Functionalization of a zirconia surface by covalently immobilized fibronectin and its effects on resistance to thermal, acid, and mechanical exposure

Silane chemistry has emerged as a powerful tool for surface modification, offering a versatile means to enhance the properties of various substrates, such as dental implant abutment materials. In this study, we investigated the stability of the 3-aminopropyldiisopropylethoxysilane (APDS) layer on yttria-partially stabilized zirconia (Y-TZP) surfaces after mechanical, acid, and thermal treatment in order to simulate fluctuations within the oral cavity. To accomplish that, the viability of human gingival fibroblasts on APDS-modified surfaces after applied treatment strategies was assessed by live/dead staining. Moreover, the hydrolysis stability and enzymatic degradation resistance of crosslinked fibronectin to the APDS layer was examined by immunostaining and western blot. The results revealed that the applied modifications were not affected by the different treatment conditions and could withstand the fluctuations in the oral cavity. Furthermore, crosslinked fibronectin on silanized Y-TZP was stable against hydrolysis over 21 days and enzymatic degradation. We thus can conclude that the proposed functionalization method has high potential to tolerate harmful effects within the oral cavity and remains unchanged on the surface.

Sub-continental-scale carbon stocks of individual trees in African drylands

The distribution of dryland trees and their density, cover, size, mass and carbon content are not well known at sub-continental to continental scales1-14. This information is important for ecological protection, carbon accounting, climate mitigation and restoration efforts of dryland ecosystems15-18. We assessed more than 9.9 billion trees derived from more than 300,000 satellite images, covering semi-arid sub-Saharan Africa north of the Equator. We attributed wood, foliage and root carbon to every tree in the 0-1,000 mm year-1 rainfall zone by coupling field data19, machine learning20-22, satellite data and high-performance computing. Average carbon stocks of individual trees ranged from 0.54 Mg C ha-1 and 63 kg C tree-1 in the arid zone to 3.7 Mg C ha-1 and 98 kg tree-1 in the sub-humid zone. Overall, we estimated the total carbon for our study area to be 0.84 (±19.8%) Pg C. Comparisons with 14 previous TRENDY numerical simulation studies23 for our area found that the density and carbon stocks of scattered trees have been underestimated by three models and overestimated by 11 models, respectively. This benchmarking can help understand the carbon cycle and address concerns about land degradation24-29. We make available a linked database of wood mass, foliage mass, root mass and carbon stock of each tree for scientists, policymakers, dryland-restoration practitioners and farmers, who can use it to estimate farmland tree carbon stocks from tablets or laptops.

Observed Impact of Long-Term Consumption of Oral Cannabidiol on Liver Function in Healthy Adults

Introduction: Previous studies have suggested that prescribed cannabidiol (CBD) products may cause elevations in liver tests (LT). This study compared the prevalence of elevated LT in an adult population self-administering CBD with the normal and general adult population prevalences. Materials and Methods: Adults 18-75 years of age across the United States taking CBD orally for a minimum of 30 days were recruited from 12 individual CBD product companies in this decentralized, observational study and sent their standard CBD regimen from the company of their choice. An app-based, 21CFR Part 11 decentralized clinical study platform (ValidCare Study) was used to securely automate consent inclusion/exclusion criteria and collect all the data for this study, including: demographic information, medical history, reasons for taking, dosage, current medications dosage, adverse effects, and efficacy. At the end of 30 days, LTs were obtained. Follow-up LTs were offered to all individuals with elevated alanine transaminase (ALT) values. Results: A total of 28,121 individuals were invited to participate in this study, 1475 enrolled, and 839 (female: 65.3%, male: 34.7%) completed the study. Full-spectrum hemp oil was used by 55.7%, CBD-isolate by 40.5%, and broad spectrum by 3.8%. The mean±SD daily dose of CBD was 50.3+40.7 mg. The prevalence of elevated ALT was 9.1%, aspartate aminotransferase (AST) 4.0%, alkaline phosphatase 1.9%, total bilirubin 1.7%, with 85.5% of the ALT elevations <2×the upper limit of normal (ULN) with only 0.3% having ALT levels >3× ULN. The prevalence of ALT and AST elevations (9.1% and 4.0%) were not significantly different from known adult general population prevalences (8.9% and 4.9%). There was no significant association between CBD dosage and LT values. Thirty-three individuals with elevated ALT levels had follow-up LT performed with 21 having normal LT, 8 having the same severity of ALT elevation, and 4 having an increase in severity, 1 of which ultimately became normal. Conclusions: Self-medication of CBD does not appear to be associated with an increased prevalence of LT elevation and most of the LT elevations are likely due to the conditions/medications for which the individuals are taking CBD.

Long-Term, Self-Dosing CBD Users: Indications, Dosage, and Self-Perceptions on General Health/Symptoms and Drug Use

Introduction

Self-dosing of off-the-shelf cannabidiol (CBD) for a myriad of health conditions is common in the USA. These CBD products are often mislabeled, suggesting that much less or much more CBD is being consumed than indicated on the label. This study examined the relationship between long-term self-dosing of CBD and (a) indications and, when a verified concentration of CBD is being consumed, (b) the daily CBD dosage, (c) the impact on general health and symptoms, and (d) over-the-counter (OTC) and prescription (Rx) drug usage.

Methods

US adults 18-75 years of age who had used unverified CBD products for >1 month were recruited to participate in this decentralized, observational, IRB-approved study and provided a concentration-verified CBD product of their choice from 15 different vendors for 4 weeks. Prior to receiving product, they were queried on their primary reason for use (PRfU), primary symptom for use (PSfU), general health score (GHS), symptom score (SS), OTC and Rx drug use, and daily CBD dose. Individuals were queried daily on OTC and Rx drug use and CBD dose and weekly on SS and GHS prior to (pre-CBD) and after (post-CBD) ingestion of CBD on that day.

Results

The PRfU included chronic pain, mental health, general health and wellness, sleep disorders, the central nervous system, digestive health, and others, while the PSfU included anxiety, back and/or joint pain, sleep, inflammation, and others. The mean daily dose was normally distributed, with a mean, median, and range of 53.1, 40.8, 8-390 mg/day, respectively. For both GHS and SS, the post-CBD was significantly higher than the pre-CBD score for each category of PRfU. The GHS scores did not change over the study, but pre- and post-CBD SS improved over time, with pre-improving more than post-CBD SS. The percentage of individuals decreasing or completely stopping OTC drugs or Rx drugs over the 4 weeks was 31.2% and 19.2%, respectively, with those taking CBD for chronic pain, decreasing drug use the most. OTC and Rx drug usage decreased when the CBD dose was changed and when GHS and SS improved.

Conclusion

Pain, mental health (primarily anxiety/stress), and sleep are the most common reasons for CBD use. Self-administration of CBD reduced OTC and Rx drug usage at daily doses less than those reported in controlled studies. CBD self-administration significantly improves self-perception of general health and decreases symptom severity, and as these improve, fewer OTC and Rx drugs are used.

The Effects of Long-Term Self-Dosing of Cannabidiol on Drowsiness, Testosterone Levels, and Liver Function

Introduction

Previous research indicated that cannabidiol (CBD) may result in low levels of male total testosterone (TT), elevations in liver tests (LTs), and daytime drowsiness (DD). We investigated the prevalences of TT and LT in a large adult sample self-administering CBD and determined the effect self-dosing of CBD has on the severity of DD.

Methods

Adult participants (18-75 years of age) who self-dose CBD orally for a minimum of 30 days were recruited for this decentralized observational study from companies that offer CBD products. Participants were sent their usual CBD regimen. A clinical study platform was used on a phone app to obtain consent and collect study data. Data included demographic information, reasons for self-dosing, dosage, current medications and dosage, medical history, adverse effects, effects on DD, and efficacy. After 30 days, LT and TT were obtained and follow-up LT was offered to participants who demonstrated elevated values of alanine transaminase (ALT).

Results

A total of 28,121 individuals were contacted, 1,475 met the criteria and were enrolled, and 1,061 (female: 65.2%, male: 34.8%) completed the study. Most of the participants used full-spectrum CBD oil or CBD isolate with the mean ± SD daily dose of CBD for all users of 55.4 ± 37.8 mg. CBD use was associated with a significant decrease in DD and a decrease in the prevalence of low TT in males >40 years of age. The prevalences of elevations in ALT and aspartate aminotransferase were not significantly different from those of the general adult population, and the prevalences of elevated levels of alkaline phosphatase and bilirubin were less than those of a healthy adult population. There was no relationship between LT and CBD dose.

Conclusions

In this large-sample study, self-dosing CBD was not associated with an increased prevalence of elevation of LT or low levels of TT in men. Furthermore, CBD administration decreased DD and was associated with a lower prevalence of low testosterone levels in older men as compared to age-adjusted population norms.

Antimicrobial efficiency and cytocompatibility of different decontamination methods on titanium and zirconium surfaces

OBJECTIVES

The purpose of this study was to investigate the efficiency of different implant-decontamination methods regarding biofilm modification and potential cytotoxic effects. Therefore, the amount of biofilm reduction, cytocompatibility, and elementary surface alterations were evaluated after decontamination of titanium and zirconium surfaces.

MATERIAL AND METHODS

Titanium and zirconium disks were contaminated with a newly developed high-adherence biofilm consisting of six microbial species. Decontaminations were performed using titanium curette, stainless steel ultrasonic scaler (US), glycine (GPAP) and erythritol (EPAP) powder air-polishing, Er:YAG laser, 1% chlorhexidine (CHX), 10% povidone-iodine (PVI), 14% doxycycline (doxy), and 0.95% NaOCl solution. Microbiologic analysis was done using real-time qPCR. For assessment of cytocompatibility, a multiplex assay for the detection of cytotoxicity, viability, and apoptosis on human gingival fibroblasts was performed. X-ray photoelectron spectroscopy (XPS) was used to evaluate chemical alterations on implant surfaces.

RESULTS

Compared with untreated control disks, only GPAP, EPAP, US, and Er:YAG laser significantly reduced rRNA counts (activity) on titanium and zirconium (p < .01), whereas NaOCl decreased rRNA count on titanium (p < .01). Genome count (bacterial presence) was significantly reduced by GPAP, EPAP, and US on zirconium only (p < .05). X-ray photoelectron spectroscopy analyses revealed relevant re-exposure of implant surface elements after GPAP, EPAP, and US treatment on both materials, however, not after Er:YAG laser application. Cytocompatibility was impaired by CHX, PVI, doxy, and NaOCl. CHX and PVI resulted in the lowest viability and doxy in the highest apoptosis.

CONCLUSIONS

Within the limits of this in vitro study, air-polishing methods and ultrasonic device resulted in effective biofilm inactivation with surface re-exposure and favorable cytocompatibility on titanium and zirconium. Chemical agents, when applied on implant surfaces, may cause potential cytotoxic effects.

Impact of the Covid-19 pandemic on melanoma and non-melanoma skin cancer inpatient treatment in Germany - a nationwide analysis

BACKGROUND

SARS-CoV-2 has massively changed the care situation in hospitals worldwide. Although tumour care should not be affected, initial reports from European countries were suggestive for a decrease in skin cancer during the first pandemic wave and only limited data are available thereafter.

OBJECTIVES

The aim of this study was to investigate skin cancer cases and surgeries in a nationwide inpatient dataset in Germany.

METHODS

Comparative analyses were performed in a prepandemic (18 March 2019 until 17 March 2020) and a pandemic cohort (18 March 2020 until 17 March 2021). Cases were identified and analysed using the WHO international classification of diseases codes (ICDs) and process key codes (OPSs).

RESULTS

Comparing the first year of the pandemic with the same period 1 year before, a persistent decrease of 14% in skin cancer cases (n = 19 063) was observed. The largest decrease of 24% was seen in non-invasive in situ tumours (n = 1665), followed by non-melanoma skin cancer (NMSC) with a decrease of 16% (n = 15 310) and malignant melanoma (MM) with a reduction of 7% (n = 2088). Subgroup analysis showed significant differences in the distribution of sex, age, hospital carrier type and hospital volume. There was a decrease of 17% in surgical procedures (n = 22 548), which was more pronounced in minor surgical procedures with a decrease of 24.6% compared to extended skin surgery including micrographic surgery with a decrease of 15.9%.

CONCLUSIONS

Hospital admissions and surgical procedures decreased persistently since the beginning of the pandemic in Germany for skin cancer patients. The higher decrease in NMSC cases compared to MM might reflect a prioritization effect. Further evidence from tumour registries is needed to investigate the consequences of the therapy delay and identify the upcoming challenges in skin cancer care.

Vascular 3D Printing with a Novel Biological Tissue Mimicking Resin for Patient-Specific Procedure Simulations in Interventional Radiology: a Feasibility Study

Three-dimensional (3D) printing of vascular structures is of special interest for procedure simulations in Interventional Radiology, but remains due to the complexity of the vascular system and the lack of biological tissue mimicking 3D printing materials a technical challenge. In this study, the technical feasibility, accuracy, and usability of a recently introduced silicone-like resin were evaluated for endovascular procedure simulations and technically compared to a commonly used standard clear resin. Fifty-four vascular models based on twenty-seven consecutive embolization cases were fabricated from preinterventional CT scans and each model was checked for printing success and accuracy by CT-scanning and digital comparison to its original CT data. Median deltas (Δ) of luminal diameters were 0.35 mm for clear and 0.32 mm for flexible resin (216 measurements in total) with no significant differences (p > 0.05). Printing success was 85.2% for standard clear and 81.5% for the novel flexible resin. In conclusion, vascular 3D printing with silicone-like flexible resin was technically feasible and highly accurate. This is the first and largest consecutive case series of 3D-printed embolizations with a novel biological tissue mimicking material and is a promising next step in patient-specific procedure simulations in Interventional Radiology.

Position statement on classification of basal cell carcinomas. Part 1: unsupervised clustering of experts as a way to build an operational classification of advanced basal cell carcinoma based on pattern recognition

Background

No simple classification system has emerged for ‘advanced basal cell carcinomas’, and more generally for all difficult‐to‐treat BCCs (DTT‐BCCs), due to the heterogeneity of situations, TNM inappropriateness to BCCs, and different approaches of different specialists.

Objective

To generate an operational classification, using the unconscious ability of experts to simplify the great heterogeneity of the clinical situations into a few relevant groups, which drive their treatment decisions.

Method

Non‐supervised independent and blinded clustering of real clinical cases of DTT‐BCCs was used. Fourteen international experts from different specialties independently partitioned 199 patient cases considered ‘difficult to treat’ into as many clusters they want (≤10), choosing their own criteria for partitioning. Convergences and divergences between the individual partitions were analyzed using the similarity matrix, K‐mean approach, and average silhouette method.

Results

There was a rather consensual clustering of cases, regardless of the specialty and nationality of the experts. Mathematical analysis showed that consensus between experts was best represented by a partition of DTT‐BCCs into five clusters, easily recognized a posteriori as five clear‐cut patterns of clinical situations. The concept of ‘locally advanced’ did not appear consistent between experts.

Conclusion

Although convergence between experts was not granted, this experiment shows that clinicians dealing with BCCs all tend to work by a similar pattern recognition based on the overall analysis of the situation. This study thus provides the first consensual classification of DTT‐BCCs. This experimental approach using mathematical analysis of independent and blinded clustering of cases by experts can probably be applied to many other situations in dermatology and oncology.

Position statement on classification of basal cell carcinomas. Part 2: EADO proposal for new operational staging system adapted to basal cell carcinomas

Background

No simple staging system has emerged for basal cell carcinomas (BCCs), since they do not follow the TNM process, and practitioners failed to agree on simple clinical or pathological criteria as a basis for a classification. Operational classification of BCCs is required for decision‐making, trials and guidelines. Unsupervised clustering of real cases of difficult‐to‐treat BCCs (DTT‐BCCs; part 1) has demonstrated that experts could blindly agree on a five groups classification of DTT‐BCCs based on five patterns of clinical situations.

Objective

Using this five patterns to generate an operational and comprehensive classification of BCCs.

Method

Testing practitioner's agreement, when using the five patterns classification to ensure that it is robust enough to be used in the practice. Generating the first version of a staging system of BCCs based on pattern recognition.

Results

Sixty‐two physicians, including 48 practitioners and the 14 experts who participated in the generation of the five different patterns of DTT‐BCCs, agreed on 90% of cases when classifying 199 DTT‐BCCs cases using the five patterns classification (part 1) attesting that this classification is understandable and usable in practice. In order to cover the whole field of BCCs, these five groups of DTT‐BCCs were added a group representing the huge number of easy‐to‐treat BCCs, for which sub‐classification has little interest, and a group of very rare metastatic cases, resulting in a four‐stage and seven‐substage staging system of BCCs.

Conclusion

A practical classification adapted to the specificities of BCCs is proposed. It is the first tumour classification based on pattern recognition of clinical situations, which proves to be consistent and usable. This EADO staging system version 1 will be improved step by step and tested as a decision tool and a prognostic instrument.

META Score: An International Consensus Scoring System on Mesh-Tissue Adhesions

BACKGROUND

Currently, the lack of consensus on postoperative mesh-tissue adhesion scoring leads to incomparable scientific results. The aim of this study was to develop an adhesion score recognized by experts in the field of hernia surgery.

METHODS

Authors of three or more previously published articles on both mesh-tissue adhesion scores and postoperative adhesions were marked as experts. They were queried on seven items using a modified Delphi method. The items concerned the utility of adhesion scoring models, the appropriateness of macroscopic and microscopic variables, the range and use of composite scores or subscores, adhesion-related complications and follow-up length. This study comprised two questionnaire-based rounds and one consensus meeting.

RESULTS

The first round was completed by 23 experts (82%), the second round by 18 experts (64%). Of those 18 experts, ten were able to participate in the final consensus meeting and all approved the final proposal. From a total of 158 items, consensus was reached on 90 items. The amount of mesh surface covered with adhesions, tenacity and thickness of adhesions and organ involvement was concluded to be a minimal set of variables to be communicated separately in each future study on mesh adhesions.

CONCLUSION

The MEsh Tissue Adhesion scoring system is the first consensus-based scoring system with a wide backing of renowned experts and can be used to assess mesh-related adhesions. By including this minimal set of variables in future research interstudy comparability and objectivity can be increased and eventually linked to clinically relevant outcomes.

The evolving field of Dermato-oncology and the role of dermatologists: Position Paper of the EADO, EADV and Task Forces, EDF, IDS, EBDV-UEMS and EORTC Cutaneous Lymphoma Task Force

BACKGROUND

The incidence of skin cancers has been increasing steadily over the last decades. Although there have been significant breakthroughs in the management of skin cancers with the introduction of novel diagnostic tools and innovative therapies, skin cancer mortality, morbidity and costs heavily burden the society.

OBJECTIVE

Members of the European Association of Dermato-Oncology, European Academy of Dermatology and Venereology, International Dermoscopy Society, European Dermatology Forum, European Board of Dermatovenereology of the European Union of Medical Specialists and EORTC Cutaneous Lymphoma Task Force have joined this effort to emphasize the fundamental role that the specialist in Dermatology-Venereology has in the diagnosis and management of different types of skin cancer. We review the role of dermatologists in the prevention, diagnosis, treatment and follow-up of patients with melanoma, non-melanoma skin cancers and cutaneous lymphomas, and discuss approaches to optimize their involvement in effectively addressing the current needs and priorities of dermato-oncology.

DISCUSSION

Dermatologists play a crucial role in virtually all aspects of skin cancer management including the implementation of primary and secondary prevention, the formation of standardized pathways of care for patients, the establishment of specialized skin cancer treatment centres, the coordination of an efficient multidisciplinary team and the setting up of specific follow-up plans for patients.

CONCLUSION

Skin cancers represent an important health issue for modern societies. The role of dermatologists is central to improving patient care and outcomes. In view of the emerging diagnostic methods and treatments for early and advanced skin cancer, and considering the increasingly diverse skills, knowledge and expertise needed for managing this heterogeneous group of diseases, dermato-oncology should be considered as a specific subspecialty of Dermatology-Venereology.

P1056Left atrial and left atrial appendage ejection fraction assessed by preprocedural cardiac CT are useful parameters for predicting the outcome of pulmonary vein isolation

Introduction

Pulmonary vein isolation (PVI) is an effective but complex treatment option for atrial fibrillation (AF). Therefore preprocedural outcome prediction is of special interest. Left atrial volume (LAVmax) is a commonly used predictor for recurring arrhythmia. Several studies have investigated different parameters for the prediction of sustained rhythm control. We hypothesized that left atrial and left atrial appendage ejection fraction (LAEF & LAAEF) assessed by high-resolution CT-imaging are even more sensitive predictors of the outcome of PVI than LAVmax.

Methods

All patients who underwent PVI between 2015 and 2018 with available preinterventional cardiac CT were included in this retrospective study and separated into 2 groups: Group A comprises all patients with sinus rhythm (SR) at follow-up and group B all patients in whom recurrence of AF was observed. Volumetric analysis of the left atrium was performed in ventricular systole (30%-Phase of the cardiac cycle) and diastole (0%-Phase). Obtained data were used to calculate left atrial and left appendage ejection fractions (LAEF & LAAEF). Success of pulmonary vein isolation was defined as clinical freedom of symptomatic AF together with sinus rhythm on the available Holter-ECG recordings during follow-up examinations. Uni- and multivariate logistic regression models and NAMS RMLE tests were used to compare LAVmax to these functional parameters.

Results

In total 152 patients with symptomatic paroxsymal or persistent AF underwent PVI at our hospital from 2015 to 2018. Due to inconsistencies in archiving in our PACS-system, 98 patients had to be excluded from analysis. Four patients were excluded due to motion artifacts. 50 patients were included in the final study (41 patients without and 9 patients with recurring AF on average 254 days after ablation). Significant differences in means were found for all assessed parameters. LAEF (accuracy 94%, sensitivity 67%) and LAAEF (accuracy 90%, sensitivity 67%) had a higher sensitivity than LAVmax (accuracy 86%, sensitivity 33%), though not significant in this study population (p = 0.18). LAVmax and LAEF in combination improved sensitivity significantly from 33% to 78% (p = 0.046). Measurements on cardiac-CT showed an excellent interobserver-reliability.

Conclusion

Reduced LAEF and LAAEF were found to be significant predictors of the outcome of PVI. Furthermore we found a trend that these functional parameters might be more sensitive than LAVmax. Thus we propose that left atrial function, assessed with preprocedural cardiac CT, offers important prognostic information for successful PVI.

Abstract Figure. Surface rendering of LA and LAA

Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society

BACKGROUND

Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias.

METHODS

The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019.

RESULTS

Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity.

CONCLUSION

This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.

EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances

Background

Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management.

Methods

The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full‐text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed.

Results

Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence.

Conclusion

This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.

G protein-coupled receptor 40 expression in human melanoma - correlation with tumour thickness, AJCC stage and survival

BACKGROUND

In melanoma, preclinical data suggest a possible role of polyunsaturated fatty acids inhibiting cell growth. A new target molecule for free fatty acids, the G protein-coupled receptor GPR40, was identified in melanoma cells.

OBJECTIVES

The aim of this study was to investigate GPR40 expression in human melanocytic tissues and to evaluate its potential as a prognostic marker.

METHODS AND RESULTS

A total of 114 tissue sections of naevi, primary melanoma and melanoma metastasis were immunohistochemically stained with anti-GPR40. The staining was evaluated, using the immunoreactivity scoring system. Compared to naevi, primary melanoma and melanoma metastasis showed significantly higher levels of GPR40 (P < 0.05). In primary melanoma, GPR40 expression positively correlated with tumour thickness (P = 0.044) and AJCC level (P = 0.017) and in melanoma metastasis with AJCC level (P = 0.035). Primary melanoma patients with high levels of GPR40 had a significantly poorer overall survival (P = 0.004) and shorter disease-free survival (0.040).

CONCLUSION

The present study identified GPR40 as a novel target molecule in melanoma. First evidence for a potential role of the receptor in tumour progression and metastases was found, and it could be demonstrated that GPR40 expression is negatively correlated with patient's survival.

A systematic review on surgical treatment of primary epigastric hernias

Objective

In this systematic review, we evaluated all literature reporting on the surgical treatment of primary epigastric hernias, primarily focusing on studies comparing laparoscopic and open repair, and mesh reinforcement and suture repair.

Methods

A literature search was conducted in Embase.com, PubMed and the Cochrane Library up to 24 April 2019. This review explicitly excluded literature on incisional hernias, ventral hernias not otherwise specified, and isolated (para)umbilical hernias. Primary outcome measures of interest were early and late postoperative complications.

Results

We obtained a total of 8516 articles and after a strict selection only seven retrospective studies and one randomised controlled trial (RCT) on treatment of primary epigastric hernia were included. In one study (RCT) laparoscopic repair led to less postoperative pain (VAS) compared to open repair (3.6 versus 2.4, p < 0.001). No significant differences in early postoperative complications and recurrences were observed. Mesh reinforcement was associated with lower recurrence rates than suture repair in two studies (2.2% versus 5.6%, p  = 0.001 and 3.1% versus 14.7%, p = 0.0475). This result was not sustained in all studies. No differences were observed in early postoperative complications after mesh or suture repair.

Conclusions

This review demonstrated that studies investigating surgical treatment of primary epigastric hernias are scarce. The best available evidence suggests that mesh reinforcement in primary epigastric hernia repair possibily leads to less recurrences and that laparoscopic repair leads to less postoperative pain. Due to the high risk of selection bias of included studies and heterogenic study populations, no clear recommendations can be conducted. High-quality studies with well-defined patient groups and clear endpoints, primarily focusing on primary epigastric hernias, are mandatory.

Electronic supplementary material

The online version of this article (10.1007/s10029-019-02017-4) contains supplementary material, which is available to authorized users.

Surgical and radiological behavior of MRI-depictable mesh implants after TAPP repair: the IRONMAN study

PURPOSE

Knowledge of postoperative behavior of mesh implants used for hernia repair is generally limited to cases of recurrence, local complications or return to the previous operative field in other pathological conditions. Previous studies with MRI-visible mesh implants in different parts of the abdominal wall have led to variable findings with regard to mesh properties and mostly described a reduction in size over time with subsequently limited mesh overlap over hernia defects which could contribute to recurrence. We aimed to evaluate implant properties in a mechanically stable anatomical region after TAPP repair of primary unilateral inguinal hernias in men with clinical and MRI examinations 4 weeks and 1 year after surgery.

METHODS

From 11/2015 to 01/2019, 23 men with primary, unilateral, inguinal hernias underwent TAPP repair with iron particle-loaded, MRI-visible mesh implants in a prospective cohort study. In 16 patients the operative outcome could be evaluated 4 weeks and 12 months after surgery by clinical examination and MRI evaluation with regard to postoperative course, possible adverse outcomes and radiological findings related to implant behavior-namely MRI-identifiability, mesh dislocation or reduction in surface area.

RESULTS

All included patients had an uneventful postoperative clinical course. MRI after 4 weeks revealed one postoperative seroma, which resolved spontaneously. No recurrence was detected. Mesh implants could be accurately delineated in DIXON-IN studies and showed neither clinically nor statistically significant changes in size or position.

CONCLUSION

4 weeks and 1 year after a standardized TAPP procedure the mesh implant used in this study showed no tendency towards dislocation or reduction in size in this anatomical position. Its MRI visibility allows accurate delineation during the postoperative course by experienced radiologists in appropriate MRI protocols. Larger patient series are desirable to further support these findings. Shrinkage of implants in the groin as a reason for early recurrence may be overestimated.

Interfragmentary Compression Forces Vary Based on Scaphoid Bone Screw Type and Fracture Location

BACKGROUND

The objective of this study was to determine the interfragmentary compression forces generated in a foam model as a function of headless compression screw type (fully threaded and central threadless) and fracture location.

METHODS

Eighty-eight polyurethane foam models were fixed across a simulated transverse fracture with either a fully threaded screw or a central threadless screw. The location of the transverse fracture varied along the length of the foam model in 2 mm increments for 11 fracture locations. The force generated at the fracture site upon fixation was utilized to determine the interfragmentary compression. Interfragmentary compression was compared using a paired t test and 2-way analysis of variance, with significance set at P < .05.

RESULTS

Interfragmentary compression was found to vary based on fracture location and screw type. The fully threaded screw generated significantly greater compression for fracture locations at 12 mm and 18 mm from the top edge of the foam model, while the central threadless screw generated significantly greater compression for fractures located 2 mm from the top edge of the foam model.

CONCLUSIONS

The central threadless screw and the fully threaded screw had different fracture locations where maximum compression force occurred. The fully threaded screw generated greater compression force toward the screw center due to greater thread purchase. However, the central threadless screw generated greater compression at the most proximal fracture location due to its greater thread pitch toward the screw head. Maximizing interfragmentary compression may aid in reducing nonunion rates associated with the internal fixation of proximal scaphoid fractures.

Influence of Wrist Position on the Metacarpophalangeal Joint Motion of the Index Through Small Finger

BACKGROUND

The metacarpophalangeal joints exhibit range of motion that is influenced by wrist position. Synergistic motion occurs between the wrist and the metacarpophalangeal joints with different static wrist positions affecting joints' motion capability. The aim of this study was to determine how different wrist positions influence the active range of motion of the index through small finger metacarpophalangeal joints.

METHODS

The active range of motion of the index through small finger metacarpophalangeal joints of 31 healthy subjects was measured in flexion/extension and radial/ulnar deviation in 5 different flexion/extension wrist positions, using biaxial electrogoniometers.

RESULTS

There was a difference in range of motion of all fingers depending on the wrist position. The minimum metacarpophalangeal joint range of motion was found in 80° wrist extension, the maximum in neutral wrist position. For the index finger, flexion/extension was 84.7° (±8.6°) to 25.9° (±10.2°) and radial/ulnar deviation was 32.1° (±11.3°) to 22.6° (±12.8°). For the middle finger, flexion/extension was 84.8° (±8.5°) to 25.9° (±10.1°) and radial/ulnar deviation 28.8° (±11.1°) to 22.1° (±8.9). The fourth finger showed a range of motion for flexion/extension of 87.2° (±11.5°) to 22.8° (±11.6°) and radial/ulnar deviation of 8.1° (±5.8°) to 32.3° (±12.4°). The highest range of motion was measured at the fifth finger with flexion/extension of 84.0° (±8.6°) to 32.1°(±16.8°) and radial/ulnar deviation of 15.1° (±12.9°) up to 54.6° (±18.7°).

CONCLUSIONS

The range of motion of the index through small finger metacarpophalangeal joints was significantly influenced by wrist position. The highest metacarpophalangeal joint range of motion of all fingers was conducted in neutral wrist positions. Apart from ergonomic implications, we conclude that metacarpophalangeal joint motion should be assessed under standardized wrist positions.

Sandbox-Dermatitis als unterdiagnostizierte Differenzialdiagnose bei juckenden Papeln an den Streckseiten der Extremitäten bei Kindern

Die Sandbox-Dermatitis ist eine weitestgehend unbekannte Erkrankung im Kindesalter, deren Prävalenz wahrscheinlich häufiger ist als angenommen. Wir berichten über den Fall eines 6-jährigen Jungen, der sich mit juckenden, stecknadelkopfgroßen, hypopigmentierten Papeln an den Streckseiten der Extremitäten, die seit den Sommermonaten bestünden, vorstellte. Da der Juckreiz für den Jungen sehr quälend war und die Eltern sich sehr besorgt zeigten, erfolgte die Vorstellung durch den Kinderarzt. Zur Diagnosefindung wurden Differenzialdiagnosen nach ihrer Lokalisation, Morphologie und nach saisonalem Auftreten bewertet. Anhand der typischen Klinik konnte die Diagnose der Sandbox-Dermatitis gestellt werden und dem kleinen Patienten weitere schmerzhafte Diagnostik erspart bleiben. Aufgrund der Einordnung war es nun möglich, eine adäquate Therapie einzuleiten und den Eltern die Sorge zu nehmen, da nun über die Harmlosigkeit, die Triggerfaktoren und den variablen Verlauf der Erkrankung aufgeklärt werden konnte.

Optimal Oblique Radiographs to Identify Fifth Carpometacarpal Dorsal Subluxations: A Cadaveric Study

PURPOSE

Carpometacarpal (CMC) joint subluxations of the fifth finger are rare injuries and are notoriously difficult to diagnose due to severe swelling and overlapping of bones on radiographs. Various radiographic studies have been suggested to identify these injuries. We hypothesize that there will be no difference between various oblique radiographs for detection of a fifth finger CMC subluxation.

METHODS

Using 4 cadaveric specimens, we took radiographs at various angles (0°, 30°, 45°, and 60°) with the fifth metacarpal in anatomic position, subluxated 25% and 50% dorsally. Radiology and orthopedic residents, fellows, and attending physicians viewed each image to determine whether a subluxation was present. Data were analyzed using area under the receiver operating curve, sensitivity, and specificity.

RESULTS

A total of 36 responses were obtained from 9 radiologists (4 residents, 3 fellows, 2 attendings) and 27 orthopedic surgeons (16 residents, 8 fellows, 3 attendings). Radiographs taken at 60° were more sensitive and specific (Sn 85, Sp 60) than at 0° (Sn 64, Sp 33), 30° (Sn 84, Sp 47), or 45° (Sn 80, Sp 49). Area under the receiver operating curve was also higher for 60° (0.87) than 0° (0.59), 30° (0.75), and 45° (0.75).

CONCLUSIONS

Sensitivity, specificity, and area under the receiver operating curve were highest for 60° radiographs. We recommend obtaining radiographs of the hand in 60° of pronation from the lateral if there is suspicion for a fifth CMC subluxation or dislocation.

CLINICAL RELEVANCE

This study suggests a simple radiographic view to enhance the diagnosis of fifth CMC subluxations.

Lower Risk of Recurrence After Mesh Repair Versus Non-Mesh Sutured Repair in Open Umbilical Hernia Repair: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND AIMS

The use of mesh repair in a small- or middle-sized umbilical hernia remains controversial, and evidence is based on only few and small heterogeneous randomized trials. The primary aim was to assess differences, if any, in recurrence (clinical and reoperation), and secondary aim was to assess differences in infections, seroma formation, hematomas, chronic pain, cosmetic result, and quality of life.

METHOD

A systematic review (predefined search strategy) and meta-analyses were conducted based on pre-study strict and well-defined methodology. The literature search was completed on 1 January 2018. The study protocol was registered in PROSPERO.

RESULTS

Five randomized controlled trials were identified (mesh repair, n = 326 versus non-mesh sutured repair, n = 330) and 602 records were excluded. Randomized controlled trials included patients with defect diameters of ⩾1 to 4 cm. Mesh repair reduced the risk of recurrence compared with sutured repair with a relative risk of 0.28 (95% confidence interval = 0.13-0.58, I² = 0%, number needed to treat = 13 patients). Additional analyses found no differences between the two surgical techniques regarding infection (relative risk = 0.80, 95% confidence interval = 0.36-1.79), seroma formation (relative risk = 1.38, 95% confidence interval = 0.57-3.32), or hematomas (relative risk = 0.55, 95% confidence interval = 0.23-1.30). Lack of sufficient data precluded meta-analysis evaluating risk of seroma formation, hematomas, chronic pain, cosmetic result, and quality of life.

CONCLUSION

Mesh repair is recommended for umbilical hernia of ⩾1 to 4 cm. More evidence is needed for the optimal placement of the mesh (sublay or onlay) and the role of mesh in patients with an umbilical hernia <1 cm.

Directing adipose-derived stem cells into keratinocyte-like cells: impact of medium composition and culture condition

BACKGROUND

Adipose-derived stem cells (ASC) are known to transdifferentiate into a wide range of different cell species in vitro including along the epidermal lineage. This property makes them a promising tool for regenerative medicine to restore the epidermal barrier.

OBJECTIVE

This study is dedicated to identify in vitro conditions enabling transdifferentiation to a keratinocyte-like phenotype. In particular, the impact of different culture conditions (media compositions, 2D, 3D cultures) and extracellular matrix (ECM) molecules was evaluated.

METHODS

Adipose-derived stem cells derived from subcutaneous abdominal fat were characterized by stemness-associated markers and subjected to different media. Epithelial differentiation in 2D cultures was monitored by pan-cytokeratin expression using flow cytometry and immunocytochemistry. To evaluate the impact of different ECM molecules on epidermal stratification, 3D cultures were produced, lifted to the air-liquid interface (ALI) and examined by histological analysis and quantitative real-time RT-PCR.

RESULTS

We identified a medium composition containing retinoic acid, hydrocortisone, ascorbic acid and BMP-4 enabling maximum pan-cytokeratin expression in 2D cultures. Moreover, adhesion to type IV collagen further promotes the pan-cytokeratin expression. When cultures were lifted to the ALI, significant stratification was observed, particularly in supports coated with type IV collagen or fibronectin. Moreover, epidermal differentiation markers (involucrin, cytokeratin 1 and 14) become induced.

CONCLUSION

Conditions with hampered wound healing such as non-healing ulcers demand new treatment regimes. The here introduced optimized protocols for transdifferentiation of ASC into keratinocyte-like cells may help to establish more effective treatment procedures.

Compact Mock Loops of the Systemic and Pulmonary Circulation for Blood Pump Testing

Mock loops are an important tool for in vitro investigations of artificial blood pumps. The simple windkessel, throttle, and atrium principle was used for the mock loop design presented. The components of the systemic and the pulmonary mock loop were designed according to calculated numerical simulation parameters. The loops offer a compact design and simple handling. For simulating biventricular assist or total artificial heart (TAH), both loops can be coupled correspondingly. The numerical simulation and the first results with the loops show very good similarity to physiological data of systemic and pulmonary circulation. The measurements of pump characteristics are significant for quantitative comparison of different pump sizes and types, or driving systems.

Electromechanical Artificial Heart with a New Gear Type and Angled Pump Chambers

The intrathoracic anatomical situation after explantation of the natural heart defines the maximum available space for the design of the housing as well as of the inlet-and outlet connectors of a fully implantable electromechanical artificial heart. Based on computer-assisted anatomical studies, a total artificial heart housing is designed which facilitates an oblique orientation of the pumping chambers for a better fluidmechanical and anatomical arrangement of the in- and outlet connectors. The pumping chamber geometry is based on modifications of an existing cardiac assist-system. Subsequently a mechanical gear which conforms to this anatomically adapted housing is developed.

Simultaner Einsatz verschiedener nuklearmedizinischer Verfahren bei Klippel-Trenaunay-Syndrom – vs. Proteus-Syndrom

Bei einem dreijährigen Jungen fiel bereits bei der Geburt ein dyspropor-tionierter Überwuchs des linken Fußes sowie ein großer Naevus flam-meus mit nodulären Veränderungen im Bereich der linken Hüfte auf, so daß der Verdacht auf ein Klippel-Trenaunay-Syndrom geäußert wurde. Im Laufe der weiteren Entwicklung kam es zu einer kontinuierlichen Progredienz dieser Befunde, mit deutlicher Weichteilschwellung sowie pa-pillomatösen und verruziformen Vegetationen des Naevus. Darüber hinaus entwickelte sich auch unterhalb der rechten Schulter eine großflächige, flache Raumforderung sowie eine Makrodaktylie der I. und II. Zehe links. Trotz zahlreicher zwischenzeitlich durchgeführter diagnostischer Maßnahmen konnte die Verdachtsdiagnose bis zu diesem Zeitpunkt nicht bestätigt werden. Anläßlich einer ausgeprägten lokalen Infektion im Hüftbereich, die die Frage nach einer operativen Sanierung aufwarf, wurden – um eine längere Ruhigstellung des Jungen zu vermeiden – am gleichen Tag eine Lymphabflußszintigraphie, eine Radio-nuklidphlebographie und -ventrikulographie sowie eine Blutpool- und Skelettszintigraphie durchgeführt. Die Ergebnisse ließen ein Lymphangiom vermuten, das nach operativer Entfernung des Befundes histologisch bestätigt werden konnte. Unter Berücksichtigung aller Untersuchungsergebnisse dürfte es sich bei dem zugrundeliegenden Krankheitsbild nicht um ein Klippel-Trenaunay-Syndrom, sondern um das seltene Proteus-Syndrom handeln.

Diagnosis of heparin-induced delayed type hypersensitivity

Heparin is commonly used for prevention and therapy of thromboembolic diseases. Recently, work from a prospective epidemiological investigation has indicated, that heparin-induced skin lesions may be more frequent, than expected. Commonly, delayed-type hypersensitivity reactions can be identified as the cause of heparin-induced skin lesions. Rarely, immediatetype hypersensitivity responses or immune-mediated heparin-induced thrombocytopenia (HIT) are diagnosed. It is of clinical importance to differentiate between those, as patient management is fundamentally different. Patients, methods: We evaluated diagnostic procedures used to identify causes of heparin-induced skin lesions. Based on clinical presentation, histology and/or allergologic testing in 32 patients, heparin-induced delayed-type hypersensitivity (HIHS) was diagnosed. Results: Sensitivity of histology and s.c. provocation was high, amounting to 100% or 78% respectively. All other tests were unspecific or had a low sensitivity: Immediate readings of prick tests were false negative in 81%. Patch, prick and i.c. testing had a sensitivity ranging from 3.1–15.6%. Conclusion: Based on these results and despite the limitations of histology we recommend performing a skin biopsy rather than allergologic testing for diagnosis of HIHS. Compared to allergologic testing, results from histology are sensitive, readily available and may allow a differentiation from other causes of heparin-induced skin lesions.

Peak and baseline concentrations of fondaparinux during prophylactic therapy

Fondaparinux is widely approved for prophylaxis and treatment of venous thromboembolic events (VTE). However, its longer half-life time compared to heparins limits its peri-procedural use.

Aim: To investigate 3h peak and 24h baseline concentrations of fondaparinux when administered for prophylaxis (1 x 2.5 mg qd). Secondary outcome measures: incidences of VTE, bleedings, HIT, allergic skin reactions, 30 days mortality.

Patients, methods: Between 02/2010 and 03/2011, 3h peak and 24h baseline levels of fondaparinux were measured with a chromogenic anti-FXa method in 75 consecutive patients. Medical data were obtained from patients' records.

Results: The 5% and 95% percentile of the 3h peak level were 0.20 μg/ml and 0.83 μg/ml (median: 0.53 μg/ml), and of the 24h baseline level 0.08 μg/ml and 0.53 μg/ml (median 0.21 μg/ml), respectively. An inverse correlation was found between fondaparinux levels and GFRs (rho=-0.617 (3h); rho=-0.648 (24h); p=0.01). Shorter (≤5 days) or longer (≥8 days) duration of prior fondaparinux exposure showed no significantly different 3h peak/24h baseline levels (p>0.6). One progressive thrombosis occurred but no major bleedings, HIT, allergic skin reactions or fatalities.

Conclusions: After fondaparinux exposure, >75% of the patients still had relevant prophylactic 24h baseline levels. This did not coincide with a high rate of bleeding events. Due to the low patient number in this study undergoing surgery or interventions, it remains to be investigated whether or at which concentrations the bleeding risk is increased when baseline levels are within prophylactic ranges.

Characteristics of different mesh types for abdominal wall repair in an experimental model of peritonitis

BACKGROUND

The use of synthetic mesh to repair a potentially contaminated incisional hernia may lead to higher failure rates. A biological mesh might be considered, but little is known about long-term results. Both biological and synthetic meshes were investigated in an experimental model of peritonitis to assess their characteristics in vivo.

METHODS

Male Wistar rats were randomized into five groups and peritonitis was induced. A mesh was implanted after 24 h. Five meshes were investigated: Permacol™ (cross-linked collagen), Strattice™ (non-cross-linked collagen), XCM Biologic^® (non-cross-linked collagen), Omyra^® Mesh (condensed polytetrafluoroethylene) and Parietene™ (polypropylene). The rats were killed after either 30, 90 or 180 days. Incorporation and shrinkage of the mesh, adhesion coverage, strength of adhesions and histology were analysed.

RESULTS

Of 135 rats randomized, 18 died from peritonitis. Some 180 days after implantation, both XCM Biologic^® and Permacol™ had significantly better incorporation than Strattice™ (P = 0·003 and P = 0·009 respectively). Strattice™ had significantly fewer adhesions than XCM Biologic^® (P = 0·001) and Permacol™ (P = 0·020). Thirty days after implantation, Permacol™ had significantly stronger adhesions than Strattice™ (P < 0·001). Shrinkage was most prominent in XCM Biologic^® , but no significant difference was found compared with the other meshes. Histological analysis revealed marked differences in foreign body response among all meshes.

CONCLUSION

This experimental study suggested that XCM Biologic^® was superior in terms of incorporation, macroscopic mesh infection, and histological parameters such as collagen deposition and neovascularization. There must be sufficient overlap of mesh during placement, as XCM Biologic^® showed a high rate of shrinkage. Surgical relevance The use of synthetic mesh to repair a potentially contaminated incisional hernia is not supported unequivocally, and may lead to a higher failure rate. A biological mesh might be considered as an alternative. There are few long-term studies, as these meshes are expensive and rarely used. This study evaluated the use of biological mesh in a contaminated environment, and investigated whether there is an ideal mesh. A new non-cross-linked biological mesh (XCM Biologic^® ) was evaluated in this experiment. The new non-cross-linked biological mesh XCM Biologic^® performed best and may be useful in patients with a potentially contaminated incisional hernia.

Critical overview of all available animal models for abdominal wall hernia research

PURPOSE

Since the introduction of the first prosthetic mesh for abdominal hernia repair, there has been a search for the "ideal mesh." The use of preclinical or animal models for assessment of necessary characteristics of new and existing meshes is an indispensable part of hernia research. Unfortunately, in our experience there is a lack of consensus among different research groups on which model to use. Therefore, we hypothesized that there is a lack of comparability within published animal research on hernia surgery due to wide range in experimental setup among different research groups.

METHODS

A systematic search of the literature was performed to provide a complete overview of all animal models published between 2000 and 2014. Relevant parameters on model characteristics and outcome measurement were scored on a standardized scoring sheet.

RESULTS

Due to the wide range in different animals used, ranging from large animal models like pigs to rodents, we decided to limit the study to 168 articles concerning rat models. Within these rat models, we found wide range of baseline animal characteristics, operation techniques, and outcome measurements. Making reliable comparison of results among these studies is impossible.

CONCLUSION

There is a lack of comparability among experimental hernia research, limiting the impact of this experimental research. We therefore propose the establishment of guidelines for experimental hernia research by the EHS.