralysis in moderate and moderate to severe courses of disease in acute lesions, moreover in chronic partial lesions and after gracilis muscle transplantation will benefit best from physical therapies. Course of disease depends on the degree of lesion, low-grade lesion will improve earlier and prognosis of motor recovery is good. To predict the course of disease in idiopathic facial paralysis nerve conduction studies can render valuable information by measuring the amplitude of the motor evoked potential in side to side comparison. In regard to scientific studies there is limited evidence that exercise therapy and biofeedback therapy improve the course of disease, motor performance recovers earlier and motor synkinesis are decreased. There is no evidence for electrotherapy to improve the course of disease nor to have any adverse effects. There is no relevant literature for massage and lymph-drainage in regard to facial paralysis. Every patient with facial paralysis--regardless to the degree of lesion--should receive a brochure with mimic exercises and instructions to support facial symmetry as basic intervention.

Burn treatment in the elderly

The population of elderly patients is expected to rise continuously over the next decades due to global demographic changes. The elderly seem to be most vulnerable to burns and their management remains undoubtedly a challenge. A clear age margin for elderly patients is not yet defined, but most studies adhere to the inclusion of patients 65 years and above, but the general condition and social situation must be taken into account. The understanding of the physiological basis of aging and its related pathophysiological changes has only marginally influenced treatment and decision making in elderly burn patients. When looking at treatment regimens currently applied in elderly burn patients, the discussion of standards in intensive care as well as surgical strategies is ongoing. However, trends towards a moderate, non-aggressive resuscitation approach and careful inclusion of key parameters like physiological age, pre-burn functional status and premorbid conditions, seem to be useful guidelines for interdisciplinary treatment decisions. Once ordered for surgical treatment, the amount of body surface area operated in one session should be adapted to the general status of the patient. Even if older burn victims have a reported higher mortality rate than younger patients, improved therapeutic options have contributed to a reduced mortality rate even in the elderly over the last decades. As a result of improved outcome, more attention has to be given to a comprehensive rehabilitation program. This review will give an overview of the current literature and will draw attention to specific topics related to this important subpopulation of burn patients.