[New options for rehabilitation of conductive hearing loss : Tests on normal-hearing subjects with simulated hearing loss]. / Neue Möglichkeiten der Rehabilitation bei Schallleitungsschwerhörigkeit : Tests an normalhörenden Probanden mit simulierter Schwerhörigkeit.

BACKGROUND: Bone conduction hearing aids can be worn as noninvasive devices using a clip or soft band that exerts pressure on the skin, or they can be surgically implanted. ADHEAR (MED-EL GmbH, Innsbruck, Austria) is a novel noninvasive bone conduction hearing aid that is attached behind the ear using an adhesive adapter and does not exert pressure on the skin. ADHEAR is indicated for patients with conductive hearing loss and normal inner ear function. The aim of this study was to evaluate the achievable hearing improvement with ADHEAR. MATERIALS AND METHODS: Twelve subjects with normal hearing participated in this study. To mimic conductive hearing loss, the participants' ear canals were occluded unilaterally with a foam ear plug. The resultant conductive hearing loss was assessed with pure tone air- and bone-conduction threshold audiometry. Hearing ability was tested with and without ADHEAR via free-field tone audiometry, number perception, and monosyllable perception, with the contralateral ear plugged depending on test requirements. RESULTS: Using ADHEAR, the free-field hearing threshold improved by 13.7 dB at 500 Hz, by 17.9 dB at 1 kHz, by 17.2 dB at 2 kHz, and by 9.8 dB at 4 kHz. In the higher frequencies, a significant pure-tone gain of 14.4 dB at 6 kHz and of 16.5 dB at 8 kHz was observed. Number perception with ADHEAR was mean 69.2% at 35 dB, 97.9% at 50 dB, 100% at 65 dB, and 100% at 80 dB. Monosyllable perception with the ADHEAR was mean 35.0% at 35 dB, 72.3% at 50 dB, 93.5% at 65 dB, and 98.8% at 80 dB. CONCLUSION: Hearing performance was significantly better with ADHEAR under all test conditions except those where maximum perception was already achieved without ADHEAR.

Chronic pain in pachyonychia congenita: evidence for neuropathic origin.

BACKGROUND: Pachyonychia congenita (PC) is a rare autosomal dominant skin disease, with chronic pain being the most prominent complaint. Histological studies showing alterations in sensory innervation, along with reports on alterations in mechanical sensitivity, suggest that PC may be a form of neuropathy. OBJECTIVES: Here, for the first time, we aim to evaluate systematically the sensory function of patients with PC vs. controls, in order to investigate the pathophysiology of PC. METHODS: Patients (n = 62) and controls (n = 45) completed the McGill and Douleur Neuropathique-4 (DN4) questionnaires. Sensory testing included detection and pain thresholds, pathological sensations, conditioned pain modulation (CPM) and temporal summation of pain. RESULTS: A moderate-to-severe chronic pain in the feet, throbbing and stabbing in quality, was highly prevalent among patients with PC (86%) and was especially debilitating during weight bearing. In addition, the majority of patients had a DN4 score ≥ 4 (62%), static allodynia (55%) and tingling (53%) in the feet. Compared with controls, patients with PC exhibited thermal and mechanical hypoaesthesia and mechanical hyperalgesia in the feet. CPM was reduced among the patients, and was associated with more enhanced mechanical hyperalgesia in the feet. The specific gene and nature of the causative mutation did not affect any of these features. CONCLUSIONS: Although thermal and mechanical hypoaesthesia may result from thicker skin, its presentation in painful regions, along with mechanical hyperalgesia and allodynia, point towards the possibility of neuropathic changes occurring in PC. The clinical features and DN4 scores support this possibility and therefore neuropathic pain medications may be beneficial for patients with PC.

PAIN OUT: the making of an international acute pain registry.

BACKGROUND: About 240 million patients undergo surgery every year, worldwide. Roughly 50% of these patients report clinically significant pain. Numerous barriers impede provision of adequate management. Lack of evidence about appropriateness and effectiveness of interventions is one. A registry can provide such information, eventually facilitating better management. This paper reports the development and feasibility of PAIN OUT, the first international acute pain registry, established with funds from the European Commission, and presents preliminary analysis to illustrate the nature of investigations that registry data make possible. METHODS: On the first postoperative day, 6347 adult patients undergoing orthopaedic or general surgery, in 11 medical centres in Europe and Israel, provided Patient Reported Outcomes (PROs) using a validated questionnaire. Clinical data were abstracted from the patient's chart. RESULTS: Feasibility worked well. Over a period of 1 year, surveyors accrued targeted data sets and entered them into an online browser. Collaborators could receive online feedback comparing their findings about PROs against anonymized findings from other centres. Missing data for the majority of variables were low. Despite considerable variability between institutions, a large number of patients were treated according to the generic, evidence-based recommendations we assessed. However, this was not sufficient to result in acceptable outcomes for the majority of patients. CONCLUSION: The initial development of PAIN OUT has been achieved. From 2013, it continues as a not-for-profit academic project, open to clinicians and researchers worldwide. The International Association for Study of Pain and PAIN OUT will work together to maintain, disseminate and develop the registry.

Feasibility of international data collection and feedback on post-operative pain data: proof of concept.

Post-operative pain exacts a high toll from patients, families, healthcare professionals and healthcare systems worldwide. PAIN-OUT is a research project funded by the European Union's 7th Framework Program designed to develop effective, evidence-based approaches to improve pain management after surgery, including creating a registry for feedback, benchmarking and decision support. In preparation for PAIN-OUT, we conducted a pilot study to evaluate the feasibility of international data collection with feedback to participating sites. Adult orthopaedic or general surgery patients consented to participate between May and October 2008 at 14 collaborating hospitals in 13 countries. Project staff collected patient-reported outcomes and process data from 688 patients and entered the data into an online database. Project staff in 10 institutions met the enrolment criteria of collecting data from at least 50 patients. The completeness and quality of the data, as assessed by rate of missing data, were acceptable; only 2% of process data and 0.06% of patient-reported outcome data were missing. Participating institutions received access to select items as Web-based feedback comparing their outcomes to those of the other sites, presented anonymously. We achieved proof of concept because staff and patients in all 14 sites cooperated well despite marked differences in cultures, nationalities and languages, and a central database management team was able to provide valuable feedback to all.

Short term inhalation toxicity of a liquid aerosol of CdS/Cd(OH)2 core shell quantum dots in male Wistar rats.

Colloidal quantum dots (QD) show great promise as fluorescent markers. The QD used in this study were obtained in aqueous medium rather than the widely used colloidal QD. Both methodologies used for the production of QD are associated with the presence of heavy metals such as cadmium (Cd). Here we investigate the short-term inhalation toxicity of water-soluble core-shell CdS/Cd(OH)2 QD. Male Wistar rats were head-nose exposed for 6 h/day on 5 days at the technically maximum concentration (0.52 mg Cd/m³). Histological examination was performed directly after the last exposure. Additional rats were used for Cd organ burden determinations. Clinical parameters in blood, bronchoalveolar lavage fluid and lung tissue were determined 3 days after the last exposure. To analyze the reversibility or progression of effects, the examinations were performed again after a recovery period of 3 weeks. The results of the study indicate that CdS/Cd(OH)2 QD caused local neutrophil inflammation in the lungs that partially regressed after the 3-week recovery period. There was no evidence that QD were translocated to the central nervous system nor that a systemic acute phase response occurred.

Characteristics of first ever ischemic stroke in the very elderly: profile of vascular risk factors and clinical outcome.

PURPOSE: Age is the most significant non-modifiable risk factor for ischemic stroke (IS). With increasing expectancy of life, the majority of IS patients will be elderly subjects. We studied the epidemiological, clinical and rehabilitation features of patients aged ≥85 years with first-ever IS. METHODS: Demographic data, prevalence of risk factors, etiology of stroke, severity of neurological deficit, major complications and mortality rates were collected from a hospital-based stroke registry and compared between patients at the age of 65-84 and ≥85. Clinical assessment was performed by means of the National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS). RESULTS: Among 216 patients aged ≥85 years there was significantly higher proportion of a history of atrial fibrillation than in 128 patients at the age of 65-84 years and lower prevalence of hypertension, diabetes mellitus, hyperlipidemia and smoking. Large artery atherosclerosis was more frequently identified in the older patients (49% vs. 32%, p=0.002). Although NIHSS scores on admission were lower in the older patients they were more disabled at discharge. CONCLUSIONS: With respect to the patients aged <85 years very old IS patients showed different vascular risk factors profile, clinical and rehabilitation course. These findings suggest specializing stroke care in the very elderly.

Higher postoperative pain and increased morphine consumption follow pre- rather than post-incisional single dose epidural morphine.

BACKGROUND: Neuraxial administration of morphine is an effective way of controlling postoperative pain and reducing analgesic consumption. Some animal models have demonstrated that preemptive administration of neuraxial narcotics reduces pain, while others have revealed the contrary. In addition, there have been no consistent results in clinical settings. This double-blind, randomized study compared the effects of pre- vs. post-incisional administration of neuraxial morphine on postoperative pain perception and analgesic requirements over 48 hours following laparotomy for open colectomy under standardized general anesthesia. METHODS: Twenty patients received epidural morphine (3 mg) before the incision and saline after wound closure (MO1 group), and twenty patients received epidural saline before the incision and morphine after wound closure (MO2 group). Postoperatively, all patients received morphine boluses (1.5 mg) via intravenous patient-controlled analgesia (IV-PCA) and rescue doses of intramuscular diclofenac (75 mg) every 6 hours, as needed. RESULTS: MO1 patients used significantly (P<0.05) more morphine than the MO2 group during the first 24 postoperative hours and activated the PCA device more frequently throughout the 48-hour study period. The MO1 group was characterized by significantly (P<0.05) higher self-rated pain scores than the MO2 group throughout the study. The self-rated levels of sedation and satisfaction of the MO2 patients were also consistently better (P<0.05) than those of the MO1 patients, especially during the second postoperative day. CONCLUSION: Pre-incisional epidural morphine in patients undergoing open colonic surgery under general anesthesia was associated with more postoperative pain, a greater need for analgesics, and poorer patient satisfaction compared to post-incisional morphine administration.

Auditory cortex activation is modulated by emotion: a functional near-infrared spectroscopy (fNIRS) study.

Visual emotional stimuli evoke enhanced activation in early visual cortex areas which may help organisms to quickly detect biologically salient cues and initiate appropriate approach or avoidance behavior. Functional neuroimaging evidence for the modulation of other sensory modalities by emotion is scarce. Therefore, the aim of the present study was to test whether sensory facilitation by emotional cues can also be found in the auditory domain. We recorded auditory brain activation with functional near-infrared-spectroscopy (fNIRS), a non-invasive and silent neuroimaging technique, while participants were listening to standardized pleasant, unpleasant, and neutral sounds selected from the International Affective Digitized Sound System (IADS). Pleasant and unpleasant sounds led to increased auditory cortex activation as compared to neutral sounds. This is the first study to suggest that the enhanced activation of sensory areas in response to complex emotional stimuli is apparently not restricted to the visual domain but is also evident in the auditory domain.

Clock drawing and rehabilitation outcome in hip fracture patients.

PURPOSE: To assess the relationship between the Clock Drawing Test (CDT) and rehabilitation outcome in hip fracture patients within normal range of the Mini Mental State Examination (MMSE). METHODS: This retrospective study was performed in a post-acute geriatric rehabilitation centre. One hundred and forty-two patients with proximal hip fracture admitted from January 2006 to June 2008 whose MMSE scores was within normal range (>23) were enrolled in the study. The patients were divided into two groups according to CDT performance (impaired versus intact). The differences between the two groups in relation to age, gender, education level, living arrangement, pre fracture functional level, fracture type, and outcome measurements [Functional Independent Measure (FIM), motor FIM, Rate of in-hospital Improvement (RI) in FIM and motor FIM, and Length of Stay (LOS)] were assessed. RESULTS: Discharge FIM score and motor FIM scores were significantly lower for the impaired CDT group (89 ± 13.7 vs. 94.9 ± 11.6, p = 0.007; 61.6 ± 11.1 vs. 65.7 ± 9.6, p = 0.022 respectively); LOS was significantly longer (28.2 ± 7.9 vs. 25.3 ± 8.5, p = 0.033) and rates of improvement in FIM and motor FIM were significantly slower (0.62 ± 0.35 vs. 0.77 ± 0.45, p = 0.036; 0.61 ± 0.34 vs. 0.75 ± 0.42, p = 0.033, respectively). Nevertheless, FIM and motor FIM scores changes were similar in both CDT groups. Following adjustment for age, LOS of patients with impaired CDT was significantly longer (p = .027). CONCLUSIONS: The CDT may assist the multidisciplinary team in identifying hip fracture patients whose MMSE scores are within the normal range, but yet need a longer training period to extract their rehabilitation potential.

Comparison of musical activities of cochlear implant users with different speech-coding strategies.

Speech coding might have an impact on music perception of cochlear implant users. This questionnaire study compares the musical activities and perception of postlingually deafened cochlear implant users with three different coding strategies (CIS, ACE, SPEAK) using the Munich Music Questionnaire. Overall, the self-reported perception of music of CIS, SPEAK, and ACE users did not differ by very much.

Brachial plexus injury as a complication after colorectal surgery.

Peripheral neuropathy associated with anesthesia is a significant source of morbidity and the second most frequent cause of professional liability in anesthetic practice. Nerve injuries are a well-recognised complication of anesthesia. Brachial plexus neuropathy is a rare syndrome with an incidence of 1.6 cases per 100,000. Unfortunately, we have a limited understanding of the relations between conventional perioperative care and the genesis of peripheral neuropathy. We describe 3 cases of postoperative brachial plexus neuropathy that occurred after abdominoperineal anterior resection for rectal cancer. The symptoms resolved postoperatively in two patients by 8 weeks and in one patient by 10 weeks with conservative treatment. The differential diagnosis between brachial plexus neuropathy and other peripheral neuropathies is important, as the prognosis of brachial plexus neuropathy is generally better. The anesthetist and the surgeon should know the risks of positioning to prevent nerve injuries, and should be aware of the possibility of brachial neuropathy in order to properly make an early diagnosis.

Inhibitory activity of a green tea extract and some of its constituents on multidrug resistance-associated protein 2 functionality.

Green tea extracts (GTE) might modulate ABC transporter gene expression or function. This may be relevant in the treatment of cancer or in influencing intestinal drug permeability. To gain more insight on the influence of a GTE on secretory transport proteins we investigated the influence of GTE and several green tea components on the mRNA expression level of P-glycoprotein (P-gp) and multidrug resistance-associated protein 2 (MRP2) in human gastrointestinal epithelial LS-180 cells. Furthermore, the functional activity of MRP2, using glutathione methylfluorescein (GS-MF) or [3H]methotrexate (MTX) as substrate, was investigated in canine kidney cells stably overexpressing human MRP2 (MDCK-MRP2). GTE, at a concentration of 0.01 mg/mL, did not increase mRNA expression of P-gp or MRP2 in LS-180 cells. Functional assays in MDCK-MRP2 cells using GS-MF did not show any effect of 0.01 mg/mL GTE on MRP2 activity. In the same cell line the cellular accumulation of MTX (a specific substrate of MRP2) was significantly increased with the MRP-specific inhibitor MK-571 or with 1 mg/mL GTE, but not with 0.1 mg/mL. The green tea components (-)-epigallocatechin gallate, (-)-epigallocatechin, theanine, or caffeine, each in corresponding concentrations to the respective concentration of GTE, did not show any effect on MRP2 function. These data demonstrate that the mRNA expression patterns of P-gp and MRP2 in LS-180 cells are not altered by 0.01 mg/mL of GTE. However, MRP2 function was inhibited by 1 mg/mL GTE, whereas none of the green tea components tested were responsible for this effect.

Retrograde tracheal intubation: beyond fibreoptic endotracheal intubation.

BACKGROUND: Flexible fibreoptic laryngoscopy is the method of choice for coping with difficult tracheal intubations, a leading cause of catastrophic outcomes in anaesthesia. However, this technique is not always available or feasible. Retrograde intubation is a minimally invasive airway management technique with a flat learning curve and a high level of skill retention. METHODS: A retrospective review of the anaesthesia records of 24 patients who underwent retrograde intubation. The success rate and the incidence of complications were recorded. RESULTS: Retrograde tracheal intubation was successful in all 24 patients. In 21 patients it succeeded on the first attempt. In two patients it succeeded when the technique was changed from sliding over a guide wire to a pulling technique. The most common complication was a sore throat in almost 60% of the patients. Two patients had mild subcutaneous emphysema and one had minimal bleeding at the puncture site. CONCLUSIONS: In these patients retrograde tracheal intubation was easy to perform, had a high success rate and a low incidence of complications. It is a reliable alternative when fibreoptic intubation is precluded, fails or is unavailable.

Bier's block; 100 years old and still going strong!

In August 1908 Karl August Bier, Professor of Surgery in Berlin, described a new method of producing analgesia of a limb which he named 'vein anesthesia'. Bier first presented his new method of intravenous regional anesthesia (IVRA) at the 37th Congress of the German Surgical Society on 22 April, 1908, only 10 years after his significant communication on spinal anesthesia (1). His method, which now bears his name, consisted of occluding the circulation in a segment of the arm with two tourniquets and then injecting a dilute local anesthetic through a venous cut-down in the isolated segment. Bier had the good fortune to use procaine, the first safe injectable local anesthetic that had been synthesized by Einhorn in 1904.

A history of neuraxial administration of local analgesics and opioids.

The history of intrathecal and epidural anaesthesia is in parallel with the development of general anaesthesia. As ether anaesthesia (1846) is considered the first modern anaesthetic since its use by Morton 157 yr ago, so Bier made history by using cocaine for intrathecal anaesthesia in 1898. The first published report on opioids for intrathecal anaesthesia belongs to a Romanian surgeon, Racoviceanu-Pitesti, who presented his experience at Paris in 1901. It was almost a century before the opioids were used for epidural analgesia. Behar and his colleagues published the first report on the epidural use of morphine for the treatment of pain in The Lancet in 1979. Epidural and intrathecal opioids are today part of a routine regimen for intra- and postoperative analgesia. Over the last 30 yr, the use of epidural opioids has became a standard for analgesia in labour and delivery, and for the management of chronic pain. Finally, epidural opioids have been shown to have a pre-emptive effect, when used before major surgery. We present the evolution of neuraxial anaesthesia and the history of intrathecal and epidural administration of opioids.

Triiodothyronine and interleukin-6 (IL-6) induce expression of HGF in an immortalized rat hepatic stellate cell line.

BACKGROUND/AIMS: Despite its being considered a primary mitogen for hepatocytes, triiodothyronine (T3) has no effect on the proliferation of hepatocytes in vitro, and in our studies, induces significant in vivo hepatocyte proliferation only during liver injury. We hypothesized that T3 may affect hepatocytes proliferation indirectly, by inducing other cells in the liver to secrete hepatic mitogens. METHODS: In vivo studies: Lipopolysaccharide, T3 and a combination of the two were injected into rats, and hepatocyte proliferation was determined by PCNA staining and mitotic index. IN VITRO STUDIES: a rat hepatic stellate cell line (HSC-6T) was cultured with T3, IL-6 and a combination of the two, and we assessed the effect of these cytokine/hormone combinations on the cell proliferation and on secretion of IL-6 and HGF, measured by ELISA. Expression of thyroid hormone receptors was assessed by RT-PCR. RESULTS: In vivo: T3, together with lipopolysaccharide, enhances PCNA staining and the mitotic index of hepatocytes in the treated rats. In vitro: the hepatic stellate cell line expresses thyroid hormone receptor alpha 1, but not beta 1. Proliferation of stellate cells is not affected by T3, with or without IL-6. T3 has no effect on secreted levels of IL-6 in the stellate cell line. Hepatic stellate cells cultured with T3 and IL-6 show significantly increased amounts of secreted HGF after 48 h in culture. CONCLUSION: T3 may induce hepatocyte proliferation in vivo during injury by turning on expression of HGF in stellate cells and acting together with IL-6.

[Cochlea implantation: results and costs, a review]. / Cochlea-Implantation: Ergebnisse und Kosten, eine Ubersicht.

The cochlear implantation, especially after bilateral operation provides a reliable and outstanding compensation in bilateral complete deafness or severe hearing impairment. Directional hearing can be restored with bilateral implantation so that warning signals are localized correctly and speech in noise is easier understood. Thus, rehabilitation is restored to a high degree. The involved expenses are severe, but are lower for the society when compared to the amount of money necessary to substitute a completely deaf patient lifelong.

Efficacy of intravenous magnesium in neuropathic pain.

BACKGROUND: Postherpetic neuralgia is a complication of acute herpes zoster characterized by severe pain and paraesthesia in the skin area affected by the initial infection. There is evidence that the N-methyl-D-aspartate receptor is involved in the development of hypersensitivity states and it is known that magnesium blocks the N-methyl-D-aspartate receptor. METHOD: A double-blind, placebo-controlled, cross-over study was conducted in which magnesium sulphate was administered as an i.v. infusion. Spontaneous pain was recorded and qualitative sensory testing with cotton wool was performed in seven patients with postherpetic neuralgia before and after the i.v. administration of either magnesium sulphate 30 mg kg(-1) or saline. RESULTS: During the administration, pain scores were significantly lower for magnesium compared with placebo at 20 and 30 min (P=0.016) but not at 10 min. I.V. magnesium sulphate was safe, well-tolerated and effective in patients with postherpetic neuralgia. CONCLUSION: The present study supports the concept that the N-methyl-D-aspartate receptor is involved in the control of postherpetic neuralgia.