Minimally invasive operation techniques for inguinal hernia: spectrum of indications in Austria

At the beginning of the 1990s, the introduction of endoscopic surgery led to the surgical treatment of hernias being reconsidered. At present, there are three groups of surgical procedures: conventional procedures (Shouldice, Bassini), open, tension-free mesh procedures (Lichtenstein, Gilbert, Rutkow) and endoscopic procedures, predominantly transabdominal preperitoneal hernioplasty (TAPP) and total extraperitoneal hernioplasty (TEP). The debate about the optimum treatment for hernias provoked by the endoscopic procedures is understandable in view of the large number of hernia operations performed. Numerous studies, some randomised, have demonstrated both advantages and disadvantages for the individual surgical procedures. In addition to the recurrence and complication rates, the cost factor and socio-economic aspects of the operations are playing an increasingly important role in deciding which method should be used. In December 1995, Austrian surgeons concerned with the problems of hernia repair both before and since the introduction of laparoscopic hernia repair came together for a consensus conference. During the meeting, the relevant aspects were summarised and a range of indications were established for surgical interventions. The main recommendation was that conventional open surgery, which can be performed under local anaesthesia, is indicated in unilateral uncomplicated primary hernias. Endoscopic hernioplasty is indicated if the contralateral findings are inconclusive or the hernia is bilateral or recurrent. The Zürser Hernienforum (Zürs Hernia Forum) has now been founded. The function of this forum is to carry out a prospective randomised study of inguinal hernia surgery throughout Austria.

Heart luxation through a right-sided traumatic pericardial defect

A traumatic defect of the pericardium is a rarely diagnosed entity. We present a patient with a right-sided luxation of the heart which was incidentally diagnosed during a thoracic CT performed for other reasons. Despite of the threatening strangulation of the great vessels, the patient had a stable circulation until surgical repair of the pericardial defect.

Detection of membrane-bound tumor necrosis factor (TNF): an analysis of TNF-specific reagents

Tumor necrosis factor (TNF) exists in two bioactive forms, the membrane integrated form and the proteolytically derived soluble cytokine. Both forms of TNF are involved in a variety of different physiological and pathophysiological situations. Here we analyzed different human and mouse TNF-specific reagents for their ability to determine the expression of membrane-expressed TNF. The data prove some antibodies to be very useful for the analysis of transmembrane TNF expression because these antibodies distinguish between the transmembrane form of TNF and soluble TNF bound to cellular TNF receptors. In addition, we found that recombinant human TNF receptor fusion proteins are advantageous tools to analyze both human and mouse transmembrane TNF expression.

Evaluation of insecticide ear tags containing ethion for control of pyrethroid resistant Haematobia irritans (L.) on dairy cattle

A field study was conducted in central Argentina to evaluate the efficacy of ear tags containing 36% ethion against pyrethroid resistant populations of Haematobia irritans on grazing dairy cattle. The treated group consisted of 45 milking Holstein cows which received two tags per head and the control consisted of 22 dry cows from the same cohort. Treated and control groups were grazed on similar lucerne pastures separated for a minimum distance of 800 m but they were not isolated from other cattle herds on the same or contiguous properties. In both groups, horn fly estimation were made weekly by examining cattle in the pastures with the aid of binoculars. The percentage reduction of fly numbers on treated cows was considered as efficacy of control provided by the tags. The ethion ear tags provided a range of 85-99% reduction in horn fly numbers for 16 weeks. During this period, the weekly mean number of H. irritans on the tagged cows ranged between 0.44 and 28.26 compared with 143.5 and 239.1 in control animals. The ethion ear tags could be a useful tool for the control of H. irritans mainly in areas where populations of this insect have developed resistance to pyrethroid insecticides.

[Mannheim concept of preoperative autologous blood donation and perioperative autologous blood transfusion in hip endoprosthesis surgery]

PURPOSE

To investigate the efficiency of preoperative autologous deposit and intra- and postoperative cell salvage (CS) to reduce homologous transfusion in hip arthroplasty and revision hip arthroplasty.

METHODS

In a retrospective study, the data of 1402 patients scheduled for hip arthroplasty and for revision hip arthroplasty were analysed.

RESULTS

767 women and 635 men, age 62.9 +/- 9.8 years (x +/- s) were included in the study. 1270 were scheduled for hip arthroplasty, 132 for revision hip arthroplasty. Of the autologous donors, 51 patients predeposited four units, 1020 patients three, 204 patients two, 39 patients one unit. 88 patients who had not enrolled in the autologous donation program but received CS served as a control group. Blood loss in autologous donors amounted to 1620 (220-5620) ml in hip arthroplasty and 2830 (950-7910) ml in revision arthroplasty. CS was employed in part of the cases in arthroplasty and in all revision operations. 470 (0-2200) ml and 705 (0-2200) were retransfused. In hip arthroplasty 227 of 1182 patients (19.2%) received homologous blood. Homologous transfusion in patients with coxarthrosis due to acetabular protrusio, avascular necrosis of the femoral head and hip dysplasia showed a trend to higher values. Patients who had donated 3 units and received CS required homologous transfusion in 12.4% of the cases. CS reduced the homolgous transfusion rate significantly if the preoperative hemoglobin concentration was < or = 12 g/dl. A group of autologous donors receiving CS was matched with patients receiving CS only. 12 of 76 (15.8%) vs. 45 of 76 (59.2%) required homologous transfusion. In revision hip arthroplasty 58 of 132 patients (43.9%) required homologous blood.

CONCLUSIONS

Preoperative deposit reduces homologous transfusion requirements considerably in hip surgery. Under the conditions studied CS should be employed in hip arthroplasty in addition to preoperative deposit if the preoperative hemoglobin concentration falls below 12 g/dl. In revision arthroplasty, 4 or more autologous units should be predeposited and CS should be used regularly.

Biocompatible alginate from freshly collected Laminaria pallida for implantation

A simple procedure is described for the extraction and purification of alginate from the inner stipes of the kelp Laminaria pallida. Alginate yield was about 10-15% of the dry mass, with a 70:30 mannuronic/guluronic acid ratio. Analysis of the purified alginate revealed a low polyphenol content while proteins were below detection level. The purified alginate was highly viscous, with 10-15 mPa s and 281 mPa s for a 0.1% and 0.5% solution, respectively, indicating a very high molecular mass (larger than 250 kDa). Bead formation occurred in the presence of divalent cations, but also in the presence of artificial serum (FCSIII) without added divalent cations. The biocompatibility of the alginate was tested with the in vitro mice lymphocyte test as well as by implantation of Ba2+ cross-linked beads beneath the kidney capsule of BB/OK rats. There was no evidence for significant mitogenic activity or fibrotic reaction. Biocompatibility of the alginate was also demonstrated by the encapsulation of human chondrocytes into Ca2+ cross-linked alginate beads. Immobilized chondrocytes grew and remained functional (i.e. they produced collagen).

Activating mutation of adenylyl cyclase reverses its inhibition by G proteins

We have implemented a yeast genetic selection developed previously by our laboratory to identify mutant mammalian type V adenylyl cyclases insensitive to inhibition by G(ialpha.) One mutation isolated was localized to the first cytoplasmic domain at a Phe residue (position 400), which is conserved in all nine isoforms of membrane-bound mammalian adenylyl cyclase. Biochemical characterization of the F400Y mutant revealed a dramatic conversion of the G(ialpha) response from inhibitory to stimulatory. This mutation results in additional activating effects. The mutant exhibits an enhanced sensitivity toward activation by either G(salpha) or forskolin. Synergism between G(salpha) and forskolin is not observed for the F400Y mutant, presumably because the mutant already is in the sensitized state. Additionally, an enhancement of the basal unstimulated activity was observed. This mutation, which is the first demonstration of an activating point in a mammalian adenylyl cyclase, mimics a sensitized conformation of the wild-type enzyme that underlies the synergism between stimulatory inputs, and additionally, removes the inhibitory regulatory input provided by G(ialpha). Because sensitizing adenylyl cyclase toward its stimulators can have profound biological implications, this raises the possibility that naturally occurring mutations resembling those at the Phe400 residue may be associated with human disease states.

Diurnal changes in xylem pressure of the hydrated resurrection plant Myrothamnus flabellifolia: evidence for lipid bodies in conducting xylem vessels

The resurrection plant Myrothamnus flabellifolia has the ability to recover from repeated prolonged and extreme desiccation cycles. During the dry state the inner walls of the xylem vessels seemed to be covered, at least partly, by a lipid film as shown by Sudan III and Nile Red staining. The lipid film apparently functioned as an 'internal cuticle' which prevented the adjacent parenchyma ray cells from complete water loss. The hydrophobic nature of the inner xylem walls was supported by the finding that benzene ascended as rapidly as water in the xylem of dry Myrothamnus branches. On watering, numerous lipid bodies were found in the water-conducting vessels, presumably formed from the lipid film and/or from lipids excreted from the adjacent living cells into the vessels. The presence of lipid bodies within the vessels, as well as the hydrophobic properties of the inner xylem walls, could explain the finding that the xylem pressure of hydrated, well watered plants (measured both under laboratory and field conditions with the xylem pressure probe) never dropped below c. -0.3 MPa and that cavitation occurred frequently at low negative xylem pressure values (-0.05 to -0.15 MPa). The xylem pressure of M. flabellifolia responded rapidly and strongly to changes in relative humidity and temperature, but less obviously to changes in irradiance (which varied between 10 and c. 4000 μmol m m^-2 s^-1 ). The morphological position of the stomata in the leaves could explain the extremely weak and slow response of the xylem pressure of this resurrection plant to illumination changes. Stomata were most abundant in the furrows, and were thus protected from direct sunlight. Simultaneous measurements of the cell turgor pressure in the leaf epidermal cells (made by using the cell turgor pressure probe) revealed that the xylem and the cell turgor pressure dropped in a ratio of 1:0.7 on changes in the environmental parameters, indicating a quite close hydraulic connection and, thus, water equilibrium between the xylem and cellular compartments. An increase in irradiance of c. 700 μmol m^-2 s^-1 resulted in a turgor pressure decrease from 0.63 to 0.48 MPa. Correspondingly, the cell osmotic pressure increased from 1.03 to 1.22 MPa. From these values and by assuming water equilibrium, the osmotic pressure of the xylem sap was estimated to be 0.25-0.4 MPa. This value seems to be fairly high but may, however, be explained by the reduction of the water volume within the vessels due to the floating lipid bodies.

Induction of cell death by tumour necrosis factor (TNF) receptor 2, CD40 and CD30: a role for TNF-R1 activation by endogenous membrane-anchored TNF

Several members of the tumour necrosis factor receptor (TNF-R) superfamily can induce cell death. For TNF-R1, Fas/APO-1, DR3, DR6, TRAIL-R1 and TRAIL-R2, a conserved 'death domain' in the intracellular region couples these receptors to activation of caspases. However, it is not yet known how TNF receptor family members lacking a death domain, such as TNF-R2, CD40, LT-betaR, CD27 or CD30, execute their death-inducing capability. Here we demonstrate in different cellular systems that cytotoxic effects induced by TNF-R2, CD40 and CD30 are mediated by endogenous production of TNF and autotropic or paratropic activation of TNF-R1. In addition, stimulation of TNF-R2 and CD40 synergistically enhances TNF-R1-induced cytotoxicity. These findings describe a novel pro-apoptotic mechanism induced by some members of the TNF-R family.

Metabolism of retigabine (D-23129), a novel anticonvulsant

Retigabine (D-23129, N-(2-amino-4-(4-fluorobenzylamino)-phenyl) carbamic acid ethyl ester) is a potent anticonvulsant in a variety of animal models. Rats metabolized [14C]retigabine mainly through glucuronidation and acetylation reactions. Glucuronides were detected in incubates with liver microsomes or slices, in plasma, and in bile and feces but were absent in urine (0-24 h) that contained about 2% of the dose as retigabine and approximately 29% of the dose in > 20 metabolites, which are derived mainly from acetylation reactions. About 67% of the radioactivity was excreted into feces, approximately 10% of the dose as glucuronide. The metabolite pattern in the urine (0-24 h) of dogs was comparatively simple in that retigabine (13%), retigabine-N-glucuronide (5%), and retigabine-N-glucoside (1%) were present. In the same 24-h interval, about 39% of unchanged retigabine was excreted into feces. Plasma profiling and spectroscopic analysis (liquid chromatography with tandem mass spectrometry NMR) of two isolated urinary metabolites obtained after single oral dosing of 600 mg retigabine in healthy volunteers indicated that both acetylation and glucuronidation are major metabolic pathways of retigabine in humans. We found that in vitro assays with liver slices from rat and humans reveal the major circulating metabolites in vivo.

Utero-ovarian interaction in the regulation of reproductive function

The physiological regulation of fertile reproductive cycle in mammals depends on interactions between hypothalamus-pituitary, ovarian and uterine stimuli. Over the past 20 years, much has been learned about the interrelation between the affluent and effluent lymph and vascular drainage in and around both ovarian and uterine tissues. An essential feature in the regulation of the fertile cycle is the functional status of the ovary, particularly the corpus luteum. During the time of implantation and the early pregnancy, an active corpus luteum is essential. As human chorionic gonadotrophin (HCG) is important in the maintenance of the corpus luteum, we investigated if it was produced by the cyclic endometrium. Immunohistochemical and in-situ hybridization reactions were performed but neither identified the presence of HCG during the proliferative phase. Positive staining and beta-human chorionic gonadotrophin (beta-HCG) mRNA were observed during the secretory phase in the glandular cells of the endometrium. The results were confirmed by Western blotting of secretory phase endometrium extracts and assessment of the functional secretory capacity of primary endometrial cultures. Polymerase chain reaction (PCR) investigations showed a positive result in the secretory phase. We postulate that, based on the very close morphological interrelation between the uterus and the ovary, the beta-HCG of the endometrium is the primary factor for the maintenance of the corpus luteum and early pregnancy.

HCG secretion by peripheral mononuclear cells during pregnancy

Peripheral mononuclear cells (MNC) in culture release a biologically active hCG. This effect is detectable during pregnancy with a maximum between the 9th and 16th wk. Peripheral MNC already secrete hCG between the 7th and 11th d after embryo transfer. The secretion of hCG is activated by the PKC-activator TPA. TPA induces hCG release into the medium, thus causing a decrease in intracellular hCG content. In contrast, db-cAMP inhibites hCG secretion into the medium. Protein synthesis inhibitors of transcription and translation suppress the production and secretion of hCG. Peripheral natural killer (NK) cells (CD56+/CD16+) and monocytes (CD14+) show the highest secretion rates. IL-1 beta, IL-4, IL-6, IL-10, TNF alpha, and GM-CSF stimulate, whereas IL-2 and INF gamma inhibit, the hCG secretion of mononuclear cells. Flow cytometric experiments with hCG antibody demonstrate a binding of hCG on the surface of monocytes more than lymphocytes. The binding capacity is improved during pregnancy. Different hCG bands are shown in the Western blot analysis. We could confirm the mRNA of beta hCG and alpha CG are in MNC as well in the placental control. Peripheral MNC, first and foremost NK cells and monocytes, produce and secrete hCG during pregnancy, which play an important role for the corpus luteum rescue during the early gestational age and possibly for the immunotolerance.

Mutations uncover a role for two magnesium ions in the catalytic mechanism of adenylyl cyclase

The recent determination of the crystal structure of adenylyl cyclase has elucidated many structural features that determine the regulatory properties of the enzyme. In addition, the characterization of adenylyl cyclase by mutagenic techniques and the identification of the binding site for P-site inhibitors have led to modeling studies that describe the ATP-binding site. Despite these advances, the catalytic mechanism of adenylyl cyclase remains uncertain, especially with respect to the role that magnesium ions may play in this process. We have identified four mutant mammalian adenylyl cyclases defective in their metal dependence, allowing us to further characterize the function of metal ions in the catalytic mechanism of this enzyme. The wild-type adenylyl cyclase shows a biphasic Mg2+ dose-response curve in which the high-affinity component displays cooperativity (Hill coefficient of 1.4). Two mutations (C441R and Y442H) reduce the affinity of the adenylyl cyclase for Mg2+ dramatically without affecting the binding of MgATP, suggesting that there is a metal requirement in addition to the ATP-bound Mg2+. The results of this study thus demonstrate multiple metal requirements of adenylyl cyclase and support the existence of a Mg2+ ion essential for catalysis and distinct from the ATP-bound ion. We propose that adenylyl cyclase employs a catalytic mechanism analogous to that of DNA polymerase, in which two key magnesium ions facilitate the nucleophilic attack of the 3'-hydroxyl group and the subsequent elimination of pyrophosphate.

Value of image subtraction in 3D gadolinium-enhanced MR angiography of the renal arteries

The objective of this study was to evaluate quantitatively and qualitatively the effect of image subtraction on the image quality of three-dimensional (3D) gadolinium-enhanced MR angiograms of the renal arteries. Breath-hold 3D gadolinium MR angiography (MRA) as well as conventional contrast angiography of the renal arteries was performed on 20 patients with suspected renovascular hypertension. MR angiograms were acquired before and during dynamic infusion of gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA). Contrast-enhanced images were compared with images that had undergone voxel-by-voxel signal intensity subtraction of contrast-enhanced data from precontrast data. One false positive finding for significant renal artery stenosis was recorded with MRA using conventional angiography as the gold standard. Image subtraction did not alter the diagnosis at MRA in any case. The mean contrast-to-noise ratio (CNR) was significantly higher (P < .05) on the subtraction MR angiograms compared to the nonsubtracted MR angiograms. There was no significant difference in the signal-to-noise ratio (SNR). Qualitative analysis revealed a significant improvement in image quality after image subtraction with respect to visualization of the distal renal arteries. In conclusion, image subtraction improves the quality of renal MRA in terms of both CNR and visualization of the distal renal arteries.

[Laparoscopic hernia surgery--status of minimal invasive techniques in a spectrum of surgical indications]

Endoscopic surgery led in the nineties to a discussion on surgical treatment of hernias. At the present time there are three groups of operative procedures: the conventional procedure--Shouldice, Bassini--the open tension-free procedure with implantation of a mesh--Lichtenstein, Gilbert-Rutkow--and the endoscopic procedure (predominantly transabdominal preperitoneal hernioplasty (TAPP) and total extraperitoneal hernioplasty (TEP)). The debate on the optimal therapy of hernias is understandable in view of the large number of hernia operations which are carried out. Numerous studies, some randomized, have demonstrated both the advantages and the disadvantages of the individual operative procedures. In addition to the recurrence rate and the complications, the cost factor and the associated socio-economic aspects of the particular operation play an increasingly important role in the decision on the method that should be used. In December 1995 some Austrian surgeons, who concerned themselves with problems of hernia repair already before the definitive introduction of laparoscopic hernia repair in today's surgery, came together on the occasion of a "Consensus Conference". During the meeting a summary of all relevant aspects of the complex of problems was worked out and summarized in a catalog of indications for the different operative interventions. The main statement was that the traditional open surgery, which can be performed under local anesthesia is indicated for an unilateral primary hernia. In case of an unclear finding at the contralateral side, as well as in case of a recurrent hernia, an endoscopic procedure is indicated. Meanwhile the Hernia Forum of Zürs ("Zürser Hernienforum") was founded. The function of this forum is the realization of a prospective randomized study for hernia repair in Austria.

Genetic selection of mammalian adenylyl cyclases insensitive to stimulation by Gsalpha

We describe the development of a genetic system allowing for the isolation of mutant mammalian adenylyl cyclases defective in their responses to G protein subunits, thus allowing for the identification of structural elements within the cyclase that are responsible for the recognition of these regulators. Expression of mammalian type V adenylyl cyclase in a cyclase-deleted yeast strain can conditionally complement the lethal phenotype of this strain. Type V adenylyl cyclase-expressing yeast grow only when the cyclase is activated by coexpression of Gsalpha or addition of forskolin to the medium; however, growth arrest is observed in the presence of both activators or under basal conditions. Utilizing this genetic system, we have isolated 25 adenylyl cyclase mutants defective in their response to Gsalpha. Sequence analysis and biochemical characterization of these mutants have identified residues in both cytoplasmic domains of the cyclase that are involved in the specific binding of and regulation by Gsalpha.

The presence of chorionic gonadotrophin beta subunit in normal cyclic human endometrium

The aim of the present study was to determine whether human endometrial cells are able to secrete beta-chorionic gonadotrophin (betaCG). Immunohistochemical studies and in-situ hybridization were performed in order to provide evidence for the occurrence of betaCG in the normal endometrium in 15 patients in the proliferative phase, two patients in the periovulatory phase and 13 patients in the secretory phase. Neither immunohistochemical nor hybridization reactions could be recognized during the proliferative phase. In contrast, both protein and betaCG mRNA were observed in the glandular cells of the endometrium during the secretory phase. The results were supported by Western blotting of secretory phase endometrium extracts and the assessment of the functional secretory capacity of primary endometrium cultures. In comparison with cultured and separated cell fractions, tissue extracts showed a higher betaCG, indicating a regulatory interaction. In conclusion, betaCG can be demonstrated in normal human cyclic endometrium, suggesting a paracrine role in endometrial physiology.