Cirrhotic Cardiomyopathy and Cardiac Failure after Liver Transplantation: A Case Series.

Preoperative cardiac functional assessment has been a long-debated topic in liver transplantation. Debate continues to exist regarding the use of invasive cardiac studies, and the utility of each prior to transplant. Despite the debate, a 7% mortality can be attributed to significant cardiac events. We present a case series of 3 patients who underwent orthotopic liver transplantation and developed significant cardiac dysfunction postoperatively. All preoperative cardiac assessments in each patient were normal with no hemodynamically significant abnormalities. Interestingly enough, each patient developed cardiac failure due to completely different diagnoses.

Impact of human immunodeficiency virus on 2-year revision rates following lumbar fusion for degenerative spinal conditions: a retrospective cohort study.

BACKGROUND: To our knowledge, no studies exist that evaluate the impact of human immunodeficiency virus (HIV) on long-term revision rates following lumbar fusion. This study aims to understand how HIV impacts 2-year revision rates and 90-day postoperative complication rates following primary lumbar fusion for degenerative spine conditions. METHODS: Data collection was done using PearlDiver Patient Records Database, a national insurance database from 2010-2019. Patients who underwent primary lumbar fusion for degenerative diseases were divided into a cohort of patients that are HIV positive (HIV), have asymptomatic HIV (AHIV), acquired immune deficiency syndrome (AIDS), and HIV-negative at the time of their procedure. Univariate and multivariable regression analyses were performed to determine rates of revision surgery, surgical site infection (SSI), neurological complications, sensory deficits, bowel/bladder dysfunction and myelopathies within two years of surgery as well as 90-day postoperative complications. RESULTS: In total, 216,587 patients were included in this study. Of these, 631 patients (0.29%) had HIV including 502 patients (0.23%) with asymptomatic HIV and 129 patients (0.06%) with AIDS. Relative to the control cohort, patients with HIV had no difference in odds of two-year revision surgery, SSI, neurological complications, sensory deficits, bowel/bladder dysfunction and myelopathies. Patients with HIV did have increased odds of postoperative pneumonia (OR 1.592; 95% CI: 1.048-2.314; P=0.021). AIDS patients had greater odds of respiratory complications (OR 2.585; 95% CI: 1.075-5.264; P=0.017) and septic complications (OR 2.702; 95% CI: 1.122-5.514; P=0.013) 90-day postoperatively. CONCLUSIONS: Our study found that HIV positive status did not significantly affect two-year revision rates compared to the control group. However, there is a higher rate of pneumonia and respiratory complications among HIV positive patients. Before deciding to proceed with surgical intervention in HIV positive individuals, surgeons must carefully consider each patient's specific diagnosis, comorbidities, and risk factors.

Utilization of Intraoperative TEE to Assess Supraventricular Tachycardia-Inducing Right-Sided Cardiac Compression by the Liver, Post-Liver-Transplantation Status.

This unique and interesting case report involves a patient who recently underwent a combined liver and kidney transplant (due to autosomal dominant polycystic kidney disease) and subsequently suffered from episodes of supraventricular tachycardia (SVT) secondary to the new liver graft compressing the right atrium and ventricle. After this was diagnosed, the patient underwent operative plication of the right hemidiaphragm. Intraoperative transesophageal echocardiography was used to demonstrate cardiac compression from the liver and demonstrate resolution of compression after plication of the hemidiaphragm.

Adherence to guidelines for the management of local anesthetic systemic toxicity is improved by an electronic decision support tool and designated "Reader".

BACKGROUND AND OBJECTIVES: A hardcopy or paper cognitive aid has been shown to improve performance during the management of simulated local anesthetic systemic toxicity (LAST) when given to the team leader. However, there remains room for improvement to ensure a system that can achieve perfect adherence to the published guidelines for LAST management. Recent research has shown that implementing a checklist via a designated reader may be of benefit. Accordingly, we sought to investigate the effect of an electronic decision support tool (DST) and designated "Reader" role on team performance during an in situ simulation of LAST. METHODS: Participants were randomized to Reader + DST (n = 16, rDST) and Control (n = 15, memory alone). The rDST group received the assistance of a dedicated Reader on the response team who was equipped with an electronic DST. The primary outcome measure was adherence to guidelines. RESULTS: For overall and critical percent correct scores, the rDST group scored higher than Control (99.3% vs 72.2%, P < 0.0001; 99.5% vs 70%, P < 0.0001, respectively). In the LAST scenario, 0 (0%) of 15 in the control group performed 100% of critical management steps, whereas 15 (93.8%) of 16 in the rDST group did so (P < 0.0001). CONCLUSIONS: In a prospective, randomized single-blinded study, a designated Reader with an electronic DST improved adherence to guidelines in the management of an in situ simulation of LAST. Such tools are promising in the future of medicine, but further research is needed to ensure the best methods for implementing them in the clinical arena.

[Vertigo and disturbance of balance concerning medico-legal principles]. / Schwindel und Gleichgewichtsstörungen nach den neuen "Versorgungsmedizinischen Grundsätzen".

The evidence of social rights for compensation and the rights of severely disabled persons has changed since January 1 (st) 2009. Now these rights have the status of laws. Furthermore the scale of disability (incapacitation) will now used as a scale of conditions due to injury. And the new scale contains a reflection on specific origins of the traumatisation.

[Nasal surgery in patients with systemic disorders]. / Rhinochirurgie bei Systemerkrankungen.

Systemic disorders represent a heterogenous group of diseases which can primarily manifest at the nose and sinuses as limited disease or secondarily as part of the systemic involvement. Rhinologists therefore play an important role in the diagnostic but also therapeutic process. Although therapy of systemic disorders is primary systemic, additional nasal surgery may become necessary. Surgical procedures include sinus surgery for the treatment of complications of the orbit and the lacrimal duct, septorhinoplasty due to saddle nose deformity and closure of septal perforation. Since many systemic disorders represent very rare diseases, recommendations are based on the analysis of single case reports and studies with a limited number of patients. Even though data is still limited, experiences published so far have shown that autogenous cartilage or bone transplants can be used in nasal reconstruction of deformities caused by tuberculosis, leprosy, wegener's granulomatosis, sarcoidosis and relapsing polychondritis. Experiences gained from these diseases support our observation that well-established techniques of septorhinoplasty can be used in systemic disorders as well. However, reaching a state of remission is an essential condition before considering any rhinosurgery in these patients. Under these circumstances revision surgery has to be expected more frequently compared to the typical collective of patients undergoing septorhinoplasty. These observations in part may also be useful for the treatment of nasal septal perforations since implantation of cartilage- or bone grafts represents an essential step in the closure of septal perforations. Apart from the treatment of orbital complications, sinus surgery has been proven beneficial in reducing nasal symptoms and increasing quality of life in patients refractory to systemic treatment.

[Traffic medicine expert opinions in otorhinolaryngology: current aspects]. / Verkehrsmedizinische Begutachtung in der HNO-Heilkunde : Aktuelle Aspekte.

According to German law granting of driving licenses depends on the proof of an adequate driving capability. The corresponding guidelines are at present in the process of being revised. At the moment bilateral deafness and high-grade hearing loss (> or = 60% in pure tone audiometry) are not exclusion criteria for driving licenses grades A, B and C, while driving licenses grade D and licenses for public transport are generally excluded. In the forthcoming revised edition of the guidelines it has been suggested that the latter group will also not be excluded. The regulations concerning dizziness are wide-sweeping at the moment as no driving license will be granted if dizziness is present but will be more specific in the next issue. In particular a division will be made between single axle and two axle vehicles. An expert assessment about driving suitability can only be made by a certified specialist with qualifications in traffic medicine.

[Expert assessment of adenocarcinomas of the nasal cavity and the paranasal sinuses caused by wood dust]. / Aktualisierung der Hinweise zur Begutachtung holzstaubassoziierter sinunasaler Adenokarzinome (BK 4203)1.

BACKGROUND: Adenocarcinomas of the nasal cavity and the paranasal sinuses after occupational exposure to sawdust from oak and beech have been listed as occupational diseases in Germany since 1988. Given that modes of treatment have changed, we analyzed the guidelines based on the recommendations of Hartung et al. for developing an expert assessment on reduced earning capacity. MATERIALS AND METHODS: A retrospective analysis of 43 cases which had been evaluated between March 1994 and February 2007 for an occupational disease #4203, in the Ear-Nose-Throat clinic of the Münster University Hospital, Germany. RESULTS: Following the guidelines of Hartung et al., it was impossible to formally classify 21 of 43 cases (48.8 %) in an unambiguous manner. This was primarily due to the assessment of the results of radiotherapy, either adjuvant or therapeutic, as well as the grading of postoperative dysfunction in the area of the sinuses operated on (Rhinitis, Ozaena). Suggestions for a revision of the classification system include a modified assessment of radiotherapy as well as evidence for grading post-therapeutic inflammations of the sinus operated on based on the need for further care. These changes enable all cases in question to be classified unambiguously. CONCLUSIONS: The use of the revised guidelines is recommended for expert assessment of adenocarcinomas of the nasal cavity and the paranasal sinuses caused by wood dust.

Magnetic resonance angiography follow-up examinations to detect iatrogenic pseudoaneurysms following otorhinolaryngological surgery.

Endoscopic endonasal surgery on a 36-year-old man was complicated by perforation of the right internal carotid artery. The immediate, substantial haemorrhage was controlled by packing the sphenoid sinus. Intra-arterial angiography of the right internal carotid artery showed small irregularities proximal to the ophthalmic artery. A follow-up examination two weeks later documented a large pseudoaneurysm in the initially irregular arterial segment, which was successfully treated by endovascular coiling. This case report illustrates the need for angiographic follow-up examinations following traumatic intracranial vessel injury in order to identify late pseudoaneurysm development.

The effect of endogenous nitric oxide on mechanical ciliostimulation of human nasal mucosa.

BACKGROUND: Endogenous nitric oxide (NO) production by the inducible NO-synthase is enhanced in the nasal respiratory epithelium of patients with allergic rhinitis. Recent experimental data suggest endogenous NO to be strongly involved in the regulation of ciliary activity, the driving force of the mucociliary transport system. OBJECTIVE: In this study, we investigated the effect of endogenous NO on mechanical stimulation of ciliary activity in a nasal mucosa explant model. METHODS: Cultures of nasal mucosa explants were incubated with TNF-alpha and bacterial lipopolysaccharides (LPS) to enhance endogenous NO production. Direct in vitro NO imaging was performed by the fluorescent NO-indicator DAF-2 DA and laser scanning confocal microscopy. Ciliary beat frequency (CBF) was determined using a photoelectric technique. Mechanical stimulation was performed by two consecutive flow increments in a closed perfusion chamber. Endogenous NO-synthesis was blocked by l-NAME before the second flow stimulation. RESULTS: Under control conditions the mean rise of CBF relative to baseline was 30.2% during the first flow increment and 30.7% during the second flow increment. Blocking of the endogenous NO synthesis in TNF-alpha/LPS-stimulated cultures reduced baseline CBF by 10.6+/-2.1% (P<0.05) but the effect of mechanical ciliostimulation on CBF remained unchanged (36.0% vs. 38.2%). CONCLUSION: In conclusion, endogenous NO- and Ca(2+)-dependent mechanical stimulation of ciliary activity probably use independent intracellular signalling pathways. The combination of both effects on ciliary activity is likely to improve the local defence against inhaled allergens in patients with nasal allergies.

Induction of CXC chemokines in A549 airway epithelial cells by trypsin and staphylococcal proteases - a possible route for neutrophilic inflammation in chronic rhinosinusitis.

While various microorganisms have been recovered from patients with chronic rhinosinusitis, the inflammatory impact of virulence factors, in particular proteases from Staphylococcus aureus and coagulase negative staphylococci on the nasal epithelium, has not yet been investigated. Expression of CXC chemokines was determined in the epithelium of patients with chronic rhinosinusitis by immunohistochemistry. In a cell culture system of A549 respiratory epithelial cells, chemokine levels were quantified by enzyme-linked immunosorbent assay (ELISA) after stimulation with supernatants originating from three different staphylococcal strains or with trypsin, representing a serine protease. Inhibition experiments were performed with prednisolone, with the serine protease inhibitor 4-(2-aminoethyl)-benzenesulphonylfluoride (AEBSF) and with the nuclear transcription factor (NF)-kappaBeta inhibitor (2E)-3-[[4-(1,1-dimethylethyl)phenyl]sulphonyl]-2-propenenitrite (BAY) 11-7085. Electromobility shift assays (EMSA) were used to demonstrate NF-kappaB-dependent protein synthesis. CXC chemokines interleukin (IL)-8, growth-related oncogene alpha (GRO-alpha) and granulocyte chemotactic protein-2 (GCP-2) were expressed in the patients' epithelium whereas epithelial cell-derived neutrophil attractant 78 (ENA-78) was rarely detected. In A549 cells, chemokines IL-8, ENA-78 and GRO-alpha but not GCP-2 were induced by trypsin and almost equal levels were induced by staphylococcal supernatants. IL-8, GRO-alpha and ENA-78 synthesis was suppressed almost completely by AEBSF and BAY 11-7085, whereas prednisolone reduced chemokine levels differentially dependent on the supernatant added. CXC chemokines were detectable in the epithelium of patients with chronic rhinosinusitis. Staphylococcal serine proteases induced CXC chemokines in A549 cells, probably by the activation of proteases activated receptors, and thus might potentially be involved in neutrophilic inflammation in chronic sinusitis.

[Principles of hearing aids]. / Grundlagen der Hörgeräteversorgung--Teil 2.

The diagnostic and therapy of hearing impairment is one of the main tasks of the Otolaryngologist. This article deals with the treatment of hearing aids in adults and young persons according to the laws and the guidelines of the "Heil- und Hilfsmittelrichtlinien" in Germany. It shall serve the Otolaryngologist as a guideline. The second part of the article is about the different strategies to adjust hearing aids. Then the examination of the hearing aids by the otolaryngologist is described. Finally the importance of aftercare is stressed and the future of hearing aids in Germany according to the concept of "OHRWELL" is pointed out.

[Principles of hearing aids]. / Grundlagen der Hörgeräteversorgung - Teil 1 -

The diagnostic and therapy of hearing impairment is one of the main tasks of the Otolaryngologist. This article deals with the treatment of hearing aids in adults and young persons according to the laws and the guidelines of the "Heil- und Hilfsmittelrichtlinien" in Germany. It shall serve the Otolaryngologist as a guideline. The first part of the article is about the indications of hearing aids laid down in the "Heil- und Hilfsmittelrichtlinien". Especially the possibilities of the treatment of uni- and bilateral hearing impairment are discussed. The principles of the actual hearing aids technology are described to support the Otolaryngologist in his consultation.

Neutrophil chemokines in epithelial inflammatory processes of human tonsils.

CXC chemokines are thought to play an important role at sites of inflammation. Because ELR(+) CXC chemokines are expressed in different types of tonsillitis we investigated the role of the surface/crypt epithelium of human tonsils in producing ELR(+) CXC chemokines: interleukin (IL)-8 (CXCL8), ENA-78 (CXCL5), GRO-alpha (CXCL1) and GCP-2 (CXCL6). Tonsillar tissue was obtained from patients undergoing tonsillectomy and chemokine expression was investigated by means of immunohistochemistry. A549 cells were used as a model to study kinetics of chemokine expression in epithelial cells. Cells were stimulated with tumour necrosis factor (TNF)-alpha, lipopolysaccharide (LPS) and supernatants derived from aerobic/anaerobic Staphylococcus aureus strains. Chemokine expression was measured by quantitative reverse transcription-polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA). We observed epithelial expression of IL-8, GRO-alpha and GCP-2 in different types of tonsillitis, whereas ENA-78 was rarely expressed. In A549 cells abundant expression of ENA-78 was detected. IL-8 and GCP-2 are expressed in an acute type of tonsillitis whereas GRO-alpha was frequently detectable both in chronically and acutely inflamed tonsils. ENA-78 does not seem to play a pivotal role in tonsillitis in vivo.

Lateral inhibition and habituation of the human auditory cortex.

The goal of this study was to compare the lateral inhibition and the habituation in the human auditory cortex, two important physiological effects during auditory processing that can be reliably measured by means of magnetoencephalography when recording auditory evoked fields. Applying 40-Hz amplitude-modulated stimuli allowed us to record simultaneously the slow transient evoked and the steady-state fields and thus to characterize the lateral inhibition and the habituation effect in primary and non-primary auditory cortical structures. The main finding of the study is that the lateral inhibition effect of non-primary auditory areas as measured on the major component of the slow transient auditory evoked field (N1) is significantly stronger than the corresponding habituation effect. By contrast, this effect was not observed for the 40-Hz steady-state fields, characterizing the activation of the primary auditory cortex in humans. The results might be interpreted as (i) evidence that the inhibition mediated by lateral connections is stronger than the habituation of excitatory neurons in the non-primary auditory cortex and (ii) the processing hierarchy in the human auditory cortex is demonstrated by the different behaviour of lateral inhibition and habituation in primary and non-primary auditory cortical structures.

[Therapeutic management of necrotizing neck infections]. / Therapeutisches Management nekrotisierender Weichteilinfektionen des Halses.

BACKGROUND: Necrotizing neck infections are uncommon soft-tissue infections, usually caused by virulent, toxin producing bacteria. Necrotizing fasciitis represents a special form of necrotizing soft tissue infection with a mortality rate of up to 76% even though aggressive therapy is recommended. PATIENTS AND METHODS: In the last 2 years we treated four patients with severe necrotizing neck infections and five suffering from necrotizing fasciitis. RESULTS: Microbiological analysis revealed mixed infections with Candida albicans, Streptococcus pyogenes, Fusobacterium, Proprioni bacteria and Staphylococcus. The surgical management was not only restricted to drainage, but also included functional neck dissection in order minimize the spread of the disease. Eight of our patients recovered completely, but one died due to toxic shock as consequence of a delayed in therapy. CONCLUSION: Complete recovery of patients suffering from necrotizing fasciitis depends on early and aggressive surgical therapy including neck dissection and drainage as well as an interdisciplinary strategy of conservative therapy. Hyperbaric oxygen should be considered as a treatment adjunct in patients with necrotizing fasciitis if surgery and antibiotic treatment fail.