The prevention of incisional hernia formation using a delayed-release polymer of basic fibroblast growth factor

OBJECTIVE: We sought to reduce the high incidence of abdominal wall incisional hernias using sustained release growth factor therapy. SUMMARY BACKGROUND DATA: Incisional hernias complicate 11% of abdominal wall closures, resulting in 200,000 incisional hernia repairs in the United States each year. Mechanical improvements alone in mesh, suture material, and surgical technique have failed to reduce the high rate of fascial wound failure. METHODS: Sprague-Dawley rats underwent midline celiotomies that were closed with fast-absorbing suture to induce early biomechanical wound failure and incisional hernia formation. In primary wounds, fascial incisions were closed adjacent to a continuous release polygalactone polymer rod containing basic fibroblast growth factor (bFGF), no growth factor (control-rod), or without rods. In a second group, incisional hernias were repaired with either bFGF or control-rod therapy. Breaking strength was measured on postoperative day (POD) 7, and the incidence of incisional hernia formation was determined on POD 28. RESULTS: Treatment with bFGF rods significantly increased fascial wound breaking strength. In the "hernia-prevention" experiments, incisional hernias developed in 90% of untreated incisions, 60% of control-rod incisions, and only 30% of bFGF-rod incisions (P < 0.05). In the "hernia-treatment" experiments, recurrent incisional hernias developed in 86% of control-rod incisions compared with only 23% of bFGF-rod treated incisions (P < 0.05). Immunohistochemistry demonstrated increased angiogenesis and collagen protein production in bFGF treated incisions. CONCLUSION: The treatment of abdominal fascial incisions with a sustained-release bFGF polymer significantly lowered the incidence of incisional hernias and the recurrence rate after repair.     

Management of Anemia in Children Receiving Chronic Peritoneal Dialysis

Little information exists regarding the efficacy, modifiers, and outcomes of anemia management in children with CKD or ESRD. We assessed practices, effectors, and outcomes of anemia management in 1394 pediatric patients undergoing peritoneal dialysis (PD) who were prospectively followed in 30 countries. We noted that 25% of patients had hemoglobin levels below target (<10 g/dl or <9.5 g/dl in children older or younger than 2 years, respectively), with significant regional variation; levels were highest in North America and Europe and lowest in Asia and Turkey. Low hemoglobin levels were associated with low urine output, low serum albumin, high parathyroid hormone, high ferritin, and the use of bioincompatible PD fluid. Erythropoiesis-stimulating agents (ESAs) were prescribed to 92% of patients, and neither the type of ESA nor the dosing interval appeared to affect efficacy. The weekly ESA dose inversely correlated with age when scaled to weight but did not correlate with age when normalized to body surface area. ESA sensitivity was positively associated with residual diuresis and serum albumin and inversely associated with serum parathyroid hormone and ferritin. The prevalence of hypertension and left ventricular hypertrophy increased with the degree of anemia. Patient survival was positively associated with achieved hemoglobin and serum albumin and was inversely associated with ESA dose. In conclusion, control of anemia in children receiving long-term PD varies by region. ESA requirements are independent of age when dose is scaled to body surface area, and ESA resistance is associated with inflammation, fluid retention, and hyperparathyroidism. Anemia and high ESA dose requirements independently predict mortality.Almost three decades after the advent of recombinant erythropoietin, the management of renal anemia has become a recent focus of attention and changing paradigms. Whereas correction of hemoglobin (Hb) levels to near-normal has previously been recommended on the basis of association studies linking more severe anemia to morbidity and mortality with dialysis,^1–3 interventional clinical trials consistently demonstrate that near-normalization of Hb increases the risk of vascular events and mortality in adults receiving maintenance hemodialysis and in those with CKD who are not undergoing dialysis.^4–6 This has prompted ongoing reevaluation and revisions of treatment targets in patients exposed to erythropoiesis-stimulating agents (ESAs).⁷The appropriateness of applying treatment recommendations established in adult hemodialysis populations at high cardiovascular risk and adults with CKD to children undergoing dialysis is questionable because cardiovascular events are far less common in children with CKD. Furthermore, two thirds of children requiring dialysis initially opt for peritoneal dialysis (PD), and there are no systematic studies in the adult PD population to inform the optimal Hb target range in these patients. The risk profile of patients receiving PD may differ from that of the hemodialysis setting because of the absence of dialysis-induced intermittent hemoconcentration and lack of contact activation of the complement and coagulation systems.Further aspects to consider in pediatric anemia management are the greater physical activity of children and the need for optimal cognitive functioning at school.^8,9 The significant physiologic variation of the normal Hb range with age¹⁰ and the relative ESA sensitivity that reportedly increases with age during early childhood are also noteworthy.¹¹The registry of the International Pediatric Peritoneal Dialysis Network (IPPN) prospectively collects detailed clinical, biochemical, dialysis, and medication-related information (including ESA types and doses and modalities of iron supplementation) from a substantial number of children undergoing long-term PD around the world. In-depth analysis of this unique database has allowed us to (1) gain insight into the demographic characteristics of renal anemia and its treatment in the pediatric PD population worldwide, (2) explore the relationship between ESA dose requirements and body dimensions, (3) identify factors contributing to ESA resistance in children, and (4) associate anemia control with patient outcomes.     

Psychosocial rehabilitation and satisfaction with life in adults with childhood-onset of end-stage renal disease

Little information is available on vocational rehabilitation and satisfaction with the quality of life in adult patients with early onset of end-stage renal disease (ESRD). A sample of 39 patients (mean age =26.7±6, range, 18 to 43 years, n =13 on dialysis, n =26 transplanted successfully) were required to report data on their vocational qualification and employment, and their degree of general and health-related satisfaction with life was surveyed. Data on psychosocial rehabilitation were collected by a structured questionnaire, whereas satisfaction with the quality of life was assessed with the standardized Questionnaire on Satisfaction in Life (FLZ). Fifty-eight percent of the patients had left school with certificates equivalent to high school graduation, 87% had completed vocational training and 67% were in paid employment. Forty-nine percent lived on their own or with a partner and 72% fully or partly earned their own living. The mean general and health-related satisfaction with life is significantly reduced compared to the general population. The patients were least satisfied in the areas partnership/sexuality and family life/offspring in general, as well as physical condition and ability to relax within health-orientated satisfaction. Final mean body height was 167.6±11.9 (SDS –1.54±1.59) for male and 153.77±8.29 for female patients (SDS –1.58±1.54). Thirty-six percent reported to be dissatisfied with their present body height compared to 4% of age-matched healthy controls. Positive perception of quality of life was significantly correlated to satisfaction with adult height ( r =0.41, P =0.008). Vocational rehabilitation of adult patients with early onset of ESRD achieves lower values than among the general population, however, more favorable percentages than among young adult patients or patients with adult onset of ESRD. The patients self-evaluation of both their general and health-related quality of life proves to be clearly muted, which is a clear indication of the physical and psychological strain of living with a chronic disease.     

Distribution of substance-P nerves inside the infrapatellar fat pad and the adjacent synovial tissue: a neurohistological approach to anterior knee pain syndrome

Introduction The purpose of the study was to determine the distribution and number of nerves inside the infrapatellar fat pad and the adjacent synovium, in particular with regards to nociceptive substance-P nerves.Materials and methods The infrapatellar fat pad of the knee was resected from 21 patients (4 male, 17 female, mean age 69 years) during the course of standard total knee arthroplasty operations performed in our clinic. The fat pad was dissected into five standardized segments, fixed in formalin and embedded in paraffin. Immunohistochemical techniques using antibodies against S-100 protein and substance-P (SP) were employed to determine and specify the nerves.Results Studying all the detectable nerves present in 50 observation fields (200-fold magnification), we found an average of 106 S-100 versus 25 SP nerves (24%) in the synovium and 27 S-100- versus 7 SP nerves (26%) in the interior of the fat pad. The total nerve count was significantly ( P <0.001) higher in the synovium than in the fat pad for both marker types. The number of S-100 nerves was significantly ( P <0.05) higher in the central and lateral segments of the fat pad, while SP nerves were equally distributed throughout all segments of the fat-pad. SP nerves were significantly more frequently associated with blood vessels inside the fat pad (43%, P <0.05) than in the synovial tissue (28%).Conclusion The occurrence and distribution of SP nerves inside the infrapatellar fat pad suggest a nociceptive function and a neurohistological role in anterior knee pain syndrome. The data support the hypothesis that a neurogenous infection of the infrapatellar fat pad could contribute to anterior knee pain syndrome.     

Musculoskeletal extremity injuries in a cohort of schoolchildren aged 6–12: A 2.5‐year prospective study

The objectives of this prospective school cohort study were to describe the epidemiology of diagnosed musculoskeletal extremity injuries and to estimate the injury incidence rates in relation to different settings, different body regions and injury types. In all, 1259 schoolchildren, aged 6–12, were surveyed weekly during 2.5 years using a new method of automated mobile phone text messaging asking questions on the presence of any musculoskeletal problems. All injuries were clinically diagnosed. Physical activity was measured from text messaging and accelerometers. A total number of 1229 injuries were diagnosed; 180 injuries in the upper extremity and 1049 in the lower extremity, with an overall rate of 1.59 injuries per 1000 physical activity units [95% confidence interval (CI) 1.50–1.68]. Upper extremities accounted for a rate of 0.23 (95% CI 0.20–0.27) and lower extremities accounted for 1.36 (95% CI 1.27–1.44). This study has added a wide overall perspective to the area concerning incidence and incidence rates of musculoskeletal extremity injuries in schoolchildren aged 6–12 years, including severe and less severe, traumatic, and overuse injuries. The understanding of injury epidemiology in children is fundamental to the acknowledgement and insurance of the appropriate prevention and treatment.     

Hepatic Resection in the Elderly

p = 0.02) and for primary neoplasia of the liver ( p = 0.002) but not for metastatic disease to the liver. This reflects the high rate of cirrhosis in hepatocellular and cholangiocellular carcinoma (88%) and gallbladder cancer (37.5%). Both pre- and postoperative severe liver dysfunction had a significantly higher risk for postoperative mortality and morbidity, which showed an incremental risk with age. Another organ system able to predict outcome at the beginning of treatment by its moderate severe dysfunction were the lungs. Overall, only right and extended right lobectomies carried a significantly higher risk for postoperative mortality and morbidity. Postoperative complications were recorded in 43% of our patients, with infection the most frequent problem in nearly all of these patients (95%). Pneumonia was the leading complication associated patient survival. All patients who developed pneumonia as a late complication during a complicated postoperative course died postoperatively. The postoperative Goris score of the patients who died was 6.9 ± 2.9 (range 3–11), whereas the surviving patients’ score averaged 2.2 ± 1.9 (range 0–9), which was significantly different ( p = 0.0003). None of the 54 patients with a GORIS score ≤ 2 died postoperatively, whereas 5 of 6 patients with a score ≥ 9 died ( p = 0.0001). Severe liver dysfunction rather than the extent of resection influences clinical mortality. Patients > 80 years of age with a preoperative severe liver dysfunction showed a postoperative mortality of 57%, and all of these patients developed postoperative complications. Therefore resection cannot be recommended for those patients. Cirrhosis led to an unacceptable mortality of 44% after hepatic resection of ≥ 5 liver segments for primary neoplasia of the liver. Major resections cannot be recommended in the aged with gallbladder cancer because 50% of the patients died after such operations. Overall, only resection of ≥ 5 liver segments with segments I to III or less remaining were found to pose a major risk for clinical mortality and morbidity, but the cause of death was preexisting liver dysfunction and cirrhosis in all of these patients. Major resections of large neoplasia of the liver can be recommended even in the aged, but a preoperative preselection of patients with respect to liver function and pulmonary function preoperatively may help lower the postoperative morbidity and mortality, especially in patients who will undergo resection of ≥ 5 liver segments. Major hepatic resection for metastatic disease to the liver in the elderly carries no additional survival risk. Patients > 65 years of age and especially those > 80 years of age are more liable to succumb to postoperative organ failure and complications, especially infections.     

Risk factors for secondary dilatation of the aorta after acute type A aortic dissection.

OBJECTIVES: Prompt diagnosis of subsequent dilatation of the dissected aorta is crucial to reduce late mortality in these patients. This study focuses on risk factors for dilatation of the aorta after type A aortic dissection (AADA) affecting a normal-sized or slightly dilated aorta. METHODS: Overall 531 CT scans were analysed. Patients were included in the study if at least 3 CT scans were available after operative repair. 64 patients (59.8%) out of 107 patients full-field the inclusion criteria. Volumetric analyses of the aorta were performed. Patients were divided in 3 groups: group A included 26 patients (40.6%) without progression of the aortic diameter, group 2, 27 patients (42.2%) with slight progression and group 3, 11 patients (17.2%) with important progression, requiring surgery in 9 patients (81.8%). Risk-factors for progression of the aortic size were analysed and compared between the groups. RESULTS: Patients from group 3 were younger 57.7+/-13.4 vs. 61.9+/-11.6 in group 1 (P<0.05) and were more frequent female (45.4 vs. 23.1%; P<0.05). Dissection of the supraaortic branches (100 vs. 80.8%; P<0.05), the presence of preoperative cerebral, visceral or peripheral malperfusion (54.6 vs. 26.9%; P<0.05) and contrast enhancement in the false lumen during the follow-up (72.7 vs. 57.7%; P=0.07) were additional risk factors for late aortic dilatation in these patients. CONCLUSIONS: Acute type A aortic dissection in younger patients, involving the supraaortic branches and/or combined with malperfusion syndrome favour secondary dilatation. A close follow-up is mandatory to prevent acute complications of the diseased downstream aorta following repair of a AADA.     

Medizinische Beurteilungskriterien zu bandscheibenbedingten Berufskrankheiten der Lendenwirbelsäule (I)

Occupational diseases Nos. 2108 and 2110 correspond to intervertebral disc-related diseases of the lumbar spine from many years of carrying or lifting heavy loads, occupations in extreme postures of full flexion or oscillation of the whole body when seated, and which compel the cessation of all activities which are or could be the cause for the origin, exacerbation or recurrence of the disease. These occupational diseases came into force at the start of 1993, but there have been considerable problems in their implementation. The present Part I of the contribution is the result of the work of an interdisciplinary study group and contains medical criteria for the assessment of possibly strain-related clinical characteristics and the evaluation of other possible causes. Part II is to be published in Volume 4/2005 and will deal with questions related to forced cessation and to the assessment of the loss of earning ability. Agreement was reached in many areas related to the assessment of occupational claims. This should allow for evidence-based decision making in the future for the occupational diseases Nos. 2108 and 2110.     

Medizinische Beurteilungskriterien zu bandscheibenbedingten Berufskrankheiten der Lendenwirbelsäule (II)

The first part of this serial paper dealt with the medical criteria used in evaluation of the clinical picture caused by physical stress and the evaluation of other candidate causes and was published in issue no. 3/2005 (pp. 711–752) of Trauma and Berufskrankheit. This follow-up paper (II) presents criteria to be used in the evaluation of whether it is necessary to give up the occupations putting the spine at risk and in estimation of the degree of disability.