Über Rudolf Borchardt: Text (Fischer Klassik Plus 293) (German Edition)

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A randomized controlled trial of brief cognitive-behavioral interventions for cannabis use disorder. Journal of Substance Abuse Treatment , 21 , 55 — Cognitive-behavioural group therapy in obsessive-compulsive disorder: Psychotherapy and Psychosomatics , 72 , Antipsychotic use in children and adolescents: Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. Surgery for psychiatric disorders. CNS Spectrums , 5 10 , 43 — Anxiety Disorders in Children and Adolescents.

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The effect of leucotomy in intractable adolescent weight phobia primary anorexia nervosa. Postgraduate Medical Journal , 49 , — A controlled study of the effect of therapies aimed at adolescent and family psychopathology in anorexia nervosa. Psychosocial treatments for cocaine dependence: Archives of General Psychiatry , 56 , — Complex treatments for eating disorders.

Cambridge Textbook of Effective Treatments in Psychiatry. Cambridge University Press , pp. What potential role is there for medication treatment in anorexia nervosa?

International Journal of Eating Disorders , 42 , 1 —8. The use of methylphenidate in children with seizures and attention deficit disorder. Annals of Neurology , B , —2. Older adults and withdrawal from benzodiazepine hypnotics in general practice: Psychological Medicine , 33 , — Journal of Family Psychology , 18 , — Does treatment really make psychopaths worse? A review of the evidence. Journal of Personality Disorders , 18 , — The application of behavioral couples therapy to the assessment and treatment of agoraphobia: Clinical Psychology Review , 18 , — Effects of fluoxetine and maprotiline on functional recovery in poststroke hemiplegic patients undergoing rehabilitation therapy.

Stroke , 27 , — Psychological therapies for adults with anorexia nervosa: A follow-up study of 10 feminine boys. Archives of Sexual Behavior , 15 , —7. Treatment of posttraumatic stress disorder with amitriptyline and placebo. Archives of General Psychiatry , 47 , — Treatment of social phobia with clonazepam and placebo. Journal of Clinical Psychopharmacology , 13 , —8. Efficacy of sertraline in preventing relapse of posttraumatic stress disorder: Fluoxetine comprehensive cognitive behavioral therapy, and placebo in generalized social phobia.

Venlafaxine extended release in posttraumatic stress disorder: Journal of Clinical Psychopharmacology , 26 3 , — Treatment of posttraumatic stress disorder with venlafaxine extended release: Archives of General Psychiatry , 63 10 , — Cognitive therapy for antisocial and borderline personality disorders: British Journal of Clinical Psychology , 35 , — The effectiveness of cognitive behavior therapy for borderline personality disorder: Journal of Personality Disorders , 20 , — Comprehensive Textbook of Psychiatry V.

Baltimore , Williams and Wilkins , pp. A quantitative analysis of clinical drug trials for the treatment of affective disorders. Psychopharmacology Bulletin , 29 , — A meta-analysis of the efficacy of second-generation antipsychotics. Archives of General Psychiatry , 60 , — Brief group psychoeducation for bulimia nervosa: Journal of Consulting and Clinical Psychology , 58 6 , —5. Group psychoeducation for bulimia nervosa with and without additional psychotherapy process sessions.

International Journal of Eating Disorders , 22 1 , 25 — Journal of Substance Abuse Treatment , 23 , 9 — Randomized, controlled trial of an intervention for toddlers with autism: Pediatrics , , e7 —e Respiratory training prior to exposure in vivo in the treatment of panic disorder with agoraphobia: Australian and NZ Journal of Psychiatry , 29 1 , — De Deyn , P. P , Rabheru , K. A randomized trial of risperidone, placebo, and haloperidol for behavioural symptoms of dementia.

Neurology , 53 , — Management of agitation, aggression, and psychosis associated with dementia: Clinical Neurology and Neurosurgery , , — Pharmacological treatment of cocaine dependence: Archives of General Psychiatry , 62 4 , — Rate of psychiatric illness one year after traumatic brain injury. Two-year follow-up study of cognitive behavioural therapy for sexually abused children suffering post-traumatic stress symptoms. Child Abuse and Neglect , 23 , —8. Ego-state therapy in the treatment of a complex eating disorder.

Contemporary Hypnosis , 20 , — Trends in the use of antidepressants in a national sample of commercially insured pediatric patients, to Psychiatric Services , 55 , — A double-blind, randomized, placebo-controlled study of quetiapine as adjunctive treatment for adolescent mania. A double-blind randomized pilot study comparing quetiapine and divalproex for adolescent mania.

De Leon , G. Textbook of Substance Abuse Treatment , 3rd ed. American Psychiatric Press , pp. Pharmacological interventions for benzodiazepine mono-dependence management in out patient settings. Department of Health Mental Health Policy Implementation Guide: Dual Diagnosis Good Practice Guide. Department of Health a. Prescription costs analysis PCA online. Department of Health b. Selective serotonin reuptake inhibitors — use in children and adolescents with major depressive disorder. Art therapy, psychodrama, and verbal therapy. An integrative model of group therapy in the treatment of adolescents with anorexia nervosa and bulimia nervosa.

Post-ECT myoclonic jerks in a depressed patient with bulimia. Convulsive Therapy , 8 4 , —9. Dickerson Mayes , S. Outcome following child psychiatric hospitalization. Differential symptom reduction by drugs and psychotherapy in acute depression. Archives of General Psychiatry , 36 , —6. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. International Journal of Obesity , 26 , — Family therapy for bulimia nervosa in adolescents: Journal of Family Therapy , 17 , 59 — The short-term impact of two classroom-based preventive interventions on aggressive and shy behaviors and poor achievement.

Journal of Applied Developmental Psychology , 14 , — Open-label, multicenter, phase 3 extension study of the safety and efficacy of donepezil in patients with Alzheimer disease. Archives of Neurology , 58 , — Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. British Journal of General Practice , 54 , — Attachment for infants in foster care: Child Development , 72 , — Developing evidence-based interventions for foster children: Journal of Social Issues , 62 , — Suicidal behaviour in youths with depression treated with new-generation antidepressants: Electroconvulsive therapy in delirium tremens.

Comprehensive Psychiatry , 13 , — European Urology , 39 , — Effectiveness of cognitive behaviour therapy for maladaptive children: Self-statement modification in the treatment of child behavior disorders: Psychological Bulletin , , 97 — Randomized controlled trial comparing the efficacy of a video and information leaflet versus information leaflet alone on patient knowledge about surveillance and cancer risk in ulcerative colitis.

Inflammatory Bowel Diseases , 8 , — Recent developments and current controversies in depression. Treatment of sleep problems in families with young children: Acta Paediatrica , 93 , — Outcomes during middle school for an elementary school-based preventive intervention for conduct problems: Behavior Therapy , 34 , — The empirical and theoretical base of family therapy and multiple family day therapy for adolescent anorexia nervosa.

Journal of Family Therapy , 27 , — Family therapy for adolescent anorexia nervosa: Journal of Child Psychology and Psychiatry , 41 , — A randomized controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: Journal of Child Psychology Psychiatry , 48 , — National Institute of Mental Health treatment of depression collaborative research program: Archives of General Psychiatry , 46 , — Clinical effects of sleep deprivation and clomipramine in endogenous depression.

Journal of Psychiatric Research , 17 4 , — Research in Developmental Disabilities , 22 , 77 — Comparison of brief dynamic and cognitive-behavioural therapies in avoidant personality disorder. British Journal of Psychiatry , , 60 —4. Alcoholics Anonymous and other Step groups. Fluoxetine for acute treatment of depression in children and adolescents: A randomized controlled trial with 6-month follow up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression.

American Journal of Psychiatry , , 73 — Yohimbine for erectile dysfunction: Journal of Urology , 2 , —6. Low-dose in obsessive-compulsive risperidone augmentation of fluvoxamine treatment disorder: European Neuropsychopharmacology , 15 , 69 — Office of the Official Publications of the European Communities. Preliminary outcomes of an experimental study comparing treatment foster care and family-centered intensive case management.

Programs and Evaluation Best Practices. Differential relapse following cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry , 49 , —8. Integration of traditional and behavioral concerns. Child and Family Behavior Therapy , 10 , 33 — Methadone maintenance at different dosages for opioid dependence. Acta Psychiatrica Scandinavica , 92 , —8. A cognitive behavioral approach to the treatment of bulimia. Psychological Medicine , 11 , — Interpersonal psychotherapy for bulimia nervosa. The Handbook of Treatment for Eating Disorders , 2nd edn. Behaviour Research and Therapy , 43 , — Eating disorders, DSM-5 and clinical reality.

British Journal of Psychiatry , , 8 — The natural course of bulimia nervosa and binge eating disorder in young women. Cognitive behaviour therapy for eating disorders: Behaviour Research and Therapy , 41 , — Transdiagnostic cognitive behavioral therapy for patients with eating disorders: A double-masked, placebo-controlled study of fluoxetine for hypochondriasis.

Journal of Clinical Psychopharmacology , 28 , — Retention rate and illicit opioid use during methadone maintenance intervention: Drug and Alcohol Dependence , 65 , — A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder. Double-blind study of high-dose fluoxetine versus lithium or desipramine augmentation of fluoxetine in partial responders and nonresponders to fluoxetine.

Journal of Clinical Psychopharmacology , 22 4 , — Psychological and pharmacological treatments of social phobia: Journal of Clinical Psychopharmacology , 21 , — Principles and Practice of Sleep Medicine in the Child. Saunders Company , pp. Benefits from mianserin augmentation of fluoxetine in patients with major depression non-responders to fluoxetine alone. Acta Psychiatrica Scandinavica , , 66 — Medical Clinics of North America , 86 1 , — Bulimic adolescents benefit from massage therapy.

Adolescence , 33 , — Evidence-based pharmacotherapy of obsessive-compulsive disorder. International Journal of Neuropsychopharmacology , 8 , — Sildenafil for male erectile dysfunction: Archives of Internal Medicine , , — The effectiveness of the nicotine patch for smoking cessation: Journal of the American Medical Association , , —7. Treating Tobacco Use and Dependence. US Public Health Service.

Assessing preferences for positive and negative reinforcement during treatment of destructive behavior with functional communication training. Research in Developmental Disabilities , 26 , — Brief physician advice for problem drinkers: Alcoholism, Clinical and Experimental Research , 26 , 36 — Treatment of depressive and obsessive-compulsive symptoms in OCD by imipramine and behaviour therapy.

British Journal of Clinical Psychology , 31 Pt 3 , — A comparison of exposure therapy, stress inoculation training, and their combination for reducing posttraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology , 67 , — Randomized placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obssessive—compulsive disorder. Acta Psychiatrica Scandinavica , 96 , — A double-blind comparison of olanzapine versus risperidone in the acute treatment of dementia-related behavioral disturbances in extended care facilities.

A guide to guidelines for the treatment of PTSD and related conditions. Journal of Traumatic Stress , 23 , — Longer-term primary prevention for alcohol misuse in young people: Addiction , 98 , — Efficacy of ethyl-eicosapentaenoic acid in bipolar depression: British Journal of Psychiatry , 46 — Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry , 47 , —9.

Psychosocial Treatments for Child and Adolescent Disorders: Empirically Based Strategies for Clinical Practice. American Psychological Association , pp. Day treatment group programme for eating disorders: European Eating Disorders Review , 12 , —8. Cognitive-behavioral treatment of obsessive thoughts: Psychosocial treatment for drug dependence. Treating Alcohol and Drug Abuse: An Evidence Based Review. Parkinsonism and Related Disorders , 16 , — Early fluoxetine treatment of post-stroke depression: Journal of Neurology , , — Combined psychotherapy plus antidepressants for panic disorder with or without agoraphobia.

Short- and long-term efficacy and safety of risperidone in adults with disruptive behavior disorders. Psychopharmacology Berlin , , — Journal of Substance Abuse Treatment , 26 , — A brief group cognitive-behavioural intervention for social phobia in childhood. Journal of Anxiety Disorders , 18 , — Rivastigmine for the prevention of postoperative delirium in elderly patients undergoing elective cardiac surgery: Critical Care Medicine , 37 , —8. Pharmacological treatment of alcohol dependence: Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: Virtual reality in the treatment of spider phobia: Behaviour Research and Therapy , 40 9 , — Comparison of the efficacy of new and conventional antipsychotic drugs in the treatment of behavioral and psychological symptoms of dementia BPSD.

Archives of Gerontology Geriatric Supplement , 9 , — Cognitive-behavioural therapy and family intervention for relapse Prevention and symptom reduction in psychosis: British journal of psychiatry , , — Sequencing and integration of treatments. Handbook of Treatment for Eating Disorders. Cognitive-behavioral therapy for anorexia nervosa. Spotlight on atomoxetine in attention deficit hyperactivity disorder in children and adolescents. CNS Drugs , 24 , 85 —8. Recovery from anorexia nervosa: International Journal of Eating Disorders , 21 , — Clinical Psychology Review , 12 2 , — Atypical antispychotics in the treatment of schizophrenia: British Medical Journal , , —6.

World Psychiatry , 1 , 48 — Additional clinical trail data and a retrospective pooled analysis of response rates across all randomized trials conducted by GSK. Bipolar Disorders , 8 Suppl. Comparison of family therapy and family group psychoeducation in adolescents with anorexia nervosa. Canadian Journal of Psychiatry , 45 , —8.

Cognitive-behavioral and pharmacological treatments of social phobia: Archives of General Psychiatry , 48 , — A meta-analysis of pharmacotherapy trials in paediatric obsessive compulsive disorder. Mechanisms and the current state of transcranial magnetic stimulation. CNS Spectrums , 8 7 , — A one year comparison of vagus nerve stimulation with treatment as usual for treatment-resistant depression. Biological Psychiatry , 58 5 , — Effects of repeated nicotine pre-treatment on mesoprefontal dopaminergic and behavioral responses to acute footshock stress.

Brain Research , , 36 — Disulfiram versus placebo for cocaine dependence in buprenorphine-maintained subjects: Biological Psychiatry , 47 , —6. Neurofeedback training in children with ADHD: Summary of the practice parameter for the use of electroconvulsive therapy with adolescents. Therapist interventions in the interpersonal and cognitive therapy sessions of the Treatment of Depression Collaborative Research Program.

American Journal of Psychotherapy , 56 , 3 — Outpatient psychotherapy for borderline personality disorder: Antidepressants for bipolar depression: Epidemiology of tobacco use in the United States. Oncogene , 21 , — A randomized controlled trial of relapse prevention therapy for first-episode psychosis patients. Journal of Clinical Psychiatry , 70 , — Clozapine use in children and adolescents.

Expert Opinion in Pharmacotherapy , 9 , — Cyproheptadine in anorexia nervosa. British Journal of Psychiatry , , 67 — Addressing treatment refusal in anorexia nervosa: Handbook of Treatment for Eating Disorders , 2nd edn. Oral sildenafil in the treatment of erectile dysfunction. New England Journal of Medicine , , — The effectiveness of a day program for the treatment of adolescent anorexia nervosa. International Journal of Eating Disorders.

Tiagabine increases cocaine-free urines in cocaine-dependent methadone-treated patients: Lithium-carbonate treatment in depression and mania: Archives of General Psychiatry , 21 4 , — Psychoendocrine antecedents of persistent first-episode major depression in adolescents: A double-blind comparison of clomipramine, desipramine, and placebo in the treatment of autistic disorder. Archives of General Psychiatry , 50 , —7. Cognitive behavioural and pharmacological treatment of generalised anxiety disorder: Behavior Therapy , 28 , — Cognitive-behavioral and pharmacological treatment for social phobia: Science and Practice , 4 , — Management of child and adolescent eating disorders: Journal of Child Psychology and Psychiatry , 45 , 63 — Outcome of outpatient psychotherapy in a random allocation treatment study of anorexia nervosa.

International Journal of Eating Disorders , 15 , 65 — Clinical effectiveness of treatments for anorexia nervosa in adolescents: Drug prescribing in child and adolescent eating disorder services. Child and Adolescent Mental Health , 15 , 18 — Principles of Addiction Medicine , 2nd edn. American Society of Addiction Medicine , Inc, pp. Cognitive-Behaviour Therapy for Children and Adolescents. Age related changes in protein binding of drugs: Clinical Pharmacokinetics , 38 , — The Journal of Neuropsychiatry and Clinical Neurosciences , 15 , — Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: Teaching Children with Autism: Strategies to Enhance Communication and Socialization.

Adherence therapy for people with schizophrenia: European multicentre randomized controlled trial. Greater London Alcohol and Drug Alliance An evidence base for the London crack cocaine strategy: Are attachment disorders best seen as social impairment syndromes? Attachment and Human Development , 5 , — Attachment disorganisation and psychopathology: Journal of Child Psychology and Psychiatry , 43 , — Inpatient treatment in child and adolescent psychiatry: Journal of Child Psychology and Psychiatry , 48 , — Parent-mediated communication-focused treatment for preschool children with autism MRC Pact ; a randomised controlled trial.

Sexual identity of 37 children raised by homosexual or transsexual parents. Sexual functioning in post-operative transsexuals: Effect of prefrontal repetitive transcranial magnetic stimulation in obsessive-compulsive disorder: The economic burden of anxiety disorders in the s. Journal of Clinical Psychiatry , 60 7 , — Differential response of hospitalized depressed patients to somatic therapy.

American Journal of Psychology , , — A 1 year double-blind placebo-controlled fixed dose study of sertraline in the treatment of obsessive-compulsive disorder. International Clinical Psychopharmacology , 10 , 57 — Journal of Clinical Psychiatry , 63 , — Patterns and predictors of cocaine and crack use by clients in standard and enhanced methadone maintenance treatment. American Journal of Drug and Alcohol Abuse , 23 , 15 — Social skills training with children: Responsiveness to modelling and coaching as a function of peer orientation.

Journal of Consulting and Clinical Psychology , 48 , — The short-term follow-up effects of hypnobehavioural and cognitive behavioural treatment for bulimia nervosa. European Eating Disorder Review , 4 1 , 12 — A comparison of anti-depressant response in younger and older women. Journal of Clinical Psychopharmacology , 23 4 , —7. The assessment and treatment of specific phobias: Current Psychiatry Reports , 8 4 , — Mindfulness-based stress reduction and health benefits: Journal of Psychosomatic Research , 57 , 35 — A randomized controlled trial of the effect of D-cycloserine on exposure therapy for spider fear.

Journal of Psychiatric Research , 41 , — An eating disorder curriculum for primary care providers. International Journal of Eating Disorder , 30 , — Zuclopenthixol in aggressive challenging behaviour in learning disability: European Eating Disorder Review , 11 , — Abuse and dependence potential for the non-benzodiazepine hypnotics zolpidem and zopiclone: Addiction , 98 , —8. Brief psychotherapy in the treatment of anorexia nervosa: Diazepam, propranolol and their combination in the management of chronic anxiety.

Archives of General Psychiatry , 43 2 , — Family therapy and outcome: Contemporary Family Therapy , 18 , — A double-blind trial of risperidone and haloperidol for the treatment of delirium. Psychosomatics , 45 , — A Comprehensive Textbook , 4th edn. Journal of Developmental and Behavioral Pediatrics , 29 , —8. Abstinence symptoms following smoked marijuana in humans. Psychopharmacology , 14 , — Marijuana withdrawal in humans: Neuropsychopharmacology , 29 , — Self-reported mental distress under the shifting daylight in the high north.

Psychological Medicine , 28 , — Clonidine for posttraumatic stress disorder in preschool children. Anorexia nervosa symptoms are reduced by massage therapy. Eating Disorders , 9 , — Comparison of long-term benzodiazepine users in three settings. British Journal of Psychiatry , , —6. Exposure therapy and sertraline in social phobia: Clinical Evidence Online June 12, pii: Psychological treatments for bulimia nervosa and binging.

Journal of Paediatrics and Child Health , 43 , 19 — A randomized controlled trial of clonidine added to psychostimulant medication for hyperactive and aggressive children. Tricyclic drugs for depression in children and adolescents. Health Technology Board for Scotland Health Technology Assessment Advice 3: Prevention of Relapse in Alcohol Dependence. Randomized controlled trial of two brief interventions against long-term benzodiazepine use: Addiction Research Theory , 12 , — Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-controlled trial, part 2: Journal of Clinical Psychiatry , 64 12 , — Altered pituitary—adrenal axis responses to provocative challenge tests in adult survivors of childhood abuse.

Cognitive-behavioral therapy for social anxiety disorder: Cognitive behavioral group therapy vs. Archives of General Psychiatry , 55 , — One-year follow-up of pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Behaviour Research and Therapy , 44 5 , — One versus five sessions of applied tension in the treatment of blood phobia. Behaviour Research and Therapy , 34 2 , — Family preservation using multisystemic therapy: Journal of Consulting and Clinical Psychology , 60 , — Cognitive behavior therapy for generalized social anxiety disorder in adolescents: Journal of Anxiety Disorders , 23 , — The World Journal of Biological Psychiatry , 8 , — Depression and psychosocial adjustment in adolescent anorexia nervosa: European Child and Adolescent Psychiatry , 2 , — Atypical antipsychotics for neuropsychiatric symptoms of dementia: Drug Safety , 29 , — Pharmacologic management of neuropsychiatric symptoms of Alzheimer disease.

Canadian Journal of Psychiatry , 52 , — Atypical antipsychotics and risk of cerebrovascular accidents.

das schne augsburg text fischer klassik plus german edition Manual

Total symptom-oriented and psychodynamic concept in inpatient treatment of anorexia nervosa: Psychotherapie Psychosomatische Medizin und Psychologie , 46 , 11 — Integrated psychological treatment for substance use and co-morbid anxiety or depression vs. BMC Psychiatry , 9 , 6. Combined pharmacotherapy and psychological therapies for post traumatic stress disorder PTSD. Contingent reinforcement increases cocaine abstinence during outpatient treatment and one year follow-up. Journal of Consulting and Clinical Psychology , 68 , 64 — Biological treatments for amfetamine dependence: CNS Drugs , 21 , — Parental abnormalities of verbal communication in the transmission of schizophrenia.

Psychological Medicine , 1 2 , — The Circle of Security intervention. Cognitive mediation of treatment change in social phobia. Journal of Consulting and Clinical Psychology , 72 , —9. Augmentation of exposure therapy with D-cycloserine for social anxiety disorder. Drug discontinuation among long term, successfully maintained schizophrenic outpatients.

Diseases of the Nervous System , 37 , — The nature of the effect of female gonadal hormone replacement therapy on cognitive function in post-menopausal women: Neuroscience , , — Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo: British Journal of Psychiatry , Suppl 35 , 71 —8. Transient postnatal elevation of serotonin levels in mouse neocortex. Brain Research , 47 , —6. Journal of Studies on Alcohol , 52 , — Addiction , 95 , — Risperidone augmentation in treatment-resistant obsessive-compulsive disorder: International Journal of Neuropsychopharmacology , 6 , — A placebo controlled crossover trial of liquid fluoxetine on repetitive behaviors in childhood and adolescent autism.

Neuropsychopharmacology , 30 , —9. Prevention of relapse following cognitive therapy vs. Clozapine alone versus clozapine and risperid one with refractory schizophrenia. Treatment of bulimia nervosa with topiramate in a randomized, double-blind, placebo-controlled trial, part 1: Journal of Clinical Psychiatry , 64 11 , — Dismantling cognitive-behavioral group therapy for social phobia. Behaviour Research and Therapy , 33 , — Treatment for delirium with risperidone: General Hospital Psychiatry , 25 , — Psychosocial Treatments for Specific Phobias: Treatment of Autistic Children.

Evaluating psychological treatments for children with autism-spectrum disorders. A group randomised, controlled trial of the Picture Exchange Communication System for children with autism. Journal of Child Psychology and Psychiatry , 48 , —8. Systematic review of early intensive behavioural interventions for children with autism. American Journal on Mental Retardation , , 23 — Long-term use of nicotine-replacement therapy.

New Developments in Nicotine-Delivery Systems. An algorithm for smoking cessation. Archives of Family Medicine , 3 , —5. Alcoholics Anonymous and Step alcoholism treatment programs. Recent Developments in Alcoholism, Vol Research on Alcoholism Treatment. Can encouraging substance abuse patients to participate in self-help groups reduce demand for health care? Clinical and Experimental Research , 25 , — Do enhanced friendship networks and active coping mediate the effect of self-help groups on substance abuse? Annals of Behavioral Medicine , 21 , 54 — Self-help organizations for alcohol and drug problems: Journal of Substance Abuse Treatment , 26 , —8.

Cognitive behavioral therapy for obsessive-compulsive disorder: Current Psychiatry Reports , 7 , — A comparison of sustained-release bupropion and placebo for smoking cessation. Peer Rejection in Childhood. The Expropriation of Health. Effectiveness of pharmacotherapy for severe personality disorders: Journal of Clinical Psychiatry , 71 , 14 — The development of brain and behavior.

The Fourth Generation of Progress. Institute of Medicine Broadening the Base of Treatment for Alcohol Problems.

Introduction

National Academy Press retrieved from http: International Psychogeriatric Association Behavioural and Psychological Symptoms of Dementia. Behavioural and Psychological Symptoms of Dementia pp. Pharmacotherapy for social anxiety disorder: Expert Reviews in Neurotherapeutics , 8 , — Efficacy of relapse prevention: Drug interactions with St. International Journal of Clinical Pharmacology Therapy , 42 , — Acute-phase and 1-year follow-up results of a randomized controlled trial of CBT versus befriending for first-episode psychosis: Psychological Medicine , 38 , — Coming to terms with risk factors for eating disorders: Psychological Bulletin , 1 , 19 — The effect of inpatient care on measured Health Needs in children and adolescents.

Journal of Child Psychology and Psychiatry , 50 , — The HerniaSurge committee thought it prudent to account for all important factors when considering recommendations on Lichtenstein and laparo-endoscopic techniques. It seems clear that when considering postoperative pain, recovery speed and chronic pain, the laparo-endoscopic techniques are superior.

In TEP and TAPP expert hands, especially when performing high-volume surgery, those techniques are probably also cost effective and very safe. However, many of the studies in this area suffer from weakness such as: Additionally, there is a well-documented difference in learning curve and initial costs favoring Lichtenstein. For comparison of the laparo-endoscopic TEP, TAPP with the open Lichtenstein technique for male primary unilateral inguinal hernia many studies must be excluded. Clear advantages have been observed for the laparo-endoscopic techniques in terms of early postoperative pain, analgesic consumption, and return to normal daily activities and to work.

When the surgeon had sufficient experience in the respective technique i. The direct operative costs for laparo-endoscopic techniques are higher than for the Lichtenstein operation. A analysis of the Herniamed Registry compared the prospective data collected for males undergoing primary unilateral IH repair using either TEP or open Lichtenstein repair. In total, 17, patients were enrolled, 10, On multivariable analyses, surgical technique had no significant effect on the recurrence rate estimated OR 0.

Nor did the complication-related reoperation rates differ significantly between the two techniques estimated OR 1. TEP was found to have benefits on the postoperative complications rate estimated OR 2. The EHS guidelines concluded, 3 mainly on the basis of the meta-analysis, that endoscopic IH techniques result in a lower incidence of wound infection, hematoma formation and an earlier return-to-normal activities or work than the Lichtenstein technique.

Laparo-endoscopic IH techniques have a longer operative time and a higher incidence of seroma formation than the Lichtenstein technique. The learning curve for performing a laparo-endoscopic hernia repair, especially TEP, is longer than that for open Lichtenstein repair, and ranges between 50 and procedures, with the first 30—50 being most critical. From a hospital perspective, an open mesh procedure is the most cost-effective operation.

In the EHS guidelines update, 4 a new meta-analysis was included. When the surgeon has sufficient experience in the respective techniques, laparo-endoscopic and Lichtenstein techniques have comparable operation times, perioperative complication rates needing reoperation and recurrence rates. Endoscopic techniques show advantages in terms of early and later postoperative pain and speed of recovery. This analysis yielded a non-significant difference in severe chronic pain and long-term recurrence.

The direct operative costs for laparo-endoscopic IH repair are higher, but fall to levels comparable with the Lichtenstein repair when considering quality-of-life aspects and total community costs. Furthermore, there is a well-documented difference in learning curve and initial costs favoring Lichtenstein. Large RCTs with good external validity and large-scale database studies are urgently needed to compare endoscopic with Lichtenstein operations for primary unilateral IHs in males.

These studies must carefully select participating surgeons, to ensure that the learning curve has been completed for the respective surgical technique. A major investment is needed worldwide to make the learning curve for laparo-endoscopic hernia surgery as smooth as possible by ensuring optimal training facilities and circumstances. HerniaSurge recommends a standardization of the laparo-endoscopic and Lichtenstein techniques, structured training programs and continuous supervision of trainees and surgeons within the learning curve. Evidence suggests that pre-peritoneal mesh placement is preferred over anterior mesh placement because of the physiologic mesh location and placement of the mesh away from the groin nerves.

There is clinical interest about whether the various surgical approaches to achieve pre-peritoneal mesh positioning leads to different patient outcomes. Laparo-endoscopic IH repair has been studied in detail with good results, but has a rather long learning curve, potentially higher procedure costs and potential risks associated with general anesthesia in certain types of patients. Additionally, logistical and financial constraints may limit the availability of quality laparo-endoscopic repairs, especially in lower resource settings.

The literature comparing laparo-endoscopic techniques with open pre-peritoneal mesh placement for primary unilateral IHs is extremely limited and heterogeneous. A meta-analysis compared laparo-endoscopic IH repair with open IH repair techniques. In later studies, plug-and-patch repairs were the main cohort in the groups that considered open pre-peritoneal mesh techniques.

Although the authors concluded that open pre-peritoneal hernia repair provides equivalent outcomes at lower costs and has potentially less severe complications compared with laparoscopic techniques, the included studies and available literature do not address our key question adequately. The SCUR Hernia repair study, which compared patients randomized to three groups open suture repair, open pre-peritoneal repair with polypropylene mesh and TAPP demonstrated that although TAPP resulted in both shorter time to full recovery and shorter time to return-to-work, it was more expensive and had a higher complication rate.

Another small four-arm randomized trial of patients studied laparoscopic TAPP and TEP as well as open pre-peritoneal repair and Lichtenstein repair. However, this study is of low methodological value according to SIGN criteria. The currently available literature does not allow us to provide any recommendation about whether laparoscopic mesh placement in the pre-peritoneal plane is superior to open pre-peritoneal techniques.

Further research is necessary. The learning curve of pre-peritoneal techniques needs to be evaluated and the theoretical advantage of a better visualization in laparo-endoscopic repair techniques against potential higher cost and complications must be researched. The EHS guidelines, recommended for bilateral primary inguinal hernia repair, either a bilateral Lichtenstein or endoscopic approach. Another question in helping to decide the surgical approach is whether both hernias need to be repaired at the same time?

A large symptomatic hernia on one side, and a small asymptomatic hernia on the other in an elderly man may only justify a unilateral repair under local anesthetic on the symptomatic side. There has been little new evidence on the preferred surgical approach for primary unilateral inguinal hernia. The outcomes for TEP and TAPP, when comparing unilateral versus bilateral, are similar, especially when taking into account the number of hernias repaired.

The authors reported that the TEP group had a shorter operation time, lower postoperative complication rate and shorter hospital stay. The EHS guidelines concluded with only moderate evidence that bilateral hernia is preferably treated by a laparo-endoscopic method provided expertise is available. No new high-level research was found, so the recommendation of the EHS guidelines have been used in the HerniaSurge guidelines. HerniaSurge by consensus decided to upgrade the level of recommendation.

Inguinal hernia treatment has changed markedly over the past seven decades. Prior to the s, hernia surgery involved an anatomical reconstruction of the inguinal canal with sutures. Many new mesh applications and variations were developed including open, anterior and posterior approaches, and endoscopic techniques Fig.

Therefore, the question confronting hernia surgeons is: As a result, questions arise as to which factors should properly guide surgical decision-making? Can IH treatment be standardized, or should it be individualized? There are no reviews, RCTs or cohort studies comparing different techniques in specific situations. One publication addresses surgical preferences in IH repair. The participating surgeons were asked to indicate preferred surgical technique in specific clinical scenarios, including patient age, gender, physical activity capabilities, physical characteristics, emergency situations, and hernia size and type.

Eighty-two percent of the surgeons chose a tailored approach and indicated that their choice of repair depended on the listed patient characteristics. Future research must address the issue of individualized treatment in specific cases. The HerniaSurge Group currently offers consensus-based examples of tailored surgical approaches in specific circumstances. In the different chapters of these guidelines some recommendations are made with regard to indicated surgical technique. We have outlined these recommendations in this chapter, but refer to these specific chapters for detailed background information.

In addition to these recommendations the consensus-based recommendations are outlined. For recurrent IHs, use the opposite approach e. In high-risk IH patients with extensive comorbidities consider an open mesh repair under local anesthesia Chapter For IH patients with high preoperative pain, consider laparo-endoscopic repair Chapter Consider a laparo-endoscopic approach in active young patients with IHs Chapter In femoral hernia patients, a pre-peritoneal mesh repair is recommended Chapter In female patients with IHs a laparo-endoscopic repair is recommended, providing expertise and resources are available Chapter In male patients with a large scrotal or irreducible hernia, an open mesh repair or a trans-abdominal laparoscopic repair TAPP is recommended HerniaSurge consensus.

An occult hernia, as defined by the HerniaSurge Group, is an asymptomatic hernia not detectable by physical examination. IH formation is considered a bilateral condition based on etiology, yet for many patients presentation with a unilateral symptomatic hernia is typical. Occasionally, a contralateral hernia will be evident on physical examination, but a number of patients will have a contralateral occult hernia at the time of initial presentation which may become symptomatic later. Another patient subset will develop a contralateral hernia de novo which may require repair at a later date.

Evidence for the recommendations and statements in this chapter is largely derived from retrospective case series involving relatively small numbers of patients. Some RCTs address certain aspects of the topics presented. A number of studies have reported on the incidence of occult contralateral hernias at the time of bilateral TEP exploration for a clinically diagnosed unilateral hernia. Additionally, the natural history of these small incidentally discovered defects is poorly understood and the clinical relevance of repair is unknown.

In those with primary unilateral IHs, the lifetime risk of developing a contralateral IH is not known exactly. Several RCTs involving patients who have undergone repair of unilateral primary IHs have reported on contralateral hernia formation during various follow-up periods. Two retrospective cohort studies address this subject. Notably, the laparoscopic features of a normal groin versus an occult hernia are not defined nor are the nature and completeness of follow-up.

One study, with a 5. The median time to contralateral hernia development was 3. Two studies address the subject of contralateral pre-peritoneal exploration at the time of unilateral primary IH TAPP repair. Visualization of the contralateral side in TAPP repair for an overt unilateral hernia is easily done without additional dissection of the contralateral side. However, without dissection of the contralateral side, some cases of lipoma of the cord will be missed. Bilateral repair proponents cite a number of advantages to their approach including: Opponents focus on the potential to do harm to a normal or near-normal groin and the associated risk of chronic pain following surgery on a normal groin.

There is a lack of evidence to allow good decision-making on this issue. The decision to proceed with routine bilateral repair mandates appropriate informed consent and a high level of surgical skill. However, the medical evidence to support this decision is either lacking or weak at present. The postoperative complications necessitated reoperation in 0. However, this study reported that these differences in intraoperative and postoperative complications between unilateral and bilateral repair decreased in experienced high-volume hernia centers.

No difference in recurrence rate, postoperative complications, conversion rate and time to recovery were reported by several studies. Many of the important clinical questions on the subject of a proper approach to occult hernias cannot be definitively answered by the currently available evidence.

Risk factors to identify this group of patients and to inform the decision on bilateral repair should be areas of future research. HerniaSurge recommends a trial with long-term follow-up specifically addressing the question whether there is a need for bilateral repair in patients with a one-sided symptomatic IH, perhaps identifying high-risk groups of early contralateral hernia development. Until evidence is available to further inform this dilemma, it is recommended to discuss the possible surgical options with patients before surgery as part of individualized treatment.

Day surgery for IH repair has become increasingly common over the past several decades. It is commonly known that day surgery is safe and feasible for many IH repairs. However, it is unclear which complex IHs should not be repaired as day cases. The current evidence on ambulatory surgery for IH repair is presented. Day surgery for IH repair involves patient discharge the same day of surgery after a period of medically supervised recovery. The year marks the first publication on the advantages of day surgery repair of IH including: Additionally, many cohort studies exist concerning various other aspects of day surgery for IHs.

These studies span the outpatient surgery spectrum including: All support the notion that day surgery is a safe option for many IH patients. However, there are no reports in the medical literature of death or severe complications being directly related to day surgery. Although open tension-free repair under local anesthetic seems most suitable for day surgery, published series support the use of other surgical and anesthetic techniques in this setting.

Day surgery should be considered for all simple inguinal herniorrhaphies both open and endoscopic provided adequate aftercare is organized. Since the laparoscopic management of large hematomas is often only possible after immediate diagnosis, short-stay treatment of these patients can also be considered.

There are insufficient data to routinely recommend outpatient repair of complex IHs see above. However, if adequate aftercare is arranged, some of these cases may be suitable for ambulatory surgery. Operations on strangulated and acutely incarcerated hernias should not be performed as day cases. Barring the exclusions cited above, IH day surgery can be considered for every patient with satisfactory care at home, including stable ASA III patients. Day surgery should also be considered for the elderly, including octogenarians. A number of additional factors will either encourage or discourage day surgery.

Surgical factors quick operations and few complications and anesthetic factors effective pain and nausea control making rapid patient discharge possible may influence the decision to proceed with day surgery. Day surgery for IH repair is becoming increasingly more popular. Healthcare financing and reimbursement almost certainly play a role. Our present and future challenge is to provide ever more effective, less invasive, and safe ambulatory hernia surgery to a broadening array of complex, aged and sicker patients. More studies are needed on these high-risk groups to determine acceptable safety and outcome parameters.

For now, the available evidence supports the idea that many patients are well served by day surgery repair of IHs. Because of human anatomy and physiology, mesh must conform to a certain structure and stability profile. Requirements for mesh construction include: Although postoperative complications may occur due to poor surgical technique or patient-specific risk factors, the risk of complications may be increased by the use of a poorly designed mesh. Mesh selection is therefore an important factor to consider if one wishes to optimize surgical outcomes. The porosity, elasticity, strength and the polymer itself are mechanical properties, which all influence tissue reaction.

A general classification, which is based on a specific property of the mesh and which is able to reflect all risks, currently is not available, and even hardly conceivable. Unfortunately, most of studies have only used the term lightweight LWM and heavyweight HWM as classification criteria; and no further details of the meshes were given in the published data.

This must be considered in evaluation of results, statements and recommendations outlined below. What characteristics are important and can be used for classifying the mesh-related risks? Various factors may impact mesh-related complications. Characterization and classification of in vivo mesh materials must account for functional and biological outcomes.

Modifications of polymers will result in substantially different biological responses. None of these parameters in isolation are able to predict the inflammatory and fibrotic tissue response and classify meshes across all mesh-related complications. Due to manufacturing process, textile meshes often have considerable anisotropy with different mechanical properties when stressed vertically or horizontally.

Therefore, any measurement of strength and elasticity is strongly affected by the setting of the test procedure e. As a result, the strength and elasticity of anisotropic meshes cannot be expressed as a single number. For construction of a mesh a monofilamental polypropylene composition is recommended, as multifilamental meshes tend to show a higher infection potential.

Importantly, pore size measurement is not accurate if looking only at length or width in one dimension, ignoring the geometry of the pore. However, a technique does exist to provide an accurate measurement of the critical pore sizes, which can avoid fibrotic bridging. Meshes with very small pores induced remarkably increased inflammation despite reduced weight. A single classification system that considers all relevant risk factors for all kind of complications, e.

Overall, 23 RCTs relate mesh material to some clinical outcomes. However, all the trials are small and are too underpowered to detect any differences of practical concern. Therefore, the lack of any significant difference does not automatically imply equality of the compared meshes with regard to the observed outcome, and thus provide no arguments against a possible impact of the mesh material for outcome.

There is strong evidence that mesh selection can change clinical outcomes e. Currently, no distinction is made between large-pore-size and lightweight meshes. Research to date has focused mainly on mesh weight. The so-called lightweight meshes LWM are typically defined as mesh constructs with large-pore size and reduced weight. However, lightweight meshes with small pores are also available.

There are only a small number of studies on this issue, which compare different outcomes of only large-pore meshes of different weight in Lichtenstein, TEP or TAPP surgery. These studies will be discussed in KQ10c. Though some of the clinical RCT studies have presented significantly different results between different treatment groups, many could not, and ended up in non-significant differences. This is often interpreted as equivalence, which is not justified. A mix of risk factors for complications is always at play.

These limitations and confounders mean that statistically significant differences are achieved only in some studies focussing just on the comparison of materials. Whereas a significantly improved outcome in a comparative clinical study can serve as an argument for a specific device, as obviously the impact exceeds the risk of an alpha-error; however, the non-finding of a significant difference may not serve as an argument due to the low statistical power in most studies. Cohorts of less than patients usually are related with an unacceptable risk for a beta-error which means that the finding is not representing the truth.

The absence of a significant finding therefore usually results from the limitations of the sample size rather than can be regarded as a real fact. Consecutively, to prove the similarity of two materials with all their possible confounders almost is impossible in clinical studies! Do lightweight meshes have benefits in open or laparoscopic IH repair? There is an ongoing debate about the mesh type best suited for IH repair. So-called LWMs are supposedly associated with lower discomfort and less pain. However, they are feared to result in higher recurrence rates than so-called HWMs.

Meta-analyses find fewer instances of chronic pain for LWM in the long term. A lower incidence of chronic pain with the use of extra-light mesh was shown in this study. Another study showed that, despite higher perioperative analgesia requirements with HWM, the incidence of chronic pain is similar to that seen with LWM. Some studies have found slight advantages concerning chronic groin pain and other symptoms like foreign-body feeling or discomfort to LWM in TEP surgery.

One of the meta-analyses concluded that short- and long-term results following surgery with either LWM or HWM are comparable across all relevant endpoints. The three meta-analyses differed broadly due to study selection for inclusion, heterogeneity of the selected studies, and quality assessment of the included studies. Additionally, the three meta-analyses only included RCTs published prior to Since then, two relevant RCTs have been published.

Regarding the many debates over different techniques and different implants, the quality of the meta-analyses on mesh is crucial for good decision-making and guidance of surgical practice. Unfortunately, most of the studies demonstrate a considerable heterogeneity of studies when defining inclusion criteria, comparing techniques and material, or outcome. As the final result often depends on the specific data of only some few studies, their inclusion or exclusion may lead to conflicting conclusions.

Also, selection criteria remain quite unclear in some cases. For example, a publication did not take into account some prospective randomized trials. Some of the included studies did not describe the mesh fixation technique used or compared different fixation methods. Given the bias in all studies HerniaSurge can only weakly suggest to use an LWM when considering postoperative pain as outcome.

Since inflammation is related to scar formation, any chronic inflammatory process results in permanent cell turnover which in turn leads to scar accumulation and constantly increasing collagen deposition. A related issue is whether the foreign-body reaction attenuates over time. Both issues impact risk assessment for mesh implants.

Tissue reaction to mesh has been studied in various animal models e. Inflammatory intensity varies with mesh location, animal species, mesh material, textile construction, time and individual host response. Although inflammatory intensity varied considerably, a foreign-body granuloma with macrophages and foreign-body giant cells reflecting persistent inflammation has always been confirmed. Since chronic inflammation stimulates local fibrosis and scar formation, long-term complications of this mesh-adjacent process must be considered.

Erosion of foreign bodies in human tissue is a well-known phenomenon. Mesh is placed in soft tissues with rapid remodeling of adjacent tissues. When biomechanical strain occurs, mesh migration is often observed in the direction of the pulling forces. Mesh erosion has been reported with all current polymers and following all hernia repair procedures. Risk of mesh movement is reduced by the use of large flat mesh in a tension-free setting. Smaller mesh surface area and tensile forces on the mesh increases the risk. Flat mesh erosion is uncommon. There are several reports of mesh erosion after hiatal hernia and incisional hernia repair.

Up to now, there is no polymer or no mesh construction known that is free from the risk of erosion if placed in a setting with tensile forces. While it is true that hernia meshes induce immunological reactions, there is no strong evidence of adaptive immunological reaction, i. In the medical literature, there is no human study of the immunogenicity of hernia mesh polymers.

Some animal studies do exist, only one demonstrating antibodies against polyester textiles in rats. In light of current knowledge, there is no need to consider allergic reactions to mesh. Notably, only a few polymers e. PVDF can be used without additives and these are supplemented with color particles. It may be that some of these adjuvants might stimulate an allergic or autoimmune syndrome in some patients. Degradation here refers to complete or partial fragmentation after placement in living tissue of a non-absorbable polymer used for hernia mesh fiber construction e. Over time, most polymers do show alteration or degradation of their polymeric structure.

These changes may become clinically relevant when mechanical loading occurs. It may be prudent to assume that hernia mesh implant instability can occur after several decades. Under electron microscopy, human mesh explants polyester, polypropylene or ePTFE all show signs of degradation.

Several investigators have studied textile structure resistance during repetitive loading in vitro and have found rapid and irreversible deformation of the textile structure. It is clear that foreign bodies like textile mesh can induce malignancies in rodents, particularly in rats.

There are, however, two reports worthy of mention. In one, abdominal wall fibromatosis developed in two patients after laparoscopic mesh placement. There is inadequate evidence in humans for the carcinogenicity of non-metallic implants other than those made of silicone. In summary, there is no evidence that meshes meaningfully increase carcinogenesis risk.

Patient age is often a critical consideration in many surgical procedures. Many IH surgery patients have years of productive life ahead of them. Therefore, it is important to know if patient age affects the complication risk profile. There are no adequately age-adjusted studies of complications following mesh-based IH repair. Also, no data exist on length of implantation period as an independent risk factor for complications. Several studies indicate that complications following mesh repair can occur after years.

National registry data analyses usually show a nearly linear increase in reoperation rate, reflecting a permanent risk with an almost constant incidence over time. Shrinkage of the mesh—caused mainly by collagen shortening—results in physiological wound contraction. This phenomenon, in turn, is related to scar tissue amount, influenced by surgery-induced local tissue trauma and patient-specific responses to tissue injury. It is also known that textile meshes induce a chronic foreign-body reaction with local inflammation and fibrosis see KQ10e. In the case of small-pore meshes this reaction can bridge the entire inter-filament distance.

Mesh infection, with its resultant inflammation and increased fibrosis, exacerbates this process and results in even more shrinkage. Of note, mesh polymers themselves do not shrink, but the textile itself shortens, pulled together by the contracting scar. Mesh shrinkage varies markedly. Synthetic mesh fixation in both open and laparo-endoscopic hernia repair involves a consideration of the strength of fixation versus the risk of trauma to local tissues and nerve damage through entrapment. Mesh fixation complications include: Various mesh fixation methods exist including: Evidence that a particular fixation method improves patient-based or surgical outcome measures may have a significant impact on clinical practice.

Analyses below covers two topics: Special patient-related circumstances are also highlighted. Which fixation methods are appropriate in primary open anterior mesh inguinal and femoral hernia repairs? The search yielded eight systematic reviews on the subject of mesh fixation in primary open IH repair.

Mesh fixation methods were assessed in one moderate-quality systematic review of 12 RCTs involving primary IH repairs. Four studies compared n -butyl-2 cyanoacrylate NB2C glues to sutures, two compared self-fixing meshes to sutures, four compared fibrin sealant to sutures, one compared tacks to sutures, and one compared absorbable sutures to non-absorbable sutures.

The most common reasons for low or very low study grading were: Thirteen of 26 recurrences were reported in one study with a 5-year follow-up utilizing NB2C glue. Surgical site infection SSI data were included in eight of the studies. No study distinguished between superficial and deep SSI. SSI diagnostic criteria were infrequently documented. Overall infection rates ranged from 0 to 3. Choice of fixation method did not result in any significant difference in infection rates.

All studies included chronic pain data. One study did not include a chronic pain definition. Overall, chronic pain rates ranged from 0 to The combined chronic pain rates for mesh fixation of various types were: Nine studies reported no significant difference in chronic pain between fixation methods. Six RCTs reported on pain in the first postoperative week. Three studies noted significantly lower mean VAS scores at one or more assessment times within week one, with FS, NB2C glue, or self-fixing mesh compared with suture fixation. The mean difference in VAS scores was 0. Although the results of these studies reveal statistically significant reduced pain after atraumatic fixation, the clinical significance of small changes in VAS scores in unclear.

Operative times were reported in 10 RCTs. Five reported significantly shorter operative times with non-suture mesh fixation. The clinical significance of this small difference is debatable. One of the meta-analyses reported no difference in other outcomes including chronic pain RR 1. These differences are remarkable, given that the articles were all published within the same year, and may reflect selection criteria for included studies and the meta-analysis methods used.

No inter-group differences in recurrence, chronic pain or SSI were found. Pubmed and Cochrane databases were systematically searched, yielding a total of 67 papers of which 34 were included after applying strict inclusion SIGN criteria. The systematic review and meta-analyses — —all judged to be of moderate quality per GRADE guidelines—revealed no significant differences in the rates of recurrence or postoperative pain between permanent tack fixation and non-fixation in either TEP or TAPP. For TEP repair, the results of six RCTs, , , , , , three case control studies, , , and two meta-analyses , demonstrate no significant risk of recurrence following mesh non-fixation.

For TAPP repair, one RCT of moderate quality, comparing tack fixation with non-fixation demonstrated no significant difference in recurrence risk. Notably, the RCTs cited above contain only limited information on hernia-defect size and type. This is especially true regarding the percentage of large direct hernias type M3, EHS classification. Based on the results of a multivariate analysis of 11, cases from a Herniamed registry study, a significant risk of recurrence is found not only in the group of non-fixation in case of direct hernias but also for combined hernias [combined versus medial: The three meta-analyses — of eight RCTs revealed no significant differences in acute and chronic postoperative pain , , Of the RCTs studying TEP repair , , , , only one detected significantly less acute and chronic pain in the non-fixation group.

Of three case control TEP repair studies, , , only one revealed a significantly lower rate of acute postoperative pain in the non-fixation group. Reporting on preoperative pain is one of the greatest shortcomings of almost all studies. This information is essential to identify patients at high risk for postoperative chronic pain. Furthermore, the pain assessment within the different studies displays significant heterogeneity.

Two meta-analyses of moderate quality , found no significant recurrence rate difference between staple and glue fixation methods. The results of three RCTs , , included in the meta-analyses, as well as another four CCSs , , , confirmed these findings. One systematic review analyzed only RCTs including TAPP repairs , , and one TEP repair Concerning acute pain, the review analysis detected no significant difference between staple and fibrin sealant groups.

A significant difference was found, however, in the incidence of chronic pain favoring the fibrin sealant group. Both reviews , revealed significant advantages of glue fixation in lessening the incidence of chronic pain. However, as noted, only one RCT was included in these two systematic reviews. In total, three RCTs have been published , , and detected no significant difference in chronic pain when glue was compared to staple fixation.

Three case control trials, , , however, found significantly less chronic pain in the glue fixation group. Two systematic reviews , failed to demonstrate an operative time difference between groups undergoing different fixation methods. Similarly, one RCT and one case control trial also noted no significant difference although a different case control trial revealed longer operative times in the glue group.

SSI rates were not significantly impacted by different fixation methods across a systematic review, two RCTs , and two case control trials , that examined the subject. One meta-analysis of moderate quality that included only RCTs , — specifically addressed glue versus staple fixation in TAPP repair. The results of six RCTs , , , — and three case control trials , , confirmed this finding.

In addition to the meta-analyses and RCTs, a recently published study from the Danish Hernia Database included patients and detected no significant difference using Cox regression analysis [hazard ratio 0. One systematic review that included four RCTs , — found no significant difference in acute postoperative pain between glue- and staple-fixation groups.

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However, five RCTs , , — and three CCSs , , found significantly less acute pain after glue versus staple fixation. One systematic review revealed a significantly higher incidence of chronic pain when the staple group was compared with the glue group. In contrast, three of six RCTs , , and two of three case control trials , reported no significant difference. An important criticism of the systematic review was that it included 1-month follow-up data from one study as chronic pain data. Another study showing no difference was excluded for unknown reasons. No significant difference was seen between fixation methods in the systematic review.

A CCS had similar results. In open primary groin hernia repair beyond the use of sutures non- or late-resorbable for mesh fixation new atraumatic devices e. A crucial precondition in large medial defects is the use of an adequate size and overlap of mesh and the reduction of the dead space caused by the dilated transverse facia.

To minimize the risk of acute postoperative pain atraumatic fixation techniques fibrin glue, cyanoacrylate should be considered. Prophylactic antibiotics in inguinal herniorrhaphies are intended to prevent infections, which is particularly important when prosthetic material is used. However, unwarranted antibiotic use may create problems, notably patient allergies, C. Antibiotic use is widely accepted in patients with risk factors and in contaminated and infected conditions.

However, prophylactic antibiotic use should be questioned under clean conditions in patients with limited risk factors for infection. Current evidence is presented. The latest Cochrane meta-analysis, encompassing 11 RCTs, was published in Eight of the articles included in this analysis are of high or moderate quality while the rest are of low or very low quality. Difficulties in data interpretation stem from the fact that inclusion criteria vary broadly across the RCTs. This variation encompasses patient risk factors e. The current analysis accounts for this variation and defines average - risk patients as those with primary hernias and minimal individual or operative risk factors.

Of note, only elective operations are included in the 17 RCTs.

High-risk patients—with comorbidities like diabetes—are only referenced in two of the 17 articles, representing 8. There is a potential risk of resistance to the prophylactic antibiotic given varying between countries and different settings. This problem is not highlighted in any study. High wound infection rates were noted in studies from Pakistan, Turkey, Japan and parts of India and Spain, and may reflect local differences in perioperative and operative practice. This cut-off has been used for this analysis. A total of seven studies with patients comprise the low-risk environment group and ten studies with patients make up the high-risk environment group.

The overall meta-analysis results of the RCTs have to be corrected for a large clinical diversity inclusion criteria variations regarding diabetes and recurrent hernia and methodological diversity surgical variations: Wound infections occurred in 2. Wound infection rates in the high-risk environment group were 8. Primarily high-risk patients as defined by national guidelines received antibiotics. Postoperative infection rates were reported as 1. In a multivariate analysis on wound healing the OR was 0. It is concluded that endoscopic repair per se has such a high benefit in reducing wound infections, that the administration of antibiotic prophylaxis is not necessary.

References

For open repair it was concluded that there was a benefit for antibiotic prophylaxis, but this summary statement did not account for factors like: Due to the low incidence of infection, the number needed to treat was to prevent one infection. Therefore, the clinical relevance of this conclusion can be argued. There is only one small, low-quality RCT demonstrating no wound infections in any group in laparo-endoscopic IH repairs.

Data from large patient cohorts in national registers do not support the use of antibiotic prophylaxis in these patients. There are very limited data on high-risk patients in a low-risk environment. Two small studies address this issue but only include a few patients who might be considered to have any increased risk for postoperative surgical site infection.

A consensus does not exist on what constitutes a high-risk patient in a low-risk environment for hernia surgery. However, common surgical practice includes antibiotic prophylaxis for increased-risk patients and these currently also include those undergoing IH repair. This is an area ripe for further studies. Univariate and multivariate analysis of individual trials reveals an increased risk of wound infections in patients undergoing bilateral open hernia repairs and recurrent hernia repairs. This is likely due to increased operative time. There are insufficient data to draw conclusions on antibiotic prophylaxis for high-risk patients with diabetes or immunosuppression.

Therefore, in institutions with high wound infection rates, antibiotic prophylaxis is highly recommended. Furthermore, in these institutions the general risk factors influencing wound infections should be checked like hygiene routines, shaving on the day before surgery and seroma aspiration, etc. It is a fact that in some countries prophylactic antibiotics are a required indicator and considered a quality measure by Centers for Medicare and Medicaid services.

HerniaSurge recommends these countries to reconsider this and adjust requirements to evidence-based guidelines. General, regional and local anesthetic techniques are used to facilitate open IH surgery. Regional anesthesia can be performed via epidural, spinal and paravertebral routes. However, a discussion of paravertebral anesthesia is not included in this section since limited data are available on this technique. The ideal anesthetic technique: The EHS guidelines on IH treatment recommends that local anesthesia be considered for all adult patients with primary reducible unilateral IHs.

We identified one meta-analysis and five reviews comparing local to general anesthesia. In addition, urinary retention data from the largest RCT comparing general to local anesthesia were omitted. These omitted figures demonstrate a lower incidence of urinary retention after local anesthesia when compared with general anesthesia. When compared with general anesthesia, local anesthesia is more cost effective when hospital and total healthcare costs are considered and provides earlier patient mobilization and hospital discharge Although perioperative pain sensation is reported and can sometimes be a reason for conversion to general anesthesia, early postoperative pain seems less in the local anesthesia group.

We identified five reviews , — and 11 randomized trials , , , , , — comparing local to spinal anesthesia. The most recent meta-analysis, published in , did not include one randomized trial of spinal versus local anesthesia. Hernia registries provide insights into IH recurrence risks with different anesthetic modalities. A Swedish Hernia Registry analysis of 59, patients found that local anesthesia is associated with an increased risk of reoperation for recurrence after primary IH repair.

A Danish Hernia Database analysis of 43, patients reported an increased reoperation rate after local anesthesia versus general or regional anesthesia after direct—but not indirect—hernia repair. They concluded that local anesthesia use in a general hospital might be a direct hernia recurrence risk factor, stressing the importance of experience in the administration of local anesthesia. Cardiovascular disease accounts for most of the mortality associated with elective hernia repair see Chapter An RCT has demonstrated that local anesthesia is associated with a superior ventilation and oxygenation pattern when compared with general and regional anesthesia.

Evidence strongly supports the idea that local anesthesia has several advantages over general or regional anesthesia in elective reducible IH repairs. As suggested by hernia database analysis, hernia recurrence may be more common following operation employing local anesthesia. Experience in local anesthetic administration might negate this downside risk. ASA class III patients undergoing IH repairs may benefit by the administration of local anesthetic over regional or general anesthetic. However, the evidence for this potential benefit is weak. Five reviews — , and nine RCTs , , , , , — comparing general to regional anesthesia were identified.

The majority of these RCTs compared general, regional and local anesthesia. A review of four randomized trials with patients reported inconclusive results on early postoperative pain. The effect on postoperative nausea was similarly inconclusive with one of two RCTs reporting a significant difference favoring spinal anesthesia while the other found no difference.

The same review reported faster patient discharge after general anesthesia. No inter-group difference is reported in patient satisfaction scores. The incidence of urinary retention is not reported in the review. The largest RCT comparing local, general and regional anesthesia was not included in the section of the review comparing general to regional anesthesia. The excluded RCT randomized patients to either regional or general anesthesia. Pain, nausea, early postoperative complications, hospital length of stay, patient satisfaction and costs were not significantly different between groups.

Another recent systematic review excluded this RCT as well because many patients underwent two different anesthetic modalities. This systematic review also reported a lower incidence of urinary retention in the general anesthesia group. Less early postoperative pain was seen in the regional anesthesia group. There were no differences between groups in the incidence of other complications. Some high-quality medical evidence is available to address KQ Several RCTs support the statements and recommendations above.

Barring the questionable value of a statistically significant but clinically negligible faster patient discharge, no clear benefits of general over spinal anesthesia have been reported except in those 65 and older. Urinary retention might be more frequent following regional anesthesia. A moderate level of evidence supports the recommendation above. Local anesthesia has several advantages to regional and general anesthesia.

However, data from hernia registries suggest that the hernia reoperation rate may be higher after local anesthesia when compared with general or regional anesthesia. A higher level of expertise in local anesthesia administration seems to be associated with a lower reoperation risk. Five observational studies have examined complication rates after open IH repair under local anesthesia by trainees.

The study authors concluded that beginners should be closely supervised during their first six operations. Trainees can safely perform these operations, but supervision by a surgeon with the requisite experience is necessary to achieve optimal outcomes. Several approaches to postoperative pain management have been studied including various medical treatments and interventions like the use of local anesthetics.

This chapter reviews the literature on preoperative, perioperative, and postoperative interventions designed to treat pain after open groin hernia repair. The use of a preoperative or intraoperative field block mostly of the ilio-inguinal and ilio-hypogastric nerves with or without local wound infiltration is superior to placebo or no treatment for reducing early postoperative pain scores and the need for supplementary analgesics.

Seven randomized trials reported that field block of the ilio-inguinal and ilio-hypogastric nerve with wound infiltration was superior to no treatment or placebo for reducing postoperative pain scores and supplementary analgesic requirements. A review summarized four randomized trials comparing wound infiltration with local anesthetic to placebo. Wound infiltration also lengthened the time-to-first-analgesic request. A prospective, double-blind, randomized trial compared subfascial to subcutaneous local anesthetic infiltration and reported improved early postoperative pain scores after subfascial infiltration.

Combination infiltration resulted in improved early postoperative pain scores, less supplementary analgesic need and longer time-to-first-analgesic request. Two studies compared local anesthetic infiltration to placebo or no treatment and found local infiltration superior with respect to early postoperative pain and supplemental analgesic use. Paravertebral nerve blocks PVBs are established methods of providing analgesia to thoracic- and abdominal-surgery patients including those undergoing groin hernia repair.

A PVB has the potential to offer sustained pain relief with minimal side effects. One systematic review and three randomized studies — found a tendency to less postoperative pain in PVB-patients when compared with general-anesthesia and spinal-anesthesia patients. The transversus abdominis plane TAP block is a relatively new regional anesthetic technique developed in an attempt to reduce postoperative pain.

It has evolved from a landmark technique to an ultrasound-guided one. Four randomized studies comparing TAP blocks with either placebo, local anesthetic infiltration, or no treatment reported conflicting results with respect to early postoperative pain and analgesic use.

In addition to the preoperative and intraoperative pain prevention and treatment methods above, non-opioid and non-steroidal anti-inflammatory medications acetaminophen, NSAIDs and selective COX-2 inhibitors should be used for postoperative pain management. However, the combination of paracetamol and a non-steroidal anti-inflammatory drug, given in a timely manner, seems to be optimal and provides sufficient analgesic during the early recovery phase provided that there is no contraindication. Opioids may cause adverse effects such as nausea, vomiting, and constipation, amongst others which may delay postoperative recovery.

Therefore, non-opioid analgesics should be used whenever possible. However, opioids can be used for moderate- or high-intensity pain, in addition to non-opioid analgesia or when the combination of an NSAID and paracetamol is not sufficient or is contraindicated. Several small studies of varying quality seem to indicate that local anesthetic administration via intra-wound catheters by repeat bolus or continuous infusion is more efficacious than placebo at reducing postoperative pain. Inguinal hernia repair results in pain postoperatively and the optimal method s to treat this pain remain s controversial.

Therefore, when general or regional anesthesia is used, local anesthetic field blocks and infiltration is recommended in all open groin hernia surgeries. Additionally, the combination of a conventional NSAID or a selective COX-2 inhibitor plus paracetamol reduces postoperative pain and is also recommended. A weakness in the review presented in this chapter stems from the variation in quality of the available randomized trials. Although postoperative pain was our focus, it was not always the primary endpoint of the included studies.

There is strong evidence for preoperative and intraoperative inguinal field blocks and wound infiltration with seven randomized studies showing superiority to no treatment or to placebo. Four randomized trials found wound infiltration superior to placebo. Provided that there is no contraindication, the use of a conventional NSAID or a selective COX-2 inhibitor is also recommended with four randomized trials and one review showing reduced postoperative pain when compared to placebo. Opioids are recommended in limited circumstances as described above. Convalescence duration—defined as sick leave from work and time away from leisure—is an important feature of the recovery phase following IH surgery.

However, most studies have not investigated the impact of recommendations on short duration convalescence. The literature search identified studies of which we included one systematic review, 14 RCTs, three cohort studies and four case—control studies. Pain and wound-related problems are the most often cited reasons for not resuming work or leisure activities as recommended evidence level—high.

The recommendations have been upgraded by HerniaSurge. Groin hernia repairs are 8—10 times more common in men compared with women. No systematic reviews or randomized controlled trials RCTs specifically address groin hernia repair in women. Data are collected mainly from subgroup analyses of epidemiological studies from national databases. Reoperation rates after anterior hernia repairs in women are higher when compared with men.

What are the outcomes? When an overt groin hernia is present, the diagnosis can often be confirmed by physical examination. Textbooks state that a femoral hernia produces swelling inferolateral to the pubic tubercle and an inguinal hernia causes superomedial swelling; however, this subtle distinction is often difficult to discern, particularly in obese women. A meta-analysis of ultrasound as an initial diagnostic imaging modality for groin hernias showed a high sensitivity and positive predictive value in cases confounded by diagnostic uncertainty.

The study cited low expense and minimal risk as advantages over other radiologic methods. Both may also miss femoral hernias entirely. The literature confirms that femoral hernias are frequently found in women undergoing groin hernia repair, but that a correct preoperative diagnosis of these hernias is uncommon. In a few large epidemiological studies from national databases, reoperation rates after open anterior groin hernia repairs in females are higher when compared with reoperation rates in males.

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