[Subdural hematoma after dural puncture: fateful complication of epidural anesthesia]. / Subdurales Hämatom nach Duraperforation: Schicksalhafte Komplikation der Periduralanästhesie.

Subdural hematoma may occur as rare, although intervention- specific complications of accidental dural puncture by neuroaxial block. Bleeding may be caused by rapid cerebrospinal fluid loss related to traction on fragile intracranial bridging veins. This article reports a case of postdural puncture headache in a 43-year-old woman after accidental dural puncture during attempted placement of an epidural catheter for induction of abortion. Bed rest, analgesics, theophylline and hydration were to no avail and only a blood patch improved the headaches. The patient presented 7 weeks later with headache and left-sided hemiplegia. Magnetic resonance imaging showed a right frontoparietal subdural intracranial hematoma which had to be surgically evacuated. The patient recovered completely. Intracranial hematoma is a rare but serious complication of central neuroaxial block. According to current German jurisdiction this risk must be addressed when informed consent is obtained. Intracranial hematoma should be considered in the differential diagnosis of atypical headache and neurological signs (e.g. focal motor and sensory deficits and seizures) following neuroaxial block and adequate image diagnostics should be carried out without delay.

Clinical study on the effect of mineral waters containing bicarbonate on the risk of urinary stone formation in patients with multiple episodes of CaOx-urolithiasis.

Investigations in healthy persons have shown that drinking mineral water containing HCO(3) has a positive effect on urine supersaturated with calcium oxalate (SS(CaOx)). The present study evaluates in a common setting whether these effects are also relevant in patients with multiepisodic urinary stone formation. A total of 34 patients with evident multiepisodic CaOx-urolithiasis were included in the study. Patients with hyperparathyroidism, renal tubular acidosis, Wilson's disease, Cushing disease, osteoporosis and malignant diseases were excluded. In a cross-over design and double-blinded the patients received 1.5 l of a mineral water with 2.673 mg HCO(3)/l (test water) or the same amount of water with a low mineral content (98 mg HCO(3)/l) (control water) daily for 3 days. During the study period the patients diet was recorded in a protocol, but not standardised. The main target parameter was SS(CaOx )in 24 h urine. In addition, urinary pH and the most important inhibiting and promoting factors were measured in 24 h urine (Ca, Ox, Mg, Cit). Both waters tested led to a highly significant increase in 24 h urine volume without a difference between each other. In the group, drinking the water containing HCO(3) the urinary pH increased significantly and was within a range relevant for metaphylaxis of calcium oxalate stone formation (x=6.73). This change was highly significant compared to the control group. In addition, significantly increased magnesium and citrate concentration were also observed. Supersaturation with calcium oxalate decreased significantly and to a relevant extent; however, there was no difference between the waters tested. As expected, the risk of uric acid precipitation also decreased significantly under bicarbonate water intake. However, an increase of the risk of calcium phosphate stone formation was observed. It is evident that both waters tested are able to lower significantly and to a relevant extent the risk of urinary stone formation in patients with multiepisodic CaOx-urolithiasis. In addition, the bicarbonate water increases the inhibitory factors citrate and magnesium due to its content of HCO(3) and Mg. Thus, it can be recommended for metaphylaxis of calcium oxalate and uric acid urinary stones.

Identification of genes involved in cytochrome c biogenesis in Shewanella oneidensis, using a modified mariner transposon.

A modified mariner transposon, miniHimar RB1, was generated to mutagenize cells of the metal-reducing bacterium Shewanella oneidensis. The use of this transposon led to the isolation of stable mutants and allowed rapid identification of disrupted genes. Fifty-eight mutants, including BG104 and BG148 with transposon insertions in the cytochrome c maturation genes ccmC and ccmF1, respectively, were analyzed. Both mutants were deficient in anaerobic respiration and cytochrome c production.

Gender differences in coping with tension-type headaches.

OBJECTIVE: To study gender differences of coping with illness strategies in tension-type headaches. METHOD: We enrolled 89 subjects (50 women, 39 men) suffering from episodic (n = 37) and chronic (n = 52) tension-type headaches (TTH). Patients were required to answer a Freiburg Questionnaire of Coping with Illness (FQCI), a Von Zerssen Depression Scale (D-S), quality-of-life questionnaires, and a headache home diary (over 4 weeks). In addition, pressure pain thresholds (temporal muscles) and Total Tenderness Scores were obtained. RESULTS: While pain intensity, frequency and quality-of-life parameters were basically the same for female and male EPISODIC TTH sufferers, women scored significantly higher on the F3 subscale (distracting and encouraging) of the FQCI and tended to score higher on the F1 subscale (depressive). Among CHRONIC TTH patients, women reported the pain to be more intense (VAS), were more depressed (D-S), and scored lower on several quality-of-life scores. Female chronic TTH sufferers scored significantly lower on the F2 subscale (active coping) and tended to score higher on F5 (denying). CONCLUSIONS: We conclude that pessimistic coping with illness strategies are more frequent in female episodic and chronic TTH sufferers. We would like to recommend special psychologic intervention in particular to female chronic TTH sufferers which would offer counseling in developing active coping skills.

Chronic epicondylitis: effects of real and sham acupuncture treatment: a randomised controlled patient- and examiner-blinded long-term trial.

OBJECTIVE: The clinical long-term effectiveness of real and sham acupuncture treatment on differentiated pain measurement was evaluated in chronic lateral epicondylitis, an example of a tendomyotic disorder. METHODS: Randomised, examiner- and patient-blinded controlled clinical study. OUTCOME MEASUREMENT: pain at rest, pain on movement, pain on exertion, frequency and duration of pain. Real acupuncture (n = 23) was tested versus invasive sham acupuncture (n = 22). Ten treatments were given (2 treatments/week). Patients were examined at baseline (E1) as well as 2 weeks (E2), 2 months (E3) and 1 year (E4) after the end of treatment. In the treatment with real acupuncture, acupuncture points were selected and mechanically stimulated while in the sham group non-acupuncture points were selected. RESULTS: There was no significant difference between the groups at baseline for any outcome parameter. Two weeks, 2 months and 1 year after the end of treatment there were significant reductions in all pain variables compared to baseline. At the first follow-up, significant group differences were registered for pain on motion and pain on exertion in favour to the real acupuncture group. These differences in pain intensity between the groups were no longer significant at the 2 months and 12 months follow-ups. CONCLUSION: The results suggest that, in the treatment of chronic epicondylitis, the selection of so-called real acupuncture points gives better results than invasive sham acupuncture at early follow-up. This additional effect can be interpreted as a specific effect of real acupuncture.

Acupuncture in chronic epicondylitis: a randomized controlled trial.

OBJECTIVE: To evaluate the clinical efficacy of acupuncture in the treatment of chronic lateral epicondylitis. METHODS: In a randomized, investigator- and patient-blinded, controlled clinical study, 23 patients were treated with real acupuncture and 22 patients received sham acupuncture. Patients each received 10 treatments, with two treatments per week. The primary outcome variables were maximal strength, pain intensity (verbal rating scale) and disability scale (Disabilities of the Arm, Shoulder and Hand questionnaire). Patients were examined at baseline (1 week before the start of treatment) and at follow-up 2 weeks and 2 months after the end of treatment. RESULTS: There was no significant difference between the groups at baseline for any outcome parameter. Two weeks and 2 months after the end of treatment, there were significant reductions in pain intensity and improvements in the function of the arm and in maximal strength in both treatment groups. At the 2-week follow-up these differences were significantly greater for all outcome parameters in the group treated with real acupuncture. At 2 months the function of the arm was still better in this group than in the sham acupuncture group; however, the differences in pain intensity and maximal strength between the groups were no longer significant. CONCLUSION: In the treatment of chronic epicondylopathia lateralis humeri, acupuncture in which real acupuncture points were selected and stimulated was superior to non-specific acupuncture with respect to reduction in pain and improvement in the functioning of the arm. These changes are particularly marked at early follow-up.

Reproducibility of sonographic soft-tissue measurement of the head and neck.

OBJECTIVE: Effectiveness of manual lymphatic drainage in the head and neck region is not supported by evidence-based data. The objective of this study was to verify if the chosen locations enable the measurement of reproducible skin-to-bone distances without marking the measurement place, providing, therefore, adequate sites for long-term follow-up of the soft tissue width. METHODS: Sonographic measurement was performed in 21 healthy volunteers by the same examiner on three consecutive days. Skin-to-bone distance was measured each time at five defined locations over the mandible and hyoid. RESULTS: The average deviation caused by consecutive measurements was estimated to be between 0.7 and 1.2 mm for the different locations. When comparing right-to-left average skin-to-bone distances, differences of a maximum of 1 mm were measured. CONCLUSIONS: Sonographic soft tissue width, as measured by the skin-to-bone distance at defined sites of the head and neck, is highly reproducible in healthy adults without marking these measurement sites. These regions can, therefore, be used to quantify the effectiveness of manual lymphatic drainage for head and neck lymphedema by monitoring the course of the skin-to-bone distance.

Non-specific effects of traditional Chinese acupuncture in osteoarthritis of the hip.

OBJECTIVES: The effectiveness of acupuncture treatment in patients with osteoarthritis of the hip was tested. DESIGN: This is a prospective, randomized, controlled, patient- and investigator-blinded clinical trial. PATIENTS AND SETTING: The study was performed at a university department for physical medicine and rehabilitation. Sixty-seven patients were separated into two treatment groups. INTERVENTIONS: Group 1 (treatment) had traditional needle placement and manipulation, whereas in group 2 (control) needles were placed away from classic positions and not manipulated. In both groups needles were placed within the L2 to L5 dermatomes. Outcome parameters were: pain (VAS), functional impairment (hip score), activity in daily life (ADL) and overall satisfaction before treatment, and 2 weeks and 2 months after treatment. RESULTS: For all parameters there was a significant improvement versus baseline in both groups 2 weeks and 2 months following treatment, but no significant difference between the two treatment groups. CONCLUSIONS: We conclude from these results that needle placement in the area of the affected hip is associated with improvement in the symptoms of osteoarthritis. It appears to be less important to follow the rules of traditional acupuncture techniques.

Early rehabilitation of head-neck edema after curative surgery for orofacial tumors.

OBJECTIVE: To evaluate a rehabilitative program for postoperative head-neck edema. DESIGN: Eleven patients completed the study. A series of ten manual lymphatic drainage were initiated and completed early after surgery. On discharge from the hospital, the patients wore "made-to-measure" or customized compression garments for the next several weeks. Tape measurements and sonographic evaluation of the soft-tissue width were used to quantify the extent of the swelling. RESULTS: After 6 wk of therapy, the patients exhibited a statistically significant (P < 0.05; Wilcoxon's test) remission; the remission continued in eight patients who were measured at 12+/-3 wk. CONCLUSIONS: This initial trial demonstrates that sequential therapy of manual lymphatic drainage and compression garments can significantly reduce early postoperative edema after curative surgery for orofacial tumors. The outcome can be quantified by comparing the course of distances between the defined anatomic marks and by sonographic evaluation of soft-tissue width. This pilot study encourages that more controlled, randomized studies, with larger numbers of patients, be conducted to verify these results.

Circadian variations in the responsiveness of human gallbladder to sulfated mineral water.

It is well known that the intake of sulfate-containing natural mineral waters leads to contraction of the gallbladder, probably induced by the release of cholecystokinin (CCK). As early as 1959, there were some hints in the literature of circadian variations in gallbladder response; to find out whether this applies with sulfate as a stimulus, a pretest for basic information about gallbladder reaction to sulfate-containing mineral water was carried out on 19 healthy volunteers. On this basis, 15 healthy subjects of both sexes were then studied. After 6h of fasting, 500 mL of a sulfate-containing mineral water (2,800 mg SO4(2-)/L) were ingested within 5 min. The size of the gallbladder was registered ultrasonographically before and 15, 30, 60, and 120 min after drinking. The experiments were carried out seven times at different hours of the day for each volunteer. After the intake of the mineral water, the mean gallbladder size decreased significantly, followed by an increase after 60 min (P < .001). Significant circadian spontaneous variation in gallbladder size was detected (acrophase around 09:00; amplitude was 30.0% of daily average, P < .001). The contraction induced by the sulfate-containing water was most marked in the early morning hours and minimal around mid-day; the amplitude of this variation accounting for 29.0% of the daily average (P < .01). In contrast, the postdrinking relaxation was maximal around 18:00 and minimal around 9:00 (amplitude 38.5%. P < .001). These results show that the basal size of the gallbladder and its reaction to stimuli show a marked circadian variation: Whereas contractibility is maximal in the morning, dilatation is stronger in the afternoon.

Determining the crystal structure of twinned 2-methylpyrazine.

Although systematic absences and symmetry relations among reflections pointed to space group I4(1)22 (one molecule in the asymmetric unit), a direct methods solution could only be obtained in I(-)4 (two molecules in the asymmetric unit). Refinement in I(-)4 was unsatisfactory until merohedral twinning was taken into account. The resulting molecular dimensions are in excellent agreement with analogous values in the literature. The molecular arrangement is described.

[Prospective study of the long-term effectiveness of inpatient rehabilitation of patients with chronic cervicobrachial syndromes and the effect of prescribing special functional pillows]. / Prospektive Studie über die Langzeitwirksamkeit stationärer Heilverfahren bei Patienten mit chronischen Zervikobrachialsyndromen und zum Effekt einer zusätzlichen Verordnung spezieller Funktionskopfkissen.

In order to investigate the long-term effect of clinical rehabilitation measures as well as the additional effect of prescription of a special pillow in patients suffering from chronic cervicobrachialgia a total of 149 patients was investigated. All patients suffered from chronic cervicobrachialgia and were admitted for rehabilitative treatment in the orthopaedic Elfenmaar-Klinik of Bad Bertrich. For a four-week period the patients were treated with physical therapy including gymnastics, electrotherapy, thermotherapy, and massage. Additionally they underwent a health-promoting programme specially designed for patients with spondylopathia. The patients were randomly divided into two groups, one receiving a special pillow (Curavario, Pala-Medic-Company) for the use during and after the rehabilitative treatment (n = 76 or n = 73, respectively). For two weeks before the treatment, during the four-week treatment period and for two weeks after the treatment the patients had to fill in a questionnaire, comprising among others six questions on the intensity of their cervicobrachialgic symptoms (pain-intensity [local pain, radiation of pain], muscular tenseness, paraesthesia and sleep disorders [caused by pain or paraesthesia]). Three, six, and nine month after the treatment period the patients received a similar questionnaire. Immediately after the treatment period a significant reduction of mean pain intensity and muscle tenseness (p < 0.001; Rep.-Mes.-ANOVA) was found. At the same time significantly lower frequencies of pain radiation and sleep disorders caused by pain or paraesthesia (p < 0.001; chi-square-test) were found. During the following nine months the intensity of the symptoms slightly re-increased, however, all parameters were still reduced nine months after treatment compared to the values before treatment (p < 0.01). Before and during the treatment no difference between the two groups could be detected, however, the follow-up showed significantly lower scores of pain intensity (p < 0.05; Student-t-test) and sleep disorders (p < 0.01; chi-square test) in the patients who had received the special pillow. It is concluded that the rehabilitative treatment is effective in patients suffering from chronic cervicobrachialgia and that the complaints in the post-treatment period can be reduced by prescription of special pillows.

[Ambulatory geriatric rehabilitation--concepts, chances and responsibilities of participating physicians]. / Ambulante geriatrische Rehabilitation--Konzepte, Chancen und Forderungen an die beteiligten Arzte.

The third stage of the bill of the health structure (GSG) still focuses on the tremendous increase of costs in hospitals. Hospitals are accused that the care of the older patients involves too much money and staff. Experts complain that geriatric-rehabilitative thinking and acting does hardly influence the daily work on the wards. Competent geriatric rehabilitation should diminish or prevent the need for nursing, should support the patients ability for self-sufficiency, and decrease hospitalization time. Since the expenses for the hospital care of older patients have increased during the last couple of years and show the greatest dynamic of increase together with the supply of aids, health politicians and health economists, physicians, health insurances, and social insurances set more and more medical and economic hope on the geriatric rehabilitation. Especially models of out of hospital programs in connection with panel doctors are discussed to relieve the hospitals and are favoured by legal institutions and health politicians. Despite the documented success of geriatric rehabilitation, it is surprising the only a few areas realize differentiated out of hospital concepts. This article summarizes the most important models of out of hospital geriatric rehabilitation as they are tested in different areas in Germany. Advantages and disadvantages are discussed and the demands of the participating physicians are demonstrated. The goal of this paper is to describe the medical role in these models to win more physicians for this task. The urgently necessary development of a country-wide out of hospital rehabilitation, introduces new important medical fields of activity.

Abdominal wall massage: effect on colonic function in healthy volunteers and in patients with chronic constipation.

Colonic massage has been claimed to be an efficacious treatment for chronic constipation, though there are no studies to prove this. We therefore investigated the effect of abdominal wall massage on stool frequency and colonic transit time of radiopaque markers in 9 constipated patients (68 +/- 5 years, 5 female, colonic transit greater than 60 h) and in 7 healthy male volunteers (27 +/- 1.2 years) in a control phase and during a three week treatment phase with 9 sessions. Massage was performed as propulsive abdominal wall massage along the presumed course of the colon in an aboral direction (each session 20 min). Stool frequency did not change significantly from control to massage, neither in patients [0.59 +/- 0.08 to 0.68 +/- 0.09 defaecations per day, 95% CI control-massage (-0.23; 0.04)] nor in healthy volunteers 1.11 +/- 0.11 to 0.86 +/- 0.13, 95% CI (-0.01; 0.53)]. Total colonic transit times remained similar during the control and massage phase in patients (126 +/- 19 and 111 +/- 17 h, 95% CI (-11; 41)] and in healthy volunteers (40 +/- 7 and 38 +/- 6 h, 95% CI (-8; 13)]. Even when patients and healthy volunteers were statistically evaluated together, control and massage did not differ significantly. In patients, scores of well-being and stool consistency did not differ significantly during control and massage periods. So colonic massage does not change parameters of colonic function to a clinically relevant degree in healthy volunteers and constipated patients of the investigated age-groups.

Free and conjugated catecholamines in human plasma during physical exercise.

To investigate changes of free and sulfoconjugated catecholamines in response to alterations in sympatho-adrenal activity, free and conjugated noradrenaline, adrenaline and dopamine were determined radioenzymatically in plasma of 49 subjects. During brief vigorous bicycle exercise (8 min, maximal heart rate: 177 beats/min) mean free noradrenaline and adrenaline values of 2.0 and 0.51 nmol/l at rest, increased to 6.7 and 2 nmol/l (P less than 0.001) respectively, at the maximal workload of 200 watt, whereas conjugated noradrenaline and adrenaline decreased from 3.4 and 0.8 nmol/l to 2.1 and 0.4 nmol/l (P less than 0.001) respectively. In the tenth min of the recovery period basal free and conjugated noradrenaline and adrenaline levels were measured. The moderate stress of a steam bath (20 min, maximal heart rate: 131 beats/min) doubled free noradrenaline and adrenaline levels. However, conjugated noradrenaline and adrenaline concentrations remained unchanged. The increase in free catecholamine values during an exhausting cross-country march over 20 km was associated with an accumulation of sulfated catecholamines. After a rest of 30 min free noradrenaline and adrenaline reached basal values, whereas conjugated noradrenaline and adrenaline remained elevated by 64 and 70% respectively, compared to pre-exercise concentrations. It was concluded that conjugated noradrenaline and adrenaline may be used as pools for free noradrenaline and adrenaline during brief vigorous exercise. In addition, they may also be indicators of chronic activation of the sympatho-adrenal system.

[Hydrotherapy in swellings with special reference to lymphedema]. / Hydrotherapie bei Schwellungen unter besonderer Berücksichtigung des Lymphödems.

Is is to be stated in summary that the majority of positive arguments in the literature publications so far for the application of hydrotherapy in swellings there are weighty counter-arguments especially in lymphatic edema in the narrow sense. The present study (which is only preliminary because of the small number of cases) appears to indicate that these arguments are evidently not so weighty as was assumed hitherto. Even though unfortunately few clinically relevant alterations occurred with hydrotherapy alone, on the other hand, study indicates that we would have to prohibit patients with lymphatic edema from taking cold immersion baths. Hydrotherapy tends to have if anything a favorable influence on the basic psychological condition and according to the data available can be recommended as an additional measure.