[Statement on the lower age limit for outpatient adenotomies and tonsillotomies]. / Stellungnahme zur Altersuntergrenze bei der ambulanten Durchführung von Adenotomien und Tonsillotomien.

At the beginning of 2023, there have been significant changes to the regulations for outpatient surgery in Germany, which were set out in a trilateral self-administration agreement between the umbrella association of statutory health insurance companies, the German Hospital Association and the Federal Association of Statutory Health Insurance Physicians. Among other things, a catalog stated circumstances under which an operation should not be carried out on an outpatient basis or should only be carried out with doubt. This catalog explains the patient's age: up to the first year of life, inpatient performance of a service can be justified. This formulation in itself means that children from one year of age on should regularly undergo outpatient surgery.In the german scientific societies for otolaryngology, head and neck surgery as well as for anesthesiology and intensive care medicine, doubts arose as to whether this age limit could also be scientifically justified for operations in the throat such as adenotomy or tonsillotomy.A search was carried out in international guidelines and in the international literature and the statements were evaluated. The results of this literature search were discussed with representatives of the Pediatric Otorhinolaryngology Working Group (AG PädHNO) of the German Society for Otorhinolaryngology, Head and Neck Surgery (DGHNO-KHC) and the scientific working group for pediatric anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) in conferences.The consensus revealed that a strict age limit of the first year of life is not appropriate for the outpatient performance of adenotomies and tonsillotomies. First of all, specifying a strict age limit is questionable because, regardless of age, a number of other medical and social factors influence the responsible performance of outpatient operations. Furthermore, the age limit of one year is not considered appropriate in view of literature, guidelines and practical experience in the international area. The assessment of the literature and the consideration of the implementation in the international area make an age limit in the range of 2-3 years seem more appropriate.This review provides the responsible doctors with a variety of insights, aspects and arguments so that they can make their decision to carry out these operations on an outpatient or inpatient basis appropriately and responsibly.

[Depth of anaesthesia during intubation: comparison between propofol and thiopentone]. / Narkosetiefe bei Intubation : Vergleich zwischen Propofol und Thiopental.

In order to study the depth of anaesthesia during endotracheal intubation, 30 patients received either thiopentone or propofol for anaesthesia induction. The BIS value as a parameter for the depth of anaesthesia and the rate pressure product (RPP) were acquired online. Patients who received thiopentone for anaesthesia induction showed significantly higher BIS values at the moment of intubation and reached BIS values >60 significantly more frequently than patients receiving propofol. The RPP in the propofol group lay significantly below that of the thiopentone patients. For all patients there was an mean increase in BIS values of 8 index points and an increase in the RPP. Therefore, BIS values around 50 should be achieved before intubation in order to avoid the critical BIS value for awareness of >60 despite the increase caused by the intubation procedure. Within 24 h of intubation all patients were interviewed for possible signs of awareness. None of the patients was able to remember the intubation or reported other experiences that indicated an unconscious awareness. Nevertheless, the progress of BIS values in a standardized intubation as performed in the normal clinical routine, shows that the use of thiopentone for initiating anaesthesia results in a very flat level of anaesthesia during intubation. The risk for patients to experience awareness should therefore, not be underestimated. Therefore, when using thiopentone it is recommended to also use a rapid acting muscle relaxant or to select a high ED95 to compensate for the flat level of anaesthesia. Alternatively, repetetive boluses of the hypnotic shortly before intubation should be considered or to revert to propofol. The dosage and pharmacokinetics of the analgesic should also be taken into consideration because an insufficient analgesia leads to a faster flattening of the depth of anaesthesia.

[Perioperative management of a patient with alcaptonuria--a case report]. / Perioperatives Management bei einer Patientin mit Alkaptonurie--Eine Kasuistik.

Alcaptonuria is a very rare enzymatic disease with a compromised degradation of the amino acids phenylalanine and tyrosine. As a consequence, homogentisic acid accumulates, most of which is cleared by the kidneys. In time, homogentisic acid forms black pigment, which accumulates throughout the body in connective tissue such as cartilage and joints. Apart from superficial discoloration, the most clinical manifestation of the disease is arthropathy, starting in middle age. From the anaesthesiologist's point of view, there is a severe risk of difficult airway because of an advanced stiffness of the cervical spine and a reduced mouth opening in these patients. Due to deformity and stiffness of the spine, difficulties in spinal and epidural anaesthesia must be reckoned with. A further risk for patients with alcaptonuria is cardiac involvement, which occurs later than degenerative changes of the joints. The accumulated pigment most likely adds to the development of degenerative changes of the valve and coronary artery disease and there is an increased risk of developing aneurysms in atherosclerotic altered vessels. Therefore, at the preoperative visit a thorough clinical cardiovascular examination should be performed. Cardiological advice and an examination should be sought from a specialist. For intubation, fibreoptic procedures should be considered. Anaesthetic management and perioperative monitoring are determined by the results of the cardiological examination and the type and extent of the operation.

A comparison study of different methods used in the detection of Giardia lamblia.

OBJECTIVE: The purpose of this study was to compare results obtained using a single fecal specimen for O&P examination, direct immunofluorescent assay (DFA), and three immunodiagnostic techniques. DESIGN: Sixty-eight human fecal specimens were collected and examined by each method. The O&P and the DFA were used as the reference method. SETTING: The study was performed at the research laboratory in the Medical Technology Department at The University of Southern Mississippi. PATIENTS OR OTHER PARTICIPANTS: The fecal specimens were collected from individuals with a suspected Giardia lamblia infection. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The amount of agreement and disagreement between methods. 1. The sensitivity and specificity of each method. 2. The working time and cost per specimen for each method. RESULTS: There was complete agreement among methods on 52 specimens (21 positive, 31 negative). Eight specimens were positive by all immunologic methods, but negative by O&P. The remaining eight specimens (12%) demonstrated discrepancies among methods. Sensitivity and specificity of each assay ranged from 91% to 100% and 89% to 100%, respectively. The cost per specimen ranged from $11.62 for the DFA method to $32.54 for the O&P method. The average cost per specimen for ELISA and EIA averaged $26.86. CONCLUSION: The study supported findings of other investigators who concluded that immunologic methods have the greater sensitivity. The immunologic methods were more efficient, quicker, and economical than the conventional O&P method.

Cranial reconstruction for metastatic breast cancer.

All women with advanced breast cancer who are medically stable despite their disease are candidates for tumor extirpation and reconstruction. Advanced breast cancer today is incurable, and many prognostic factors can be used to try to predict a clinical course and response to therapy; however, no guidelines are available. Our case report most likely represents a metastasis to the calvarium with intracranial extension, reported to occur in about 3 percent of primary breast cancer patients. As demonstrated here, tumor ablation with immediate, one-stage reconstruction of large scalp defects is possible without the need for free tissue transfer or a delay in adjuvant therapy. Local tissue rearrangement has been employed for coverage of defects up to 50 percent of the cranium. The resulting donor defects can be closed with split-thickness skin grafts over pericranium. Serial tissue expansion and rearrangement can be used secondarily to replace skin grafts with hair-bearing scalp. Bony defects can be managed with either autogenous or alloplastic materials. Split-calvarial bone grafts can be harvested from the same operative field and cover small to medium-sized defects. Other sources of autogenous grafts include split ribs and iliac bone. Metals, calcium ceramics, and polymers such as methylmethacrylate can be used to cover intracranial contents and restore calvarial contour when defects are large or when autogenous material is not available. Palliation from tumor burden, prevention of pathologic fracture and oncologic emergencies, controlling pain, and enhancing quality of life are the goals of the oncologic and reconstructive surgeons in cases of advanced breast cancer. These goals are becoming even more important as new forms and combinations of chemotherapy, radiation, and gene therapy are extending the life expectancy of women with breast carcinoma.

Intracranial hypotension presenting with severe encephalopathy. Case report.

A patient with severe and protracted symptoms from intracranial hypotension is described. The patient's presentation was marked by diffuse encephalopathy and profound depression of consciousness. This case report expands the presently known clinical spectrum of this uncommon and generally benign illness. The clinical and laboratory findings typically observed in the syndrome of intracranial hypotension are outlined. The pathophysiological mechanisms of the phenomenon are briefly discussed. Intracranial hypotension is a potentially severe illness with specific treatments that are distinct from the treatment of most neurological diseases. Three cardinal features--postural headache, pachymeningitis, and descent of midline cerebral structures--should prompt the diagnosis.

Reverse-phase high-performance liquid chromatography of nerve growth factor receptor-like proteins identified with monoclonal antibodies.

Human neuroblastoma SK-N-SH-SY5Y (SY5Y) and rat pheochromocytoma PC12 cells are model cell lines used in the study of nerve growth factor (NGF) effect. The effects of NGF are initiated by binding to cell surface receptors (NGFR). The amino acid sequence for NGFR has been deduced based on the identification of a single gene for NGFR. However, there are two kinds of NGF binding activities and several reported molecular weights of NGFR. We report here on the demonstration of NGFR-like proteins from PC12 and SY5Y cells by sequential lectin chromatography, reverse-phase HPLC, and SDS-PAGE analysis of immunoprecipitates obtained with NGFR-specific monoclonal antibodies. For both human and rodent NGFR, there was a tendency for the higher molecular-weight species of NGFR-like proteins to be eluted in more hydrophobic fractions. Also, the expression of different species of NGFR could be modified by treatment with retinoic acid (RA). These results are consistent with the hypothesis that the different molecular species of NGFR may result from the generation of a truncated form of NGFR, the presence of sugar residues on the NGFR protein, dimer formation between NGFR, or the association of NGFR with a receptor-associated protein.

Autoimmune hemolytic anemia with anti Jka specificity in a patient taking aldomet.

Autoimmune hemolytic anemia (hemoglobin 5.2 g, reticulocyte count 31.0 per cent) developed in a 53-year-old hypertensive woman who was taking Aldomet. Both the patient's serum and the eluate prepared from her red blood cells contained an antibody with anti-Jka specificity. Rapid sustained improvement in the anemia occurred after cessation of Aldomet and a two week course of prednisone therapy. Eight months later, anti-Jka was no longer detectable in the patient's serum and the direct antiglobulin test was nonreactive.