[Burden of Parents of Pediatric Cancer Patients in Pediatric-oncological Rehabilitation]. / Belastungen bei Eltern krebskranker Kinder in der familienorientierten Rehabilitation.

Burden of Parents of Pediatric Cancer Patients in Pediatric-oncological Rehabilitation All family members experience high burden in case of paediatric cancer. Family-oriented rehabilitation (FOR) aims to improve the physical and mental situation of the families. We investigated anxiety and depression (HADS) and cancer-related burden of parents (n = 69) before and after FOR and analysed its association with quality of life of the ill children. At beginning of FOR 70 % of the parents showed moderate to high anxiety scores and 47 % moderate to high depression scores. They reported cancer-related burden such as exhaustion, cancer-related fears and a burden of family's daily life due to the cancer disease. At the end of FOR 40 % of the parents showed moderate to high anxiety scores and 30 % moderate to high depression. Cancer-related burden measured with self-developed items also decreased after FOR. Compared to age- and gender-adapted norm values, mothers show significantly higher anxiety and depression scores, whereas fathers show no differences in depression scores compared to norm values at the end of FOR. Quality of life of ill children and anxiety and depression scores in the parents are significantly associated with each other. Results of the study show that parents stabilise after FOR and improve their mental situation. However, the results also underline the need for long-term psychosocial support for all family members.

[Burden and Rehabilitation Goals of Families in Pediatric-oncological Rehabilitation]. / Belastungen und Reha-Ziele von Familien in der pädiatrisch-onkologischen Rehabilitation.

Burden and Rehabilitation Goals of Families in Pediatric-oncological Rehabilitation Survival rates of childhood cancer patients increased during the past years up to 80 %. Therefore, pediatric oncological rehabilitation is essential for reintegrating children with cancer into normal life. We performed an analysis of the current state in pediatric oncological rehabilitation with regards to the impairments of the participants and results in rehabilitation. Descriptive and content analyses of 422 medical discharge summaries were conducted. 55 % of the pediatric patients are male; the average age is 8.7 years. Children attending rehabilitation program are affected by various functional and psychosocial impairments. We identified global rehabilitation-goals such as integration in peer group and specific goals such as pain relief. According to rehabilitation physicians' opinion most patients achieve their rehabilitation-goals. Accompanying family members report a range of psychosocial burden and diverse concerns for rehabilitation. Medical discharge summaries display the complexity of family-oriented rehabilitation. We conclude that rehabilitation treatment needs to be tailored according to individual burdens and the whole family.

Evidence-Based Hernia Treatment in Adults.

BACKGROUND: Inguinal hernia repair is the most common general surgical procedure in industrialized countries, with a frequency of about 200 operations per 100 000 persons per year. Suture- and mesh-based techniques can be used, and the procedure can be either open or minimally invasive. METHODS: This review is based on a selective search of the literature, with interpretation of the published findings according to the principles of evidence-based medicine. RESULTS: Inguinal hernia is diagnosed by physical examination. Surgery is not necessarily indicated for a primary, asymptomatic inguinal hernia in a male patient, but all inguinal hernias in women should be operated on. For hernias in women, and for all bilateral hernias, a laparoscopic or endoscopic procedure is preferable to an open procedure. Primary unilateral hernias in men can be treated either by open surgery or by laparoscopy/endoscopy. Patients treated by laparoscopy/endoscopy develop chronic pain less often than those treated by open surgery. A mesh-based repair is generally recommended; this seems reasonable in view of the pathogenesis of the condition, which involves an abnormality of the extracellular matrix. CONCLUSION: The choice of procedure has been addressed by international guidelines based on high-level evidence. Surgeons should deviate from their recommendations only in exceptional cases and for special reasons. Guideline conformity implies that hernia surgeons must master both open and endoscopic/laparoscopic techniques.

What is a Certified Hernia Center? The Example of the German Hernia Society and German Society of General and Visceral Surgery.

To date, the scientific definition "hernia center" does not exist and this term is being used by hospitals and private institutions as a marketing instrument. Hernia surgery has become increasingly more complex over the past 25 years. Differentiated use of the various techniques in hernia surgery has been adopted as a "tailored approach" program and requires intensive engagement with, and extensive experience of, the entire field of hernia surgery. Therefore, there is a need for hernia centers. A basic requirement for a credible certification process for hernia centers involves definition of requirements and its verification by hernia societies and/or non-profit organizations that are interested in assuring the best possible quality of hernia surgery. At present, there are two processes for certification of hernia centers by hernia societies or non-profit organizations.

Peritoneal resorption capacity for the inflammatory mediators in acute experimental Staphylococcus aureus peritonitis.

BACKGROUND: Elevations in both endotoxin and interleukin-6 (IL-6) concentrations in peritoneal exudates are a thousand times higher than their respective concentrations in the peripheral blood in patients with gram-positive or gram-negative peritonitis. We aimed in this study to evaluate the resorption capacity of the peritoneum for endotoxin and IL-6 in a model of bacterial (gram-positive) peritonitis. METHODS: Intraperitoneal (i.p.) injection of mucin-pretreated staphylococci in phosphate buffered saline (PBS) or of PBS alone was performed in 93 male Wistar rats. Studies of resorption were undertaken at time points of 4 hours (h), 8h, 12h and 24h. Endotoxin was intraperitoneally injected in 44 rats and IL-6 in 49 rats. After 0, 5, 10, 15, 30 and 60 minutes (min), blood was sampled. Endotoxin and IL-6 were measured using the limulus-amoebocyte-lysate (LAL) test and ELISA technique, respectively. RESULTS: No endotoxin or IL-6 was measured in the blood of controls. Plasma endotoxin and IL-6 levels were significantly high in the peritonitis groups. There was no further increase in endotoxin plasma levels after i.p. injection of endotoxin. Following i.p. injection of IL-6, there was an increase in IL-6 level over the time of sampling in the peripheral blood at 4h of peritonitis. CONCLUSION: There was a clear reduction in peritoneal resorption of endotoxin and IL-6 in this acute model of gram-positive peritonitis.

[Course of psychosocial distress and health-related quality of life in patients at different age groups during cancer rehabilitation]. / Verlauf der psychosozialen Belastung und gesundheitsbezogenen Lebensqualitat bei Patienten verschiedener Altersgruppen in der onkologischen Rehabilitation.

OBJECTIVES: This study investigates psychosocial distress and health-related quality of life in younger (up to 40 years), middle-aged (up to 50 years), and elderly cancer patients (up to 60 years). METHODS: 637 patients (94%women, 75% breast-cancer patients) completed validated questionnaires measuring distress, anxiety, depression, fear of progression, and quality of life at the beginning (T0) and the end (T1) of a cancer rehabilitation program (T0/T1 response rate: 72 %) as well as at 1-year follow-up (T2) (n = 485, T2 response rate: 76 %). RESULTS: Patients in the different age groups did not differ significantly in psychosocial distress at T0 except for fear of progression, which is lower among the younger age group. Elderly patients have a significantly lower physical quality of life. At the beginning of the rehabilitation program, patients in all age groups were significantly more anxious compared to population-based normative values, whereas higher depression was found only in younger and middle-aged patients. Patients in all age groups have a significantly lower quality of life compared to population-based normative values. In particular, large effect sizes were found for physical functioning domains. Patients in all age groups improve significantly in psychosocial distress and quality of life over time; however, significant interaction effects between age group and time were not observed in psychosocial distress and quality of life. CONCLUSIONS: Age differences are predominantly observed in physical quality-of-life dimensions rather than in psychosocial distress. This finding should be considered for the development of rehabilitation services.

Endotoxemia and endotoxin tolerance in patients with ARDS.

BACKGROUND: The significance of endotoxemia in man is controversial, induces cytokine release and stimulates the immune system. Exaggerated cytokine release of mononuclear cells was observed in acute lung injury/acute respiratory distress syndrome (ALI/ARDS). However, repetitive administration of endotoxin can cause tolerance. OBJECTIVE: To investigate endotoxemia, plasma TNFalpha, IL-1beta, IL-6, the liberation capacity of those cytokines from mononuclear cells after LPS challenge (Delta values), and plasma antibodies to endotoxins and alpha-hemolysin of Staphylococcus aureus in ALI/ARDS. DESIGN: A prospective clinical study was conducted. SETTING: The study was carried out at the University Hospital Ulm, Ulm, Germany. SUBJECTS: The respondents were 23 patients with ALI/ARDS. INTERVENTIONS: ALI/ARDS was defined according to the American-European Consensus Conference on ARDS. Blood was collected periodically. Parameters were measured by LAL or ELISA. RESULTS: ARDS (P(a)O(2)/F(i)O(2) < 200) revealed higher endotoxemia (0.22-0.46 [0.06-1.15] EU/mL vs 0.05-0.14 [0.02-0.63] EU/mL) than ALI (P(a)O(2)/F(i)O(2) > 200) but lower DeltaIL-6 (124-209 [10-1214] pg/mL vs 298-746 [5-1797] pg/mL), DeltaTNFalpha (50-100 [6-660] pg/mL vs 143-243 [12-2795] pg/mL), and DeltaIL-1 (2-3 [0-26] pg/mL vs 2-14 [0-99] pg/mL). Endotoxemia correlated negative with P(a)O(2)/F(i)O(2) (r, -0.44 to -0.50). All patients presented antibodies to lipopolysaccharides and alpha-hemolysin, but the level did not correlate with P(a)O(2)/F(i)O(2). CONCLUSIONS: ALI/ARDS is associated with endotoxemia. The more severe the disease, the more intense is endotoxemia but the lower is the capacity of mononuclear cells to release cytokines (tolerance). Antibodies against Gram-positive and Gram-negative bacteria are detectable in the plasma but without relation to P(a)O(2)/F(i)O(2).

Laparoscopic repair of parastomal hernias: a single surgeon's experience in 66 patients.

INTRODUCTION: The repair of parastomal hernias represents a surgical problem with high complication and failure rates. A basic principle is the necessity of mesh-based techniques. The study was performed to evaluate a laparoscopic approach, primarily based on the intraperitoneal on lay mesh technique. METHODS: Sixty-six patients with a symptomatic parastomal hernia were enrolled in the prospective study between November 1999 and February 2006. After complete adhesiolysis, the mesh was introduced to cover the fascial defect of the hernia and the original midline incision. In special cases, a two-mesh technique was used. First, an incised mesh was placed around the stoma sling. The second mesh was used to cover the abdominal wall with the first mesh; the stoma sling was placed between the two meshes for at least 5 cm. RESULTS: The two-mesh technique proved to be superior in terms of recurrence rate especially in cases with a lateral fascial defect. CONCLUSIONS: The laparoscopic repair of parastomal hernias is a surgically challenging procedure with promising results when using the two-mesh technique. Therefore, two meshes should be used in all cases of parastomal hernias. Polyvinylidene fluoride was revealed to be the most suitable material for the sandwich repair in terms of possible ingrowth and infection resistance.

Preoperative immunonutrition suppresses perioperative inflammatory response in patients with major abdominal surgery-a randomized controlled pilot study.

BACKGROUND/AIM: Perioperative administration of immunoenriched diets attenuates the perioperative inflammatory response and reduces postoperative infection complications. However, many questions still remain unresolved in this area, such as the length of diet administration, diet composition, and the mechanisms involved. We performed an open, randomized, triple-arm study comparing the effect of two perioperative feeding regimens with a postoperative one. METHODS: 46 candidates for major elective surgery for malignancy in the upper gastrointestinal tract were randomized to drink preoperatively either 1 L of an immunoenriched formula (Impact) for 5 days (IEF group) or 1 L of Impact plus (Impact enriched with glycine) for 2 days (IEF plus group). The same product as the patient received preoperatively was given to both groups for 7 days postoperatively. In the control group (CON group), patients only received Impact for 7 days postoperatively; there was no preoperative treatment. The main outcome measures were postoperative C-reactive protein (CRP) serum levels. RESULTS: In the two preoperatively supplemented groups (treatment groups), perioperative endotoxin levels, CRP (postoperative day 7), and TNF-alpha (postoperative days 1 and 3) levels were significantly lower compared to the CON group (p < .01). Furthermore, the length of postoperative IMU/ICU stay (Impact 1.9 +/- 1.3 days; Impact plus 2.2 +/- 1.1 days; control group 5.9 +/- 0.8 days) and length of hospital stay (Impact 19.7 +/- 2.3 days; Impact plus 20.1 +/- 1.3 days; control group 29.1 +/- 3.6 days) were both reduced in the treatment groups compared to the control group. Infectious complications (Impact 2/14 (14%); Impact plus 5/17 (29%); control group 10/15 (67%)) also showed a trend toward reduction in the treatment groups. CONCLUSIONS: Perioperative administration of an immunoenriched diet significantly reduces systemic perioperative inflammation and postoperative complications in patients undergoing major abdominal cancer surgery, when compared with postoperative diet administration alone. A shortened preoperative feeding regimen of 2 days with Impact enriched with glycine (Impact plus) was as effective as Impact administered for 5 days preoperatively.

Minimal adhesions to ePTFE mesh after laparoscopic ventral incisional hernia repair: reoperative findings in 65 cases.

OBJECTIVES: Laparoscopic ventral incisional hernia repair involves intraabdominal placement of a synthetic mesh, and the possibility of formation of severe visceral adhesions to the prosthesis is a principal concern. Little clinical information based on reoperative findings is available about adhesions to biomaterials placed intraabdominally. We conducted a multiinstitutional study of adhesions to implanted expanded polytetrafluoroethylene (ePTFE) mesh at reoperation in patients who had previously undergone laparoscopic incisional hernia repair done with the same mesh implantation technique. METHODS: Nine surgeons retrospectively assessed the severity of adhesions to ePTFE mesh at reoperation in 65 patients. For each case, adhesions were assigned a score of 0 to 3, with 0 indicating no adhesions and 3 severe adhesions. RESULTS: The mean time from mesh implantation to reoperation was 420 days (range, 2 to 1739 days). No adhesions were observed in 15 cases. Forty-four cases received an adhesion score of 1, and 6 cases a score of 2; no scores of 3 were assigned. Thus, 59 patients (91%) had either no or filmy, avascular adhesions. No enterotomies occurred during adhesiolysis. CONCLUSIONS: In this large series of reoperations after laparoscopic incisional hernia repair, no or minimal formation of adhesions to implanted ePTFE mesh was observed in 91% of cases, and no severe cohesive adhesions were found. Comparative analyses of newer materials based on clinical reoperative findings are warranted to assess the safety of intraabdominally placed meshes.

Photosynthetic performance of an Arabidopsis mutant with elevated stomatal density (sdd1-1) under different light regimes.

In the Arabidopsis mutant sdd1-1, a point mutation in a single gene (SDD1) causes specific alterations in stomatal density and distribution. In comparison to the wild type (C24), abaxial surfaces of sdd1-1 rosette leaves have about 2.5-fold higher stomatal densities. This mutant was used to study the consequence of stomatal density on photosynthesis under various light regimes. The increased stomatal density in the mutant had no significant influence on the leaf CO(2) assimilation rate (A) under constant light conditions. Mutant and wild-type plants contained similar amounts of carbohydrates under these conditions. However, exposure of plants to increasing photon flux densities resulted in differences in gas exchange and the carbohydrate metabolism of the wild type and mutant. Increased stomatal densities in sdd1-1 enabled low-light-adapted plants to have 30% higher CO(2) assimilation rates compared to the wild type when exposed to high light intensities. After 2 d under high light conditions leaves of sdd1-1 accumulated 30% higher levels of starch and hexoses than wild-type plants.

Small intestinal bacterial overgrowth in human cirrhosis is associated with systemic endotoxemia.

OBJECTIVES: Systemic endotoxemia has been implicated in various pathophysiological sequelae of chronic liver disease. One of its potential causes is increased intestinal absorption of endotoxin. We therefore examined the association of small intestinal bacterial overgrowth with systemic endotoxemia in patients with cirrhosis. METHODS: Fifty-three consecutive patients with cirrhosis (Child-Pugh group A, 23; group B, 18; group C, 12) were included. Jejunal secretions were cultivated quantitatively and systemic endotoxemia determined by the chromogenic Limulus amoebocyte assay. Patients were followed up for 1 yr. RESULTS: Small intestinal bacterial overgrowth, defined as > or = 10(5) total colony forming units per milliliter of jejunal secretions, was present in 59% of patients and strongly associated with acid suppressive therapy. The mean plasma endotoxin level was 0.86 +/- 0.48 endotoxin units/ml (range = 0.03-1.44) and was significantly associated with small intestinal bacterial overgrowth (0.99 vs 0.60 endotoxin units/ml, p = 0.03). During the 1-yr follow-up, seven patients were lost to follow up or underwent liver transplantation and 12 patients died. Multivariate Cox regression showed Child-Pugh group to be the only predictor for survival. CONCLUSIONS: Small intestinal bacterial overgrowth in cirrhotic patients is common and associated with systemic endotoxemia. The clinical relevance of this association remains to be defined.

The subtilisin-like serine protease SDD1 mediates cell-to-cell signaling during Arabidopsis stomatal development.

Wild-type stomata are distributed nonrandomly, and their density is controlled by endogenous and exogenous factors. In the Arabidopsis mutant stomatal density and distribution1-1 (sdd1-1), the establishment of the stomatal pattern is disrupted, resulting in stomata clustering and twofold to fourfold increases in stomatal density. The SDD1 gene that encodes a subtilisin-like Ser protease is expressed strongly in stomatal precursor cells (meristemoids and guard mother cells), and the SDD1 promoter is controlled negatively by a feedback mechanism. The encoded protein is exported to the apoplast and probably is associated with the plasma membrane. SDD1 overexpression in the wild type leads to a phenotype opposite to that caused by the sdd1-1 mutation, with a twofold to threefold decrease in stomatal density and the formation of arrested stomata. While SDD1 overexpression was effective in the flp mutant, the tmm mutation acted epistatically. Thus, we propose that SDD1 generates an extracellular signal by meristemoids/guard mother cells and demonstrate that the function of SDD1 is dependent on TMM activity.