Incidence of coronary heart disease and cardiac events in patients undergoing kidney and pancreatic transplantation.

One major cause of graft loss after kidney transplantation or simultaneous kidney and pancreas transplantation is death of the recipient due to cardiac events. Records of 261 patients who underwent sole kidney (group A) or combined kidney-pancreas transplantation (group B) were retrospectively analyzed. Patients were divided into groups with basic cardiac evaluation (chest X-ray, electrocardiogram) and patients with additional diagnostics [echocardiography, exercise stress test, myocardial perfusion test, and coronary angiography (CAG)]. The results of the performed CAGs were as follows: proven coronary artery disease (CAD) in 22 patients (12.43%) in group A and 37 patients (44.05%) in group B; stenosis of one main coronary artery of 70% or greater in 8.47% (group A) and 16.67% (group B) of the patients. Subsequent revascularization procedures were performed in 15 candidates (8.47%) of group A and 11 (13.10%) of group B. The incidence of posttransplant cardiac events (PCE) was lower in recipients in both groups who underwent additional cardiac evaluation. Late postoperative deaths were reported in 3.45% of kidney recipients with no additional evaluation (group A), in 2.06% of patients with further diagnostics (group A), and in only 1.19% of patients with invasive pretransplant evaluation (group B). Patients with known CAD and no further invasive diagnostics or subsequent revascularization are at great risk. PCE were observed in three of seven patients in this subgroup. Careful cardiac evaluation including echocardiography, exercise stress test, myocardial perfusion test, and CAG is associated with a low incidence of PCE.

The third occipital condyle, a constituent part of a median occipito-atlanto-odontoid joint: a case report.

A compound conjunction between basiocciput, atlas (anterior arch), and dens of axis (odontoid process) was found incidentally during routine dissection of the head of an 83-year-old man. According to the patient's history, no neck disability had been recorded. A median saw-cut of the head-and-neck conjunction revealed that the basion was anteriorly reinforced by an osseous pillar 4 mm in length and 3 mm in width. Such a formation is known as a third occipital condyle (condylus tertius, CT). In our case it exhibited one surface oriented in an anterior-inferior direction and articulating with the superior border of the anterior arch of the atlas, and another surface oriented in a posterior-inferior direction and articulating with the superior portion of the dens of axis. The dens of axis itself articulated with the anterior arch of the atlas, forming the (normal) median atlanto-axial joint. Post-mortem computed tomography and post-mortem histological examination completed the investigation. The cartilage of the articular compartment between the CT and the anterior arch of the atlas and the related anterior fibrous disc exhibited severe arthrosis. The findings were discussed in the light of developmental and comparative anatomy.

[Course of the hypoglossal nerve in tongue musculature]. / Verlauf des N. hypoglossus in der Zungenmuskulatur.

BACKGROUND: The main trunk of the hypoglossal nerve enters the tongue body anterior to the hypoglossal muscle and runs in a medial direction. RESULTS: Close to the lingual septum, the nerve changes its direction to a superior path and in a second change to an anterior path. The terminal branches disperse in the apical part of the tongue. To avoid injury of the hypoglossal nerve during surgical procedures within the body of the tongue, two fingerbreadth areas should be preserved. The first area lies in a vertical direction, from the entry of the nerve up to the longitudinal superior and inferior muscles. The second area extends from here in an anterior direction up to the lingual apex.

Liver transplantation without venovenous bypass: morbidity and mortality in patients with greater than 50% reduction in cardiac output after vena cava clamping.

OBJECTIVE: To investigate whether a decrease in cardiac output of >or=50% after vena cava clamping is associated with an increase in perioperative morbidity or mortality in patients undergoing orthotopic liver transplantation without venovenous bypass. DESIGN: Retrospective, clinical study. PARTICIPANTS: Patients undergoing elective orthotopic liver transplantation without venovenous bypass (n = 172). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In 82 patients (group 1), the decrease in cardiac output after vena cava clamping was >or=50%; in 90 patients (group 2), the decrease was <50%. Hemodynamics during surgery and perioperative morbidity and mortality were compared between group 1 and group 2 patients. Mean arterial pressure during the anhepatic phase was not significantly different between groups, but cardiac output and mixed venous oxygen saturation were significantly lower in group 1 patients. Perioperative mortality, need for postoperative renal replacement therapy, postoperative serum creatinine levels, and graft function were not different between groups. CONCLUSION: A >50% reduction in cardiac output after vena cava clamping is not associated with an increase in perioperative morbidity and mortality when compared with patients with a less pronounced reduction in cardiac output. These results question the common practice of basing the indication for venovenous bypass during the anhepatic phase on a reduction in cardiac output of >50% after a trial of vena cava clamping.

Orthotopic liver transplantation in a patient with severe portopulmonary hypertension.

Liver transplantation in patients with severe portopulmonary hypertension (PPH) has been associated with mortality rates in the range of 70% to 80%. Preoperative long-term epoprostenol therapy reverses pulmonary hypertension and may be a valuable possibility to reduce mortality in patients with severe PPH undergoing orthotopic liver transplantation. We want to report a patient with severe PPH, who was treated with intravenous epoprostenol for an 8-month period, after which pulmonary vascular resistance had decreased from 12 to 3 Wood units. Nevertheless, the patient developed intractable perioperative right heart failure necessitating transient mechanical circulatory support. The patient was weaned from mechanical circulatory support, but died from another episode of acute right heart failure after 28 days. Complicated liver transplantation associated with major cardiovascular stress is obviously not tolerated in patients with severe portopulmonary hypertension even after preoperative long-term epoprostenol therapy.

Anastomosis between the external branch of the superior laryngeal nerve and the recurrent laryngeal nerve.

An incidental finding in the anatomy lab showed up a plexus of the external branch of the right superior laryngeal nerve (SLN), including an anastomosis with the recurrent laryngeal nerve (RLN). The external branch of the SLN divided in two extensions: The ventral extension reached the mesopharynx laterally and by supplying the latter, ended at the cricothyroid muscle. The dorsal extension formed a plexus a finger's breadth beneath the inferior margin of the pharynx, on the lateral aspect of the esophagus. The anastomosis ran from the lower part of the plexus to the RLN along the esophagus, laterally.

Pneumothorax following nasogastric feeding tube insertion in a tracheostomized patient after bilateral lung transplantation.

We report the case of a pneumothorax caused by the improper placement of a nasogastric feeding tube in a tracheostomized patient after bilateral lung transplantation. We discuss the contribution of low-pressure cuffed tracheostomy tubes to the inadvertent respiratory tract misplacement of a nasogastric feeding tube, as well as the problems of nasogastric feeding tube insertion in the sedated patient, why the previously installed closed-tube thoracostomy did not prevent the pneumothorax and possible pitfalls in confirming the proper position of the nasogastric feeding tube. In conclusions, we stress that in high risk patients a nasogastric feeding tube should only be inserted under direct vision and that a subsequent routine X-ray is mandatory for confirming proper positioning.

Force distribution across the heel of the hand during simulated manual chest compression.

According to most published guidelines of cardiopulmonary resuscitation chest compression is performed on the lower half of the sternum by compressing the sternum with the heel of one hand and the other hand on top of the first. In all guidelines and during CPR training great importance is attributed to exact localisation of the so-called compression point. In a laboratory investigation we assessed the force distribution across the heel of the hand and defined the total breadth in contact with the sternum. In order to find out whether there is any difference in the force pattern with the right or the left hand in direct contact with the sternum we determined the resultant maximal force of that part of the heel of the hand exerting the maximal force. A total of 12 anaesthetists performed simulated chest compressions onto a flat surface covered with an integrated force sensor mat. The distance between the most ulnar part and the most radial part of the hand was determined to be 9.2 cm. Similar mean total forces were measured (right hand in contact: 644 N; left hand in contact: 621 N). In all except one anaesthetist the hypothenar part of the heel exerted a significantly higher force compared to the thenar part, independent of whether the right hand or the left hand was in contact. The distance between points of maximal force when the right hand or when the left hand in contact was 2.2 cm corresponding to the breadth of one and a half fingers. To reduce the potential risk of sternal fractures by chest compressions applied too far in a cephalad direction, we recommend use of the right hand in contact if the rescuer kneels at the right side of the patient and vice versa.

[The openings of the inferior thyroid vein(s)]. / Das Mündungsverhalten der Vena(e) thyroidea(e) inferior(es).

Because of the importance concerning angiography and approach in neck surgery the venous drainage from the inferior border of the thyroid gland, including its variants, had been reported in numerous times in surgical and anatomic literature. Statistical information on the frequency of opening sites and number of the thyroid veins are rather poor and differ with the variant authors tremendously, due to the small number of patients or preparations investigated. To provide more accurate data are the objectives of this paper. Our issues derive from examinations on cadavers of the dissecting-courses in the years 1987-1992 (n = 168). Preparations showing signs of semiresection of the thyroid gland had been rejected for this study, obviously. In regard to the brachiocephalic veins three groups of venous drainage could be established: A) Exclusive drainage to the right or left brachiocephalic vein or their junction, respectively; B) Combinations of the possibilities shown in A); C) Special cases with supernumerary drainage to other veins of the mediastinum. Besides detailed descriptions of the frequency of the variants found, the discrepancies to the known literature are discussed. Some of the variants described by us have not been mentioned at all.

Who publishes in the large anaesthesia journals?

We have analysed, with the aid of an online database, the number of all types of contributions from scientists of various countries to four leading international anaesthesia journals (British Journal of Anaesthesia, Anaesthesia, Anesthesia and Analgesia and Anesthesiology) during the period 1987-1991. Although American and British publications played the leading roles in the total number of anaesthetic publications (40.4% and 32.5%, respectively), more detailed analysis revealed an unexpectedly high "publication output" of smaller countries, which sometimes exceeded those of larger nations (publications per million inhabitants: United Kingdom 41.9, Denmark 24.2, Sweden 15.4, Finland 15.3, Israel 14.6, Ireland 13.1, U.S.A. 11.9, Switzerland 11.0).

The use of rocuronium (ORG 9426) in patients with chronic renal failure.

The pharmacodynamics of an initial dose of 0.6 mg.kg-1 rocuronium followed by three maintenance doses of 0.15 mg.kg-1 were studied during nitrous oxide/oxygen/isoflurane anaesthesia in patients with normal renal function (n = 12) and chronic renal failure (n = 12). The mean (SD) duration (min) of block after the initial dose was 28.0 (5.5) and 25.6 (11.7) respectively. The mean (SD) duration (min) of the effect of the three maintenance doses was 15.3 (4.0) and 14.2 (7.0); 17.3 (3.2) and 17.4 (8.7); 18.1 (2.8) and 19.1 (10.1) for the normal and renal failure patients respectively. The induced and spontaneous recovery indices were 3.7 (0.7) and 17.1 (6.9) in the normal group compared with 3.9 (0.5) and 19.0 (12.5) in the renal failure group and these values did not differ between the two groups. In this small study rocuronium appears to be suitable for patients with chronic renal failure. There is no evidence of prolonged block even when the drug is given in repeated doses for maintenance.

Atrial natriuretic factor release during hypovolemia and after volume replacement.

OBJECTIVE: To examine plasma atrial natriuretic factor activity during hypovolemia and after vascular volume replacement. DESIGN: Prospective, descriptive study. SETTINGS: Scene of emergency, Emergency Department, and the ICU of a university hospital. PATIENTS: A total of 47 trauma patients with evidence of hypovolemia were grouped according to their major injury into a thoracic injury group (15 patients; mean Injury Severity Score = 38.5 +/- 3.1 [SEM], Hospital Trauma Index = 14.1 +/- 0.7), an abdominal injury group (14 patients; Injury Severity Score = 36 +/- 3.3, Hospital Trauma Index = 14 +/- 0.9), and a severe head injury group (18 patients; Injury Severity Score = 23 +/- 1.5, Hospital Trauma Index = 10 +/- 0.6). MEASUREMENTS AND MAIN RESULTS: Measurements were taken at the scene of emergency; after volume replacement in the Emergency Department; and after 3, 7, 12, 24, 36 hrs and on day 5 in the ICU. In all groups, the average plasma atrial natriuretic factor levels were increased at the scene of emergency and declined significantly to normal values with volume replacement. In the thoracic injury group, plasma atrial natriuretic factor activity decreased from 253 +/- 73 to 115 +/- 83 pg/mL (p less than .0017); in the abdominal injury group, plasma atrial natriuretic factor activity decreased from 194 +/- 42 to 91 +/- 24 pg/mL (p less than .006); in the severe head injury group, plasma atrial natriuretic factor activity decreased from 167 +/- 28 to 70 +/- 13 pg/mL (p less than .02) with volume replacement. Plasma atrial natriuretic factor levels at the scene of emergency were significantly (252 +/- 73 vs. 167 +/- 28 pg/mL; p less than .05) higher in the thoracic injury group and in the abdominal injury group (194 +/- 42 vs. 167 +/- 28 pg/mL; p less than .05), as compared with the severe head injury group. CONCLUSIONS: In trauma patients, plasma atrial natriuretic factor concentrations were markedly increased in patients with untreated hypovolemia and were decreased to normal values with vascular volume replacement. Thus, atrial natriuretic factor seems to play an important physiologic role during hypovolemia.

[Plasma levels of atrial natriuretic peptide, cyclic guanosine monophosphate and renin following 7.5% NaCl + 6% hydroxyethyl starch or Ringer's lactate. A comparative study of 6 normal subjects]. / Plasmaspiegel des Atrialen-Natriuretischen-Peptids (ANP), des zyklischen-Guanosin-Mono-Phosphats (cGMP) sowie des Renins nach Gabe von 7.5% NaCl + 6% Hydroxyäthylstärke (HH) oder Ringer-Laktat (RL). Vergleichsstudie an 6 gesunden Probanden.

Small-volume resuscitation with hypertonic saline in combination with dextran appears to be very successful in experimental animals, where better results are achieved than in animals treated with a traditional infusion regime. This effect is apparently related to improved organ blood flow due to reflex vasodilatation. This reflex is based on the arrival of hypertonic solution in the pulmonary circulation. The expansion of intravascular volume would seem to be of secondary importance. Atrial natriuretic peptide (ANP) is released from secretory granules located in atrial cardiocytes. Atrial distention appears to be the predominant stimulus triggering ANP production. In addition to the natriuretic and diuretic effects, ANP leads to vasodilation, especially when vascular tone is elevated; the sympathetic reflex seems to be attenuated. Cyclic Guanosine Monophosphate (cGMP) is an intracellular messenger and is partly released by ANP in the membrane-bound form. Renin excretion is highly influenced by ANP. The object of this study was to evaluate the influence of a hypertonic solution on this hormonal regulatory system. METHOD. This study compared a hypertonic sodium chloride solution (7.5%) in combination with hydroxyethyl starch (6%) (HH) to Ringer's lactate (RL). Six healthy volunteers received 4 ml/kg HH and 1 week later 500 ml RL. The infusion was administered in 20 minutes via a central venous catheter 70 cm in length. Blood pressure, heart rate, hemoglobin (Hb), hematocrit (Hk), colloid osmotic pressure (COP), sodium (Na+), chloride (Cl-), and plasma osmolarity were measured before starting and 5 and 30 min following infusion. At the same times ANP, cGMP, and plasma renin were also determined. RESULTS. Both groups showed no change in blood pressure or heart rate. The decrease of Hb, Hk, and COP in the HH and RL groups indicated the expansion of circulating plasma volume. HH infusion caused significant increases in ANP and cGMP, whereas plasma renin declined significantly. After RL infusion, ANP and renin values were very similar to the HH group except in one volunteer, who showed an extreme increase in ANP (760 pg/ml) 5 min after HH infusion. cGMP did not increase significantly in the RL group. On comparison of the two groups, only a significant difference in plasma osmolarity and in sodium and chloride levels was noted. CONCLUSION. We found that hypertonic NaCl (7.5%) with HH was well tolerated. Release of ANP and cGMP after HH infusion in healthy volunteers was not as high as expected, and the vasodilatory effect of hypertonic solutions was not explained by ANP or cGMP release in this investigation.

[Intra-oral block anesthesia of the inferior alveolar nerve]. / Zur Durchführung der Leitungsanästhesie des N. alveolaris inferior--Auswirkungen verschiedener Definitionen für die Okklusionsebene.

One of the landmarks for intra-oral block anesthesia of the inferior alveolar nerve is the occlusal plane. But to our knowledge, 7 different definitions of the occlusal plane have been reported in the literature. Depending on the definition chosen, different results may be obtained. We tried to find the most useful definition by measuring macerated mandibles. Our investigations suggest that the occlusal plane is best defined by the following 3 points: the buccal cusps of the first and second lower molars on the side of the injection and the buccal cusp of the second lower premolar on the contralateral side.

[Articular disk degeneration in the TMJ]. / Zu den Degenerationsvorgängen am Discus articularis des Kiefergelenkes.

Arthroscopic, macroscopic and histological signs of degenerative changes in the articular disc were found in 228 temporo-mandibular joints from corpses. In this way it was possible to identify a degenerative development series. Three preferred sites are typical of degenerative metaplastic processes: antero-lateral in the fibrocartilaginous section, lateral at the transition between fibrocartilaginous and bilaminar section and postero-central in the bilaminar zone. The beginning of a degenerative process was never detected in other sections of the disc. Degeneration commences in the fibrocartilaginous section with fragmentation of the collagen fibres, destruction of interzellular substance and loss of collagen fibres proceeding from the cranial surface. This leads to thinning, rupture and, finally, to dehiscence. In the bilaminar zone the degeneration develops in the caudal section of the cranial lamella. It leads to ganglia formation due to mucoid liquefaction. After tearing of the cranial lamella the caudal lamella thins down until it finally ruptures. Dehiscence thus occurs dorsally, too.

[The temporomandibular joint in computerized tomography]. / Das Kiefergelenk in der Computertomographie.

The first part describes details of the temporomandibular joint (TMJ) which are of interest for the examination by computed tomography. In the second part three new planes of reference for scanning of the ventral, middle or dorsal part of the joint are presented. CT examinations were made of 14 TMJ of corpses to identify the medial or ventral parts of the articular disc, medial wall of the articular capsule and medial or triangular recessus to achieve this were scanned the corpses with opened and closed mouth, as well as with closed sets of teeth using a sort of hypomochlion in the molar region to distract the TMJ. More over we applicated different contrast mediums like air and niob.