Improvements in patients with lipedema 4, 8 and 12 years after liposuction.

BACKGROUND: Long-term results following liposuction in patients with lipedema were available only for an average period of 8 years. OBJECTIVE: To find out whether the improvements persist for a further 4 years. METHODS: In 60 patients with lipedema a single-centre study with a mail questionnaire - often in combination with clinical controls - was performed after an average period of 12 years following liposuction(s). All patients in this group had already been surveyed 4 and 8 years after surgery. RESULTS: Compared with the earlier results improvement persisted with regard to spontaneous pain, sensitivity to pressure, edema, bruising and restriction of movement; similar outcomes were observed for self-assessment of cosmetic impairment, reduction in quality of life and overall impairment. While in the period from 4 to 8 years postoperatively complaints slightly increased, this was not the case for the period 8 to 12 years postoperatively. In addition a similar reduction of conservative treatment (decongestive therapy, compression garments) was observed as after 4 and 8 years postoperatively. Compared with the body weight before liposuction, 55% of the patients showed a reduction of 6.2 kg on average and 43.3% had a weight increase with an average of 7.9 kg. CONCLUSION: The results show, that the positive effects of liposuction last 12 years postoperatively without relevant worsening. They imply that liposuction for lipedema leads to a permanent reduction of symptom severity and need for conservative therapy.

Acetylcholinesterase and butyrylcholinesterase in cardiosurgical patients with postoperative delirium.

BACKGROUND: Patients in intensive care units (ICU) are often diagnosed with postoperative delirium; the duration of which has a relevant negative impact on various clinical outcomes. Recent research found a potentially important role of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) in delirium of critically ill patients on non-surgical ICU or in non-cardiac-surgery patients. We tested the hypothesis that AChE and BChE have an impact on patients after cardiac surgery with postoperative delirium. METHODS: After obtaining approval from the local ethics committee, this mechanistic study gathered data of all 217 patients included in a randomized controlled trial testing non-pharmacological modifications of care in the cardiac surgical ICU to reduce delirium. Delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Nursing Delirium Screening Scale (Nu-DESC) twice a day for the first 3 days after surgery. Further outcome variables were somatic laboratory parameters and variables regarding surgery, anesthesia, and postsurgical recovery. 10 µl venous or arterial blood was drawn and AChE and BChE were determined with ChE check mobile from Securetec. RESULTS: Of 217 patients, 60 (27.6%) developed postsurgical delirium (POD). Patients with POD were older (p = 0.005), had anemia (p = 0.01), and worse kidney function (p = 0.006). Furthermore, these patients had lower intraoperative cerebral saturation (NIRS) (p < 0.001) and higher intraoperative need of catecholamines (p = 0.03). Delirious patients showed more inflammatory response (p < 0.001). AChE and BChE values were mainly inside the norm. Patients with values outside the norm did not have POD more often than others. Regarding AChE and BChE patients did not differ in having delirium or not (p > 0.10). CONCLUSIONS: Postoperative measurement of AChE and BChE did not discern between patients with and without POD. The effect of the cardiac surgical procedure on AChE and BChE remains unclear. Further studies with patients in cardiac surgery are needed to evaluate a possible combination of delirium and the cholinergic transmitter system. There might be possible interactions with AChE/BChE and blood products and the use of cardiopulmonary bypass, which should be investigated more intensively. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00006217.

A score to identify patients with metastatic spinal cord compression who may be candidates for best supportive care.

BACKGROUND: The objective of the current study was to develop a scoring system that identifies those patients with metastatic spinal cord compression who may be candidates for best supportive care or single-fraction radiotherapy. METHODS: Ten potential prognostic factors were retrospectively analyzed in 2029 patients, including age, gender, Eastern Cooperative Oncology Group performance status, tumor type, number of involved vertebrae, further bone metastases, visceral metastases, interval from time of cancer diagnosis to the development of MSCC, time to the development of motor deficits, and ambulatory status. RESULTS: On multivariate analysis, Eastern Cooperative Oncology Group performance status, tumor type, bone metastases, visceral metastases, interval from cancer diagnosis to the development of metastatic spinal cord compression, time to the development of motor deficits, and ambulatory status were found to be significantly associated with survival. The risk score represented the sum of the scores for each of these factors, obtained from the probability of the patient dying within 2 months (shown as the percentage) divided by 10. Risk scores ranged between 6 and 25 points. At a cutoff value of ≥ 24 points, the specificity was 99.8% and the positive predictive value was 96.0%, which indicates that approximately 4% of the patients predicted to die within 2 months survived > 2 months. CONCLUSIONS: This score identifies patients who have a very poor survival with a high specificity and a high positive predictive value. Patients with a score of ≥ 24 points have a very high probability of dying within 2 months. Thus, overtreatment with intensive therapies can be avoided in these patients, who are very unlikely to benefit.

Preoperative regional cerebral oxygen saturation is a predictor of postoperative delirium in on-pump cardiac surgery patients: a prospective observational trial.

INTRODUCTION: Postoperative delirium is an important problem in patients undergoing major surgery. Cerebral oximetry is a non-invasive method to detect imbalances in the cerebral oxygen supply/demand-ratio. Low preoperative cerebral oxygen saturation (ScO2) levels have been associated with postoperative delirium in non-cardiac surgery patients. The present prospective observational study determines the relationship between pre- and intra-operative ScO2 levels and postoperative delirium in patients undergoing on-pump cardiac surgery. METHODS: After approval of the local ethical committee and written informed consent, N = 231 patients scheduled for elective/urgent cardiac surgery were enrolled. Delirium was assessed by the confusion-assessment-method for the intensive care unit (CAM-ICU) on the first three days after surgery. ScO2 was obtained on the day before surgery, immediately before surgery and throughout the surgical procedure. Preoperative cognitive function, demographic, surgery related, and intra- and post-operative physiological data were registered. RESULTS: Patients with delirium had lower pre- and intra-operative ScO2 readings, were older, had lower mini-mental-status-examination(MMSE) scores, higher additive EuroScore and lower preoperative haemoglobin-levels. The binary logistic regression identified older age, lower MMSE, neurological or psychiatric disease and lower preoperative ScO2 as independent predictors of postoperative delirium. CONCLUSIONS: The presented study shows that a low preoperative ScO2 is associated with postoperative delirium after on-pump cardiac surgery.

Opipramol improves subjective quality of sleep the night prior to surgery: confirmatory testing of a double-blind, randomized clinical trial.

OBJECTIVE: Due to its pharmacological properties, opipramol may be useful in the context of evening premedication in anaesthesiology. This trial examines whether quality of sleep the night prior to surgery can be improved by opipramol and whether this effect is dose dependent. A second objective of this study is to examine whether the emotional state (in particular anxiety) is affected by opipramol. METHOD: 72 female patients were randomly assigned to 100 mg opipramol, 150 mg opipramol or placebo (24 patients per group) in a double-blind trial. Drug application was in the evening prior to an elective surgery. Effects were recorded the next morning by means of self-rating questionnaires regarding subjective sleep quality of the last night and patients' current subjective state. The self-rating was done by use of the Wuerzburg Sleep Questionnaire, by use of mood inventories [BSKE (EWL) and STAI-X1] and by use of the Multidimensional Somatic Symptom List. Further dependent variables were heart rate and blood pressure. Confirmatory data analysis was conducted for subjective quality of sleep. RESULTS: 100 mg opipramol as well as 150 mg opipramol significantly improved subjective quality of sleep (p < 0.001). The drug conditions did not differ in this effect. Opipramol marginally reduced anxiety (STAI-X1). The autonomic variables remained uninfluenced. There were no adverse events and no hints for interaction with anaesthesia. CONCLUSION: Opipramol may be used as a premedication in the evening prior to surgery if the primary target is an impact on the experienced quality of sleep. For this a single dosage of 100 mg opipramol is sufficient and can be recommended.

Impact of general versus local anesthesia on early postoperative cognitive dysfunction following carotid endarterectomy: GALA Study Subgroup Analysis.

BACKGROUND: The aim of this study was to compare the influence of either general (GA) or local (LA) anesthesia on the postoperative neurocognitive outcome in patients undergoing carotid endarterectomy (CEA) in a randomized study. Therefore, we performed a subgroup analysis of the multicenter GALA study. METHODS: A total of 40 patients were enrolled and randomized to receive either LA (n = 17) or GA (n = 23) anesthesia. The indication for intraoperative shunting was based on the intraoperative cognitive performance in the LA group and on the clinical experience of the surgeon in the GA group. Outcome measurements included patient performance on a neuropsychological Trail Making Test, evaluation of patients mood using the self-report inventory BSKE, and serum levels of the neurobiochemical marker S100beta. The data were analyzed for each variable using a t-test and were presented as the mean (SD). Differences in shunt frequency were analyzed performing a chi-squared test. Group differences in the Trail Making Test, BSKE evaluation, and S100beta concentrations were derived from the analyses of covariances with repeated measurements using preoperative values as covariates. RESULTS: Compared to baseline, the S100beta concentrations increased significantly in the GA group [0.086 (0.038) vs. 0.061 (0.024) microg/l; p < 0.001] before unclamping of the carotid artery, whereas there were no changes in the LA group [0.068 (0.024) microg/l, p = 0.09 vs. 0.061 (0.021) microg/l, p = 0.09). Furthermore, we detected significant group differences after surgical intervention (GA 0.087 (0.031) microg/l; LA 0.06 (0.021) microg/l; p = 0.006). The postoperative neurocognitive performance in the Trail Making Test decreased significantly in the GA group, whereas there were no significant changes in the LA group. The self-report inventory BSKE evaluation revealed no significant group differences. CONCLUSIONS: We concluded that performing local anesthesia in patients undergoing CEA positively influenced early postoperative neurocognitive outcomes. Significant group differences in postoperative S100beta concentrations confirmed the beneficial effect of local anesthesia.

Validation of a german language questionnaire for screening for migraine, tension-type headache, and trigeminal autonomic cephalgias.

BACKGROUND: To develop a German language questionnaire for screening for migraine, tension-type headache, and trigeminal autonomic cephalgias. OBJECTIVE: Aim of the study was to develop a German language self-administered headache questionnaire for screening for migraine (MIG), tension-type headache (TTH), and trigeminal-autonomic cephalgias (TAC). METHODS: Questionnaire-based diagnoses were blindly compared with those of headache experts. RESULTS: Overall 278 headache patients (MIG = 97, TTH = 60, TAC = 98, MIG plus TTH = 23) as well as 42 patients with low back pain without headache and 47 healthy subjects were studied. The Cohen's kappa for 7 headache syndromes including all combination diagnoses was 0.64 (95% CI 0.58-0.70). Sensitivity and specificity for migraine were 0.73 and 0.96, for TTH 0.85 and 0.98, for TAC 0.63 and 0.99, and for MIG plus TTH 0.62 and 0.97, respectively. Ignoring all combination diagnoses, the kappa-coefficient for the monodiagnoses MIG, TTH, and TAC (193 out of 278 patients) was 0.93 (CI 0.83-1.0). The retest-reliability (4 weeks later) was 0.95. CONCLUSION: We present the first questionnaire in German language including 3 most common primary headaches for use in epidemiological research.

Using Latent Mixed Markov Models for the choice of the best pharmacological treatment.

The choice of the best pharmacological treatment for an individual patient is crucial to optimize convalescence. Due to their effects on pharmacokinetics variables like gender and age are important factors when the pharmacological regimen is planned. By means of an example from anaesthesiology the usefulness of Latent Mixed Markov Models for choosing the optimal anaesthetic considering patient characteristics is demonstrated. Latent Mixed Markov models allow to predict and compare the quality of recovery from anaesthesia for different patient groups (defined by age and gender and treated with different anaesthetic regimens) in a multivariate non-parametric approach. On the basis of observed symptoms immediately after surgery and a few days later the probabilities for the respective dynamic latent status (like health or illness) and the probabilities for transition from one status to another are estimated depending on latent class membership (patient group).

Efficacy of lidocaine patch 5% in the treatment of focal peripheral neuropathic pain syndromes: a randomized, double-blind, placebo-controlled study.

Peripheral neuropathic pain syndromes (PNPS) are difficult to treat because commonly used analgesics are often ineffective when, for example, touch-evoked allodynia, hyperalgesia, and pain paroxysms are present. To investigate whether lidocaine patch 5% treatment is also effective in postherpetic neuropathy (PHN) and in other PNPS, 40 patients with various forms and localizations of PNPS completed a prospective, randomized, placebo-controlled, two-way, cross-over study in three medical hospitals. Patients suffering from pain in a localized skin area with intensity above 40 mm visual analog scale (VAS) and a stable consumption of pain medication were included in this study. The study was divided into four phases: 3-day run-in phase, treatment phase 1, wash-out period, and treatment phase 2, each lasting 1 week. At the discretion of the patients, up to four patches (covering a maximum of 560 cm2) were applied onto the maximally painful area for 12 consecutive hours daily, always either by day or at night. Throughout the four phases, ongoing pain, allodynia, quality of neuropathic symptoms, quality of sleep, and adverse events were assessed. When, after the wash-out period, the pain intensity scores did not return to the pre-treatment values (+/-20%), these patients were excluded from the study. The present study revealed that, as an add-on therapy, the lidocaine patch 5% was clearly effective in reducing ongoing pain (P=0.017) and allodynia (P=0.023) during the first 8 h after application and that the patches also worked well over a period of 7 days (P=0.018) in diverse focal PNPS. Calculation of the numbers needed to treat (NNT) to obtain one patient with more than 50% relief of ongoing pain revealed that the NNT of 4.4 in the present study compared reasonably well with other studies of PHN, such as topically applied capsaicin (NNT: 5.3-infinity) or systemic treatment with gabapentin (NNT: 3.2-5.0).

Effects of opipramol as an evening anaesthesiologic premedication.

To date, opipramol has not been examined within the context of evening premedication in anaesthesiology. A suitable drug for such an application should induce anxiolytic and sleep-favouring effects. Due to its pharmacological properties, one would expect opipramol to lead to these effects. In order to test this possibility, 72 female patients were randomly assigned to 50 mg opipramol, 100 mg opipramol, or placebo (n = 24 patients per group) in the evening prior to surgery in a double-blind trial. Effects were recorded in the morning prior to the operation by means of self-rating questionnaires, regarding the patients' current subjective state and their judgement of the quality of sleep during the night before. The self-rating was done by the Multidimensional Mood Inventory BSKE (EWL), by use of the Multidimensional Somatic Symptom List (MSKL), and by use of the Würzburg Sleep Questionnaire. Further dependent variables were heart rate and blood pressure. Opipramol significantly improved sleep quality. Especially the frequency of awakening at night was reduced. These effects could be observed predominantly after 100 mg opipramol. At this dosage, inner excitement was reduced as well. The autonomic variables remained uninfluenced. There were no adverse events and no hints for interactions with anaesthesiology.