[Intraoperative guidance of anesthesia: Analgesie Nociception Index (ANI) vs. standard care for hysterectomy under anesthesia with sevoflurane : A randomized controlled simple blinded study on intraoperative opioid consumption, postoperative pain and patient satisfaction]. / Intraoperative Analgesiesteuerung: Analgesie Nociception Index (ANI) vs. "standard care" bei Hysterektomien unter Sevoflurannarkose : Eine randomisierte kontrollierte Einfachblindstudie zu intraoperativem Opioidverbrauch, postoperativen Schmerzen und Patientenzufriedenheit.

BACKGROUND: General anesthesia leads to different effects depending on the drugs used (hypnosis, analgesia, muscle relaxation). While there are validated methods for clinical monitoring and control of hypnosis and muscle relaxation in routine anesthesia, the assessment of analgesia is still mainly based on the interpretation of clinical vital parameters, such as heart rate, blood pressure, perspiration or intraoperative movements of the patient. The present clinical study investigated whether the use of a so-called nociception monitor to record the intraoperative need for analgesics is superior to the previous analysis of vital parameters. The analgesia nociception index (ANI; MDoloris, Lille, France) was used, which is one of several nociception monitors currently on the market for recording the sympathicovagal balance. In the case of the ANI, the measurement is based on the analysis of the heart rate variability (HRV) as a function of breathing. The index is given in the form of a dimensionless score between 0 and 100, where 0 stands for a lack of parasympathetic activity and 100 for a very strong parasympathetic activity. According to the manufacturer, a value between 50-70 under anesthesia corresponds to sufficient intraoperative analgesia. METHODS: This was a clinical prospective randomized study in which 110 patients who underwent laparoscopic hysterectomy under balanced anesthesia using propofol, fentanyl and atracurium for induction and sevoflurane and fentanyl for anesthesia maintenance, were divided into two groups. In the intervention group (ANI group), during the operation analgesics were administered with the aid of the ANI monitor (bolus of 0.1 mg fentanyl if the ANI was < 50), whereas in the comparison group analgesics were administered according to previous clinical parameters (vital parameters, intraoperative defensive movements). The groups were then compared with respect to intraoperative fentanyl consumption (primary outcome), postoperative pain and opioid-induced side effects (measured by the numeric rating scale [NRS]) as well as patient satisfaction on postoperative day 3 (secondary outcome). RESULTS: The observations showed a higher total intraoperative consumption of fentanyl in the intervention group, due to a significantly higher number of individual doses (0.54 vs. 0.44 mg, p < 0.001). With respect to the other observation points, there were hardly any differences between the groups, neither with respect to the pain score nor the side effects in the recovery room. At most there was a trend towards a slightly lower pain score at the first measurement point in the recovery room (NRS at 15 min). In the patient survey on the postoperative day 3, there was a difference with respect to the subjectively described reduction in vigilance in the ANI group, but not other side effects or overall satisfaction with the pain therapy. CONCLUSION: In this group of patients the additional use of the ANI monitor for intraoperative control of analgesia led to an increased consumption of fentanyl compared to the comparison group, without having an impact on the postoperative pain score, opioid-induced side effects or patient satisfaction. An optimization of pain therapy through intraoperative use of the ANI monitoring in hysterectomy patients under balanced anesthesia with sevoflurane and fentanyl could therefore not be proven. Transferability of the results to a much older and/or sicker patient collective remains questionable.

Validation of High-Resolution Ultrasound Measurements of Intima-Media Thickness of the Radial Artery for the Assessment of Structural Remodeling.

Radial artery (RA) intima-media thickness (IMT) could be used to study short- and long-term structural vascular adaptation following transradial cardiac catheterization. We aimed at assessing the reliability and reproducibility of RA-IMT measurement. Using high-resolution ultrasound, we studied RA-IMT in 17 patients, who underwent transradial catheterization via the right RA 1 to 12 months before. Radial artery intima-media thickness was measured in both arms, with the left RA as control. Repeated measurements were performed by 2 examiners and offline analyses were performed by independent blinded interpreters. Radial artery intima-media thickness was highly reliable with an interclass correlation coefficient (ICC) of 0.911 [0.870-0.939], a high examiner (ICCexaminer 0.910 [0.883-0.931]), and interpreter agreement (ICCinterpreter 0.963 [0.954-0.971]). Intima-media thickness at the radial access site was significantly increased compared with the contralateral RA (0.30 ± 0.056 vs 0.41 ± 0.055 mm, P < .00001). Radial artery intima-media thickness can be measured reliably using high-resolution ultrasound. Initial data suggest that transradial catheterization leads to long-term structural adaption processes.

Development and validation of a clinical index to predict survival after cardiac resynchronisation therapy.

OBJECTIVE: To develop and validate a prognostic risk index of cardiovascular mortality after cardiac resynchronisation therapy (CRT). DESIGN: Prospective cohort study. SETTING: District general hospital. PATIENTS: 148 patients with heart failure (mean age 66.7 (SD 10.4) years), New York Heart Association class III or IV, LVEF <35%) who underwent CRT. INTERVENTIONS: CRT device implantation. MAIN OUTCOME MEASURES: Value of a composite index in predicting cardiovascular mortality, validated internally by bootstrapping. The predictive value of the index was compared to factors that are known to predict mortality in patients with heart failure. RESULTS: All patients underwent assessment of 16 prognostic risk factors, including cardiovascular magnetic resonance (CMR) measures of myocardial scarring (gadolinium-hyperenhancement) and dyssynchrony, before implantation. Clinical events were assessed after a median follow-up of 913 (interquartile range 967) days. At follow-up, 37/148 (25%) of patients died from cardiovascular causes. In Cox proportional hazards analyses, (DSC) Dyssynchrony, posterolateral Scar location (both p<0.0001) and Creatinine (p = 0.0046) emerged as independent predictors of cardiovascular mortality. The DSC index, derived from these variables combined, emerged as a powerful predictor of cardiovascular mortality. Compared to patients with a DSC <3, cardiovascular mortality in patients in the intermediate DSC index (3-5; HR: 11.1 (95% confidence interval (CI) 3.00 to 41.1), p = 0.0003) and high DSC index (> or =5; HR: 30.5 (95% CI 9.15 to 101.8), p<0.0001) were higher. Bootstrap validation confirmed excellent calibration and internal validity of the prediction model. CONCLUSION: The DSC index, derived from a standard CMR scan and plasma creatinine before implantation, is a powerful predictor of cardiovascular mortality after CRT.

Effect of posterolateral left ventricular scar on mortality and morbidity following cardiac resynchronization therapy.

OBJECTIVES: To determine the effect of a posterolateral (PL) left ventricular scar on mortality and morbidity following cardiac resynchronization therapy (CRT). METHODS: Sixty-two patients with heart failure (age 67.3 +/- 9.6 yrs [mean +/- SD], 45 males, New York Heart Association class [NYHA] class III or IV, left ventricular ejection fraction [LVEF]= 35%, left bundle branch block, QRS > or = 120 ms) underwent late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) for scar imaging. Patients were followed up for 741 (75-1602) days (mean [range]). RESULTS: The presence of a PL scar emerged as an independent predictor of the composite endpoint of cardiovascular death or hospitalization for worsening heart failure (HR: 3.06 [1.63, 7.7, P < 0.0001]) as well as the endpoint of cardiovascular death (HR: 2.63 [1.39, 6.65], P = 0.0016). A transmural PL scar was the strongest predictor of these endpoints (both P < 0.0001). The symptomatic responder rate (improvement by > or =1 NYHA classes or > or =25% in 6-min walking distance) was 83% in the group with non-PL scars, but only 47% in the group with transmural PL scars (P < 0.0001). Pacing over the scar was associated with a higher mortality and morbidity than pacing outside the scar (all P < 0.05). CONCLUSIONS: A PL scar is associated with a worse clinical outcome following CRT, particularly if it is transmural. Pacing scarred left ventricular myocardium carries a greater risk of mortality and morbidity than pacing nonscarred myocardium.

Ultrasonic force microscopy on strained antimony nanoparticles.

Ultrasonic force microscopy (UFM) is used to resolve the elastic nanostructure of strained antimony (Sb) particles. These nanoparticles were formed by aggregation and spontaneous rapid crystallization of thermally deposited Sb onto the (0001) basal planes of highly oriented pyrolytic graphite (HOPG) and molybdenum disulfide (MoS(2)). UFM reveals clear contrast within individual nanoparticles, which can be attributed to differences in the local stiffness. This interpretation is confirmed by transmission electron microscopy (TEM) images, in which bending contours prove the existence of strained regions within the nanocrystals.

The cancer risk in the stomach subjected to nonresecting procedures. An experimental long-term study.

Whereas there is no longer any significant controversy regarding whether the resected stomach is subject to an increased risk of cancer, this question remains of great importance in terms of the cancer risk of nonresecting procedures performed on the stomach. Attention was given in particular to investigating with respect to carcinogenic potential the influence of gastrotomy. Heineke-Mikulicz pyloroplasty, gastrotomy plus pyloroplasty, vagotomy plus pyloroplasty, and gastroenterostomy without resection. As with resecting procedures, the carcinomas were also first observed in larger numbers following the nonresecting procedures without application of carcinogen. Of the 227 animals surviving the prescribed period 16 developed carcinomas of the stomach following application of carcinogen. 20 developed gastric carcinomas without carcinogen. Which individual factors in this multifactorial process might be the main contributors to carcinogenesis cannot be ascertained from our study.

[Carcinogenesis following vagotomy. Experimental long-term animal studies]. / Zur Karzinogenese nach Vagotomie. Tierexperimentelle Langzeituntersuchungen.

The risk of carcinoma in the stomach after non resecting surgery is not yet clear, because 12 to 14 years of clinical follow ups after vagotomy and especially selective proximal vagotomy are not long enough. Our experimental long term studies showed for the first time carcinoma in animals after vagotomy without application of a carcinogen. Due to the the operation and probably to carcinogenesis are atrophy of the mucosa, achlorhydria and ulcer as well as duodeno-gastric-reflux after drainage-operation and the lesion by the operation itself, in different and varying extents. Observing the cautious reservations needed for transferring experimental results to human conditions, vagotomy is no longer an operation out of competition compared with gastric resections, especially when a drainage-operation must be done. Careful postoperative and clinical surveillance including endoscopy and biopsy after vagotomy is necessary after resections of the stomach.

[Surgical therapy of achalasia for prevention of reflux esophagitis]. / Chirurgische Therapie der Achalasie zur Vermeidung einer Refluxösophagitis.

Not only the conservative dilatation treatment achalasia is at disposal, but also the operative cardiomyotomy. The former treatment followed often by recurrent danger of perforation as well as both methods lead in a definite percentage of cases to refluxesophagitis. Therefore, in our department since 1973 a combination of cardiomyotomy and fundoplication are performed consecutively. By using this method the reflux is surely, according to our experiences, avoidable. The indication of conservative treatment is to be performed by inoperable patients.

[Pathology of the anal region and its care in proctologic practice]. / Pathologie de la région anale et les soins en pratique proctologique.

The anal dermis, with its sensitive receptors, is an important part of the anorectal apparatus. Anal fissures and perianal phlebothrombosis can cause considerable pain. According to anatomical diagnostics, there are three clear stages in the development of an anal fissure. At the first stage, a treatment using a glass dilator gives good results. The subsequent two stages, however, require surgery. In current practice there are two types of operation: the association of a fissurectomy with dorsal sphincterotomy under local or general anaesthetic; or fissurectomy associated with an inferior lateral sphincterotomy, a technique improved by Notaras. A comparison between the two types of treatment shows that fissurectomy associated with lateral sphincterotomy constitutes the more effective method. As the rate of recidivism and complications is the same, the operation can be performed on an ambulatory basis during hours of consultation. Thrombectomy under local anaesthetic may be used for the treatment of perianal phlebothrombosis in its most critical phases. This always relieves the patient's pain, and it, too, may be performed on an ambulatory basis.

[On the relationship between the return blood circulation and sports]. / A propos des rapports entre la circulation sanguine de retour et les sports.

The authors discuss the consequences of various kinds of sport such as canoeing, the numerous forms of jumping, football and cycling on the venous system and go on to consider the treatment of varicose veins and to recommend fairly broad indications for surgery based on stripping along the length of the internal saphenous vein, completed if necessary, by phlebosclerosis. The importance of keeping the leg in a sterile state during the post operative period is emphasised. Some easy precautions to be carried out while practicing various sports are described.

[Benign tumors of the esophagus (author's transl)]. / Gutartige Tumoren der Speiseröhre.

Benign esophageal tumors are rare. Intraluminal and intramural tumors may be distinguished according to localization,--intramural leiomyomas occur most often. Retrosternal pain and dysphagia are the most frequent symptoms, rather often there are however no symptoms at all. X-ray examination and esophagoscopy should be applied for making a diagnosis, intramural tumors however may escape endoscopic diagnosis. Biopsies are indicated only, if mucosal alterations can be observed macroscopically. For final diagnosis the tumor has to be removed completely by surgery. In most cases this can be achieved by transthoracal enucleation, in special cases it may be necessary to remove part of the esophagus. Nine cases are reported.

[Clinical experience with acute mesenteric vascular occlusion (author's transl)]. / Akuter Mesenterialgefässverschluss.

Between 1964 and 1978 twenty patients suffering from acute mesenteric vascular occlusion were treated in the surgical department (University of Münster). The average duration of the anamnesis until their hospitalization was 3.1 days and the actual operation was performed 11.35 hours later on the average. In only 15% of the cases had a correct preoperative diagnosis been given. As regards the frequency of causation, 60% of the mesenteric vascular occlusions were caused by a mesenteric arterioembolism, 20% by a mesenteric venous embolism, 10% by a mesenteric arterial thrombosis and 10% by a non-obstructive occlusion. In a post cardiac infarction condition was the predisposing factor in 50% of all cases, valvular defect in 33.5% and tachyarrhythmia in 16.6%. The causes found for the mesenteric venous tbrombosis were insufficiency of the right heart, absolute bradyarrhythmia, recurrent venous thrombosis of the leg, and myeloproliferative syndromes.