Prognostic tools for hypertrophic scar formation based on fundamental differences in systemic immunity

Unpredictable hypertrophic scarring (HS) occurs after approximately 35% of all surgical procedures and causes significant physical and psychological complaints. Parallel to the need to understanding the mechanisms underlying HS formation, a prognostic tool is needed. The objective was to determine whether (systemic) immunological differences exist between patients who develop HS and those who develop normotrophic scars (NS) and to assess whether those differences can be used to identify patients prone to developing HS. A prospective cohort study with NS and HS groups in which (a) cytokine release by peripheral blood mononuclear cells (PBMC) and (b) the irritation threshold (IT) after an irritant (sodium lauryl sulphate) patch test was evaluated. Univariate regression analysis of PBMC cytokine secretion showed that low MCP‐1, IL‐8, IL‐18 and IL‐23 levels have a strong correlation with HS (P < .010‐0.004; AUC = 0.790‐0.883). Notably, combinations of two or three cytokines (TNF‐a, MCP‐1 and IL‐23; AUC: 0.942, Nagelkerke R²: 0.727) showed an improved AUC indicating a better correlation with HS than single cytokine analysis. These combination models produce good prognostic results over a broad probability range (sensitivity: 93.8%, specificity 86.7%, accuracy 90,25% between probability 0.3 and 0.7). Furthermore, the HS group had a lower IT than the NS group and an accuracy of 68%. In conclusion, very fundamental immunological differences exist between individuals who develop HS and those who do not, whereas the cytokine assay forms the basis of a predictive prognostic test for HS formation, the less invasive, easily performed irritant skin patch test is more accessible for daily practice.     

Long-term results in the treatment of menorrhagia and hypermenorrhea with a thermal balloon endometrial ablation technique.

BACKGROUND AND OBJECTIVES: Evaluation of long-term results using a thermal balloon endometrial ablation technique to treat menorrhagia and hypermenorrhea, considered dysfunctional uterine bleedings. METHODS: A single-arm, prospective study with long-term follow-up of 48 months at the department of obstetrics and gynecology, University of Kiel, Germany. Following hysteroscopic evaluation of the uterine cavity and fractionated curettage, the Cavaterm endometrial thermal ablation technique was performed on 70 patients over the age of 40 with menorrhagia and hypermenorrhea in whom medical treatment had previously failed. The study included a group of 10 patients with adenomyosis and uterine fibroids. RESULTS: In 65 patients, a complete 48-month follow-up evaluation was possible: 58% of patients reported amenorrhea and 33% hypomenorrhea. Nine percent of patients remained eumenorrheic. Fifty percent of the small group with failed indications for the procedure had to undergo a hysterectomy. CONCLUSIONS: The Cavaterm thermal coagulation system in the earlier mode of application (15 minutes at a temperature of 70 degrees C and a pressure of 200 mm Hg) is a safe and highly effective method of endometrial ablation resulting in a minimal amount of posttreatment menstrual bleeding.     

Role and value of laparoscopic training devices in assessing nondominant and two-handed dexterity

Background and objectives: To determine improvement in hand dexterity with targeted laparoscopic skill exercises desirable for use in the operating rooms among in-training laparoscopic gynaecological surgeons and medical students. Design: Cross-sectional study with paired analysis. Setting: Kiel School of Gynaecological Endoscopy and Reproductive Medicine, Germany, between February and April 2005. Subjects: Twenty third-year medical students and 20 in-training gynaecological endoscopic surgeons from various parts of the world. Interventions: Demonstration and explanation of a set of five laparoscopic skill exercises desirable for use in the operating rooms before administering a pretest. This was followed by voluntary practice of these exercises for at least 10 times over 1 day. The posttest was performed the next day once the participant was comfortable performing the skill. Pre- and posttest assessments were conducted by independent supervisors. Main outcome measures: Time to completion of tasks with minimal errors. Results: There was significant reduction in mean time for all the laparoscopic skill exercises performed with dominant, nondominant, and both hands, before and after the training and practice (p-value <0.01; paired t-test). Moderate to high correlation (0.617–0.901) was seen with the intermediate and complex/difficult tasks, whereas low correlation was seen with the simple/easy task (0.200–0.336). Medical students and gynaecologists both showed improvement in performance from pretest to posttest in terms of reduction in mean time taken to perform all the tasks with minimal errors. Conclusions: Simple laparoscopic training devices can substantially help an individual hand’s improvement and acquisition of laparoscopic skills. Simple laparoscopic training devices along with animal models will continue to provide an efficient and effective environment for learning and teaching laparoscopic surgical skills. With this training, performance improves progressively with practice.     

Realität der operativen endoskopischen Chirurgie in der gynäkologischen Chirurgie

Zusammenfassung Das Spektrum der gyn?kologisch-operativen Endoskopie hat sich seit den Tagen von RaoulPalmer in Frankreich 1964 mit den gut 25-j?hrigen Aktivit?ten von KurtSemm zum h?ufigsten gyn?kologischen Eingriff überhaupt entwickelt. Am gesamten Genitale, am Uterus, den Tuben und an den Ovarien lassen sich fast alle benignen Ver?nderungen endoskopisch diagnostizieren und therapieren. Selbst die endoskopischee supracervikale Hysterektomie stellt heutzutage keine schwierige Operation mehr dar. Die atypisch lokalisierte Schwangerschaft kann pelviskopisch diagnostiziert und therapiert werden. Bei malignen Ver?nderungen raten wir derzeit von einer endoskopischen Therapie ab, da das Metastasierungsrisiko noch nicht ausdiskutiert ist. Die pelvine Lymphonodektomie ist endoskopisch leicht m?glich und die Chirurgen und Urologen gehen uns dabei bereits endoskopisch voran. Die „Minimal Invasive Chirurgie“ per endoskopiam ist keine Schlüssel-Loch-Chirurgie mehr, sondern wird auf dem Videoschirm bereits allen im Operationssaal anwesenden ?rzten und Schwestern zur Kritik und Verbesserung zug?nglich gemacht. Ein echtes Teamwork von Operateur, Assistent, Kameramann und Schwester führt zu einer für die Patientin bei Einhalten der Sicherheitsschritte befriedigenden und sicheren Operation. Das gesamte Spektrum der Operationen in der Gyn?kologie hat sich auch per laparotomiam in den letzten Jahren der Organerhaltung zugewandt. Eine kombinierte medikament?s-operative Therapie erlaubt jetzt selbst die Uteruserhaltung bei Myomen, die knapp s?uglingskopfgro? werden k?nnen. Grenzen zur endoskopischen Chirurgie setzt heute immer noch das Instrumentarium, obwohl dieses der modernen Zeit zunehmend angepa?ter von vielen Firmen weiter entwickelt wird. Beispiele dafür bietet der Serrated Edged Macro-Morcellator S.E.M.M. zur Entfernung von bis zu faustgro?en Myonen und verbesserte Nahttechniken. End-Zu-End-Anastomosen an den Tuben, die noch vor einigen Jahren Dom?nen der Mikrochirurgie waren, sind mit der gleichen Erfolgsrate pelviskopisch durchführbar. Ovarialtumoren werden unter zu Hilfenahme verschiedener Technologien (Laser, Koagulation etc.) aus ihrem Bett ausgesch?lt und aus der K?rperh?hle extrahiert. Die Ovarialnaht wird durch eine Endonaht oder durch Fibrinkleber adaptiert.     

Role of laparoscopy in identifying the clinical significance and cause of adhesions and chronic pelvic pain: a retrospective review at the Kiel School of Gynecological Endoscopy.

OBJECTIVES: We sought to define the role of laparoscopy in identifying the clinical significance, cause, and association between adhesions and chronic pelvic pain. METHODS: A retrospective chart review was conducted from October 2004 to July 2005, at the Kiel School of Gynecological Endoscopy, University Hospitals Schleswig-Holstein, Campus Kiel, Germany. Included in the study was the analysis of 462 laparoscopic procedures; 275 (59.5%) of the patients undergoing these procedures had pelvic or abdominal adhesions. Of these, 84 (30.5%) patients were admitted with the main complaint of chronic pelvic pain. Further evaluation and assessment of this group was carried out. RESULTS: Among those patients with adhesions, the second most frequent reason for admission was chronic pelvic pain (30.5%) (P<0.0005). In our study, adhesions were found in 79.2% (n=84) of patients (n=106) with chronic pelvic pain. These adhesions were thin-filmy (19.0%) or thick-fibrous (81.0%) adhesions containing blood vessels. Thick-fibrous adhesions were present in 50.0% of patients at multiple abdominopelvic sites (P<0.005). CONCLUSIONS: Thick-fibrous adhesions that extend beyond the pelvic sidewall can cause significant chronic abdominopelvic pain.     

Evaluation of filling materials in membrane‐protected bone defects. A comparative histomorphometric study in the mandible of miniature pigs.

In recent years, bone grafts and bone substitutes have been increasingly utilized underneath barrier membranes to optimize the treatment outcome of bone reconstructive therapy for defects in the alveolar process. In the present study, 4 different filling materials were evaluated in bone defects of similar dimensions in the mandible of miniature pigs. Blood clots and autografts were used as controls. The defects were covered with barrier membranes and allowed to heal for 4, 12 or 24 weeks. Histologic examination demonstrated that bone repair progressed through a programmed sequence of maturation steps closely resembling the pattern of bone development and growth regardless of whether bone grafts or substitutes were present or not. Histomorphometric analysis showed that autologous bone grafts (autografts) had the best osteoconductive properties during the initial healing period, with 39% of newly formed bone inside the membrane-covered defects at 4 weeks of healing. In addition, 87% of the graft surfaces were already covered by bone at this time. Both values were significantly higher for autografts than for the 4 alternative bone fillers (P < or = 0.05). At 12 weeks, these differences were no longer apparent, with all 5 filling materials showing similar values. Among the tested bone substitutes, tricalcium phosphate (TCP) showed a significantly higher percentage of bone fill at 24 weeks of healing. It can be concluded that sites filled with autografts clearly demonstrated the best results underneath barrier membranes in the early phase of healing. As far as degradation and substitution are concerned, TCP showed the most promising results. This filler, however, needs to be tested further in a more demanding animal model. Less favorable results were obtained for coral-derived hydroxyapatite granules and for demineralized freeze-dried bone allografts.     

Bufadienolides from Urginea hesperia

For the first time the composition of the bufadienolide complex in URGINEA HESPERIA Webb & Berth. has been investigated. From an extract of lyophilized plants, thirteen bufadienolides were isolated. By means of FAB-MS, (1)H-NMR, and (13)C-NMR studies the compounds were structurally elucidated as scillarenin, scilliphaeosidin, scillarenin-3- O-alpha- L-rhamnoside, scilliphaeosidin-3- O-alpha- L-rhamnoside, gamabufotalin-3- O-alpha- L-rhamnoside, 11alpha-hydroxyscilliglaucosidin-3- O-alpha- L-rhamnoside, scillarenin-3- O-alpha- L-2',3'-diacetylrhamnosido-4'-beta- D-glucoside, scillarenin-3- O-alpha- L-rhamnosido-4'-beta- D-glucosido-3'-beta- D-glucoside, scillarenin-3- O-alpha- L-rhamnosido-4'-beta- D-glucosido-4'-beta- D-glucoside, scillarenin-3- O-alpha- L-2',3'-diacetylrhamnosido-4'-beta- D-glucosido-3'-beta- D-glucoside, scillarenin-3- O-alpha- L-2',3'-diacetylrhamnosido-4'-beta- D-glucosido-4'-beta- D-glucoside, scilliphaeosidin-3- O-alpha- L-rhamnosido-4'-beta- D-glucosido-3'-beta- D-glucoside, and scilliphaeosidin-3- O-alpha- L-rhamnosido-4'-beta- D-glucosido-4'-beta- D-glucoside.     

ACTH increases noradrenaline release in the rabbit heart

Summary The effects of ACTH on the release of noradrenaline and the increase of heart rate produced by sympathetic nerve stimulation (1 Hz) were studied in isolated perfused rabbit hearts. ACTH-(1–24) 0.1–100 nmol/l increased the stimulation-evoked overflow of noradrenaline concentration-dependently, reversibly and up to two-fold. The basal outflow of noradrenaline, the basal heart rate and the stimulation-evoked increase in heart rate were not changed. Human ACTH-(1–39) also increased the evoked overflow of noradrenaline. The effect of ACTH-(1–24) 0.3 nmol/l persisted after blockade of -adrenoceptors with propranolol and blockade of neuronal catecholamine uptake by cocaine. ACTH-(1–24) 3 nmol/l did not change the removal of noradrenaline from the perfusion fluid, when hearts were perfused with medium containing 59 nmol/l noradrenaline. The results show that ACTH increases the action potential-evoked release of noradrenaline from cardiac postganglionic sympathetic neurones, probably by activating specific presynaptic ACTH receptors. The high potency of ACTH suggests that these presynaptic receptors may be activated in vivo by circulating ACTH under certain pathophysiological conditions.Send offprint requests to B. Szabo at the above address