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Biomedical subjects

E A M Neugebauer

Publications and source records attributed to E A M Neugebauer.

18 recordsLinked to original sources
PubMed2006

[Pain therapy in addicted patients].

Each individual is entitled to an adequate and sufficient pain therapy. However, only a few studies have examined the peculiarities of pain management in drug-dependent or formerly addicted patients. Any addiction is disadvantageous for a successful pain therapy, since some of the prescribed drugs may themselves cause addiction. Drug-dependent patients are often tolerant to opioids. Additionally, there is a risk of iatrogenic pain becoming chronic due to disregard for already known risk factors and comorbidities. However, a history of addiction should not prevent sufficient pain therapy, especially since there is no risk of addiction when the pain therapy employed is adequate for the pathophysiology involved. There are adequate pain therapies for addicted patients. The best results are achieved by taking into account the physiological and psychological peculiarities of drug-dependent patients. Importantly, this should be combined with a variety of different, optimized, multimodal therapeutic regimes, as well as with an interdisciplinary approach.

Acupuncture Therapy↗
PubMed2005

Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery.

BACKGROUND: Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. METHODS: A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. RECOMMENDATIONS: Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. CONCLUSIONS: Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Abdomen↗
PubMed2005

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has advantages over the open procedure for postoperative pain. However, a systematic review of postoperative pain management in this procedure has not been conducted. METHODS: A systematic review was conducted according to the guidelines of the Cochrane Collaboration. Randomized studies examining the effect of medical or surgical interventions on linear pain scores in patients undergoing laparoscopic cholecystectomy were included. Qualitative and quantitative analyses were performed. Recommendations for patient care were derived from review of these data, evidence from other relevant procedures, and clinical practice observations collated by the Delphi method among the authors. RESULTS: Sixty-nine randomized trials were included and 77 reports were excluded. Recommendations are provided for preoperative analgesia, anesthetic and operative techniques, and intraoperative and postoperative analgesia. CONCLUSIONS: A step-up approach to the management of postoperative pain following laparoscopic cholecystectomy is recommended. This approach has been designed to provide adequate analgesia while minimizing exposure to adverse events.

Analgesia↗
PubMed2005

Local administration of TGF-beta1 to reinforce the anterior abdominal wall in a rat model of incisional hernia.

The purpose of this study was to investigate different forms of the local application of TGF-beta(1) for augmentation of the anterior abdominal wall in an appropriate model of an incisional hernia. Sixty male Sprague-Dawley rats were divided into six groups. Artificial defects of the anterior abdominal wall were closed with one of the following methods: running Prolene suture, Vicryl mesh, prolene suture followed by an intramuscular injection of 1 mug TGF-beta(1), Vicryl mesh coated with 1 mug TGF-beta(1), and prolene suture coated with 1 mug TGF-beta(1). A control group did not receive any defect and treatment. Six weeks after operation, tensile strength, collagen content, gene expression of collagen I and III, blood vessels, and thickness of collagen fibres were evaluated. Tensile strength was strongest in the controls (14.2 (10.5-18 N)). There was no increase in tensile strength due to the administration of TGF-beta(1). On the contrary, bolus injection of the growth factor resulted in a significantly decreased strength of the wound tissue when compared to the groups 1, 4, 5, and 6 (9.1 (4.2-9.1 N)). These results correlated with the gene expression of collagen I and III. Local application of TGF-beta(1) did not augment the strength of the abdominal wall after 6 weeks.

Abdominal Wall↗
PubMed2004

Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES).

BACKGROUND: The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectiveness and surrounding circumstances of the various types of obesity surgery. METHODS: A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued. RECOMMENDATIONS: After the patient's multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

Adolescent↗
PubMed2004

Laparoscopic versus open surgery for suspected appendicitis.

BACKGROUND: Laparoscopic surgery for acute appendicitis has been proposed to have advantages over conventional surgery. OBJECTIVES: To compare the diagnostic and therapeutic effects of laparoscopic and conventional 'open' surgery. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SciSearch, the congress proceedings of endoscopic surgical societies. SELECTION CRITERIA: We included randomized clinical trials comparing laparoscopic (LA) versus open appendectomy (OA) in adults or children. Studies comparing immediate OA versus diagnostic laparoscopy (followed by LA or OA if necessary) were separately identified. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality. Missing information or data was requested from the authors. We used odds ratios (OR), relative risks (RR), and 95% confidence intervals (CI) for analysis. MAIN RESULTS: We included 54 studies, of which 45 compared LA (with or without diagnostic laparoscopy) vs. OA in adults. Wound infections were less likely after LA than after OA (OR 0.45; CI 0.35 to 0.58), but the incidence of intraabdominal abscesses was increased (OR 2.48; CI 1.45 to 4.21). The duration of surgery was 12 minutes (CI 7 to 16) longer for LA. Pain on day 1 after surgery was reduced after LA by 9 mm (CI 5 to 13 mm) on a 100 mm visual analogue scale. Hospital stay was shortened by 1.1 day (CI 0.6 to 1.5). Return to normal activity, work, and sport occurred earlier after LA than after OA. While the operation costs of LA were significantly higher, the costs outside hospital were reduced. Five studies on children were included, but the result do not seem to be much different when compared to adults. Diagnostic laparoscopy reduced the risk of a negative appendectomy, but this effect was stronger in fertile women (RR 0.20; CI 0.11 to 0.34) as compared to unselected adults (RR 0.37; CI 0.13 to 1.01). REVIEWERS' CONCLUSIONS: In those clinical settings where surgical expertise and equipment are available and affordable, diagnostic laparoscopy and LA (either in combination or separately) seem to have various advantages over OA. Some of the clinical effects of LA, however, are small and of limited clinical relevance. In spite of the mediocre quality of the available research data, we would generally recommend to use laparoscopy and LA in patients with suspected appendicitis unless laparoscopy itself is contraindicated or not feasible. Especially young female, obese, and employed patients seem to benefit from LA.

Acute Disease↗
PubMed2004

Limitations of score-based daily outcome predictions in the individual intensive care patient. An example of the RIAHDH algorithm.

OBJECTIVE: The nature of score-based predictions is probabilistic, and their accuracy depends on the reliability and validity of the applied system. As an example, the present study investigates the accuracy of the RIP-algorithm (RIP = Riyadh Intensive Care Program) based on daily APACHE II scores, and compares it with published results of that algorithm from other investigators. DESIGN: Prospective observational study and review of the literature. PATIENTS AND METHODS: 1,986 consecutive admissions of 1,808 patients to a surgical intensive care unit were documented. Daily changes of score values were used to derive a risk of death estimation. Sensitivity and the rate of false predictions were calculated for score-based predictions. Health status one year after discharge was assessed in survivors predicted to die. RESULTS: Daily application of the algorithm identified 109 situations leading to death predictions in 56 patients. Five of these patients were discharged alive from the hospital (positive predictive value 91%). One year later 3 of these patients were still alive. The algorithm identified 51 of the non-survivors (sensitivity 19%), 110 died in the ICU without prediction. Altogether 270 patients died during their hospital stay. Among the 6 independent validation studies, similar results were found, but differences occurred due to the problematic assessment of consciousness. CONCLUSIONS: Sequential assessment of scores in intensive care could identify high risk patients, but with some degree of uncertainty. Therefore, the scores should only be used by those familiar with their limitations and risks.

APACHE↗
PubMed2004

New approaches to shock and trauma research: learning from multidisciplinary exchange.

BACKGROUND: Our understanding of the complex network of pathophysiology after multiple injury is limited. It is proposed to overcome the limitations of the traditional linear reductionism approach by merging the expertise of biology and medicine with other disciplines such as mathematics, physics and computer science. METHODS: We organized a two-days-workshop, where surgeons and surgical scientists explained the problem from the medical (pathophysiological) perspective to a well selected group of German applied mathematicians and computer scientists. Vice versa they presented and discussed their approaches to complex system analysis. RESULTS AND CONCLUSIONS: Physicians found it difficult to develop questions and concepts that go beyond the classic mechanistic thinking. Well formulated questions are the most important prerequisites for successful application of mathematical tools. The possibilities and borders of Artificial Neural Networks (ANN), Hidden Markow Models (HMM), Agent Based Models (ABM), differential equations for problem solving were discussed. There is no master model for all aspects of pathophysiology, however, application of the models to specific problems is mandatory. CONCLUSIONS: Future breakthroughs can only be expected if we overcome language problems between disciplines. This cross talk was considered by all participants as a most important step.

Communication↗
PubMed2003

[Risk factors for the development of pneumonia in multiple injured patients. Results of a prospective clinical trial].

Pneumonia is the most common infectious complication in multiple trauma patients. In a prospective clinical cohort study, 266 multiply injured patients were examined for the development of pneumonia. Various risk factors were tested in uni- and multivariate analyses. Three different definitions of pneumonia were used in order to examine how results depended on definition. The incidence of pneumonia was 41%, but varied with definition (30-50%). Injuries to the thorax, head,and abdomen were associated with a significantly increased risk of pneumonia (adjusted relative risk: 1.77, 1.97,and 1.52, respectively).Furthermore, increasing age led to a higher risk of pneumonia. Although the primary analysis revealed a higher pneumonia risk in male patients (adjusted relative risk: 2.23; 95% CI: 1.43-3.05), this result could not be consistently reproduced when using other definitions of pneumonia. Trunk and head injuries and age are proven risk factors for developing posttraumatic pneumonia. The association between male gender and an increased rate of infectious complications remained questionable.

Abbreviated Injury Scale↗
PubMed2003

Fingers, hands or patients? The concept of independent observations.

In hand surgery trials, it is often possible to take several measurements from the same patient, because many disorders here affect bilateral or multiple structures, such as the hand itself, the finger joints or the tendons. Most conventional statistical analyses that take place on the level of hands, digit rays or joints rather than patients violate the assumption that observations should be independent. Furthermore, ignoring the multiplicity of data inflates sample size and thus may lead to spurious significance. This article describes three options to deal with such problems. First, the analysis can simply be restricted to only one measurement per patient. Second, a self-controlled design may be advantageous for conditions that usually have a bilateral pattern. Third, complex statistical modelling (involving generalized estimating equations) can be used to analyse all available measurements with adjustment for data dependency.

Controlled Clinical Trials as Topic↗
PubMed2002

Severity scores in surgery: what for and who needs them? An introduction: definition, aims, classification and evaluation.

Every patient represents a unique and complex situation a clinician has to deal with. In order to cope with this complexity of information, reduction is necessary, especially in communication about diseases or therapy. The first reduction is made when a patient is given a diagnosis which reflects a constellation of similar symptoms. A score also reduces the given amount of clinical data into a one-dimensional value. The primary aim of a score is a systematic comparison between patients and institutions. Scores reduce information to focus on the essentials. They are used for severity classification and prognosis, evaluation of outcome and treatment effects, case-mix adjustments in comparative audits, and economic evaluation. Quality criteria of score systems which should be considered in the development and application are: reliability, validity, measurability, applicability, and clinical relevance. This introductory article gives a brief description of these terms.

General Surgery↗
PubMed2002

[Evidence based trauma surgery].

It is wise for surgeons to critically analyze their decision making, to add evidence in addition to the normal approaches, i.e. expert opinion and pathophysiological rationale. What evidence, is how it works, how often it is used in orthopedic surgery are the main topics of this article, as well as problems and limits to evidence-based medicine (EbM). EbM operates in five steps: 1. formulate an answerable question with respect to the patient's problems; 2. search the relevant literature; 3. critically appraise the assembled information through evidence based standards; 4. implement these evidence supported findings in your daily practice; 5. evaluate your evidence-based practice. When one builds decisions upon evidence the following effects become apparent: rational choice of possible, alternative decisions, reduction of diagnostic and therapeutic risks, improvements in medical education and efficient delivery of health care. A literature search reveals few evidence-based investigations published in orthopedic surgery. Lastly, we discuss limitations of EbM, showing that both misunderstanding about EbM and technical problems contribute to mistrust in EbM. These may include problems with population heterogeneity, standardization of surgical procedures, conducting random studies, the lack of statistical power and often "publication bias". Overcoming present problems with EbM by further ("evidence-based") research should lead to better understanding of the evidence paradigm and eventually modify this approach. The literature already demonstrates that EbM attains its goal. A valid judgment of EbM will result if one evaluates one's own evidence-based practices. The implementation of EbM is also a matter of policy.

Decision Support Systems, Clinical↗
PubMed2002

Randomized clinical trial of suture repair, polypropylene mesh or autodermal hernioplasty for incisional hernia.

BACKGROUND: Since conventional suture repair for incisional hernia is associated with high recurrence rates, alloplastic and autoplastic prosthetic techniques have been suggested. METHODS: In a randomized trial, 160 patients with simple or complex hernias underwent either suture repair, autodermal skin graft or onlay polypropylene mesh repair. Suture repair was not done in complex hernias. This report concerns a planned interim analysis. RESULTS: At mean follow-up of 16 months, there were 17 hernia recurrences that were distributed similarly between the surgical techniques. There were fewer infectious complications after suture repair (three of 33 patients) than after skin graft or mesh repair (seven of 39 and five of 28 for simple hernias; seven of 31 and ten of 29 respectively for complex hernias) (P not significant). The severity of infections after polypropylene mesh implantation prompted the trial committee to discontinue the study. No differences were noted in duration of stay in hospital and quality of life. However, pain was significantly more frequent after polypropylene mesh repair (pooled risk ratio 2.9 and 1.8 at 6 weeks and 1 year respectively). CONCLUSION: Suture repair was safe for small incisional hernias. Both autoplastic and alloplastic hernia repair yielded comparably low recurrence rates, but led to a high rate of wound infection.

Female↗
PubMed2002

Retrospective clinical studies in surgery: potentials and pitfalls.

As many surgical studies are performed retrospectively, it is desirable to improve the conduct, analysis and reporting of such research designs. This article reviews some of the most common forms of bias encountered in clinical research and outlines various types of study design and analysis that can help to minimize the amount of bias introduced into the results. We describe the advantages and disadvantages of 'raw' data analysis, stratified analysis, matched pair analysis and multivariate analysis, and apply them to an example of a hypothetical hand surgery study.

Controlled Clinical Trials as Topic↗
PubMed2002

[The role of preoperative oesophageal manometry in patients with gastro-oesophageal reflux disease].

BACKGROUND: Oesophageal manometry has become a standard investigation in the management of functional disorders of the oesophagus. However, the importance of the various manometry parameters for the surgical management of patients with gastro-oesophageal reflux disease (GERD) has not yet been studied adequately. AIM: This study examined the importance of manometric findings on surgical treatment results in patients with GERD. PATIENTS AND METHODS: Between January 1995 and January 2000, 123 consecutively referred patients with GERD symptoms were studied. Ninety-seven of these (52 women and 45 men, mean age 48 years) underwent Nissen fundoplication in conventional or laparoscopic technique. Preoperatively, each patient received stationary oesophageal manometry with a water perfusion catheter, gastroduodenoscopy and 24h-pH-metry of the oesophagus. Independent of manometric results, patients received 360 degrees fundoplicatio with 2 cm cuff ("floppy Nissen"). RESULTS: Eighty-five of the 97 patients (88 %) had an incompetent lower oesophageal sphincter. Hypomotility was diagnosed in 17 (18 %). Amotile achalasia and diffuse oesophageal spasms were seen in two and one patient, respectively, who were not operated on. Follow-up data were available for 92 % of patients (mean follow-up time 1.8 years). Five and 8 patients (1 and 2 of these with hypomotility) postoperatively developed persistent dysphagia and GERD recurrence, respectively (relative risks 1.2 and 1.6). Two patients (one with hypomotility) required surgical revision. CONCLUSIONS: Preoperative oesophageal manometry in GERD patients is useful only for determining the position of the upper boundary of the lower oesophageal sphincter and for ruling out specific motility disorders. In patients with oesophageal hypomotility, "floppy Nissen" fundoplicatio can be performed without an excess risk of dysphagia.

Deglutition Disorders↗