Dynamic parameters of fluid responsiveness in the operating room : An analysis of intraoperative ventilation framework conditions.

BACKGROUND: Reliable assessment of fluid responsiveness with pulse pressure variation (PPV) depends on certain ventilation-related preconditions; however, some of these requirements are in contrast with recommendations for protective ventilation. OBJECTIVE: The aim of this study was to evaluate the applicability of PPV in patients undergoing non-cardiac surgery by retrospectively analyzing intraoperative ventilation data. MATERIAL AND METHODS: Intraoperative ventilation data from three large medical centers in Germany and Switzerland from January to December 2018 were extracted from electronic patient records and pseudonymized; 10,334 complete data sets were analyzed with respect to the ventilation parameters set as well as demographic and medical data. RESULTS: In 6.3% of the 3398 included anesthesia records, patients were ventilated with mean tidal volumes (mTV) > 8 ml/kg predicted body weight (PBW). These would qualify for PPV-based hemodynamic assessment, but the majority were ventilated with lower mTVs. In patients who underwent abdominal surgery (75.5% of analyzed cases), mTVs > 8 ml/kg PBW were used in 5.5% of cases, which did not differ between laparoscopic (44.9%) and open (55.1%) approaches. Other obstacles to the use of PPV, such as elevated positive end-expiratory pressure (PEEP) or increased respiratory rate, were also identified. Of all the cases 6.0% were ventilated with a mTV of > 8 ml/kg PBW and a PEEP of 5-10 cmH2O and 0.3% were ventilated with a mTV > 8 ml/kg PBW and a PEEP of > 10 cmH2O. CONCLUSION: The data suggest that only few patients meet the currently defined TV (of > 8 ml/kg PBW) for assessment of fluid responsiveness using PPV during surgery.

Titanium nitride oxide coating on rough titanium stimulates the proliferation of human primary osteoblasts.

OBJECTIVES: Titanium is widely used in contemporary endosseous implantology and there is considerable thrust to further promote osseointegration by implant surface modifications. The aim of this study was to evaluate the effect of a titanium-nitride-oxide (TiNOx) coating on commercially pure microroughened titanium by assessing the proliferation and differentiation of human primary osteoblasts. MATERIALS AND METHODS: Cell proliferation, gene expression, alkaline phosphatase activity, osteoprotegerin and osteocalcin secretion were analyzed for a time course of 3 weeks, with or without additional stimulation by 1.25(OH)(2) vitamin D(3) 100 nM. RESULTS: A 1.5-fold increase in the proliferation rate of cells grown on TiNOx-coated titanium as compared with uncoated surfaces was observed. SEM views indicated that the cells' normal morphology with their numerous extensions was maintained. The differentiation process on the TiNOx surface was only affected to a minor degree and translated into a slight delay in osteoblast maturation when compared to uncoated titanium. CONCLUSION: Pending confirmation of these results in vivo, TiNOx coatings could potentially accelerate and enhance osseointegration.

[Maternity in Geneva (1874-1907), a new entrance portal into life?]. / La maternité de Genève (1874-1907), une nouvelle porte d'entrée dans la vie?

Geneva's maternity hospital was set up in order to answer the needs of the new medical school in the 1870's. The early years of the Geneva maternity hospital illustrate the heterogeneity of the first generation of teachers as well as the difficulties of the school to gain control of appointments and autonomy in the management of clinics and courses. The sources used allow insights into two apparently separate fields: the social organisation of childbirth and the difficulties of a generation of doctors and teachers to adapt to rapidly changing medical knowledge.

[Between liberty and control, the private docents and medical teaching in Geneva between 1876 and 1917]. / Entre liberté et contrôle, les privat-docents et l'enseignement de la médecine à Genève entre 1876 et 1917.

The University of Geneva was founded in 1876 with two sets of teachers established as competitive entities: the salaried professors and the nonsalaried privat-docents. The ease with which physicians obtained the title of privat-docent, a series of abuses of that status and the professors' desire to manage teaching at all levels, resulted in a conflictual situation. The subsequent drive of professors to gain control over all teaching reveals tensions between the medical faculty and the political authorities, but also strains within the medical community itself. Ultimately, the result was the professors' leadership over the rest of the medical community.

[Rapidly progressive ascites]. / Ascite rapidement progressive.

A 50-year-old woman rapidly developed ascites with jaundice and worsening of general condition. On admission a nodule of the left breast was noted. Workup showed slight anomalies in liver tests and led to the diagnosis of portal hypertension, without visible lesion (CT scan, ultrasonography) of the liver. The patient suffered severe bleeding caused by esophageal varices necessitating urgent sclerotherapy. Several days later, her condition worsened rapidly due to acute respiratory distress syndrome followed by irreversible shock.

The repeated measurement of vital capacity is a poor predictor of the need for mechanical ventilation in myasthenia gravis.

OBJECTIVE: Testing the hypothesis that, in myasthenia gravis (MG), repeated measurements of vital capacity (VC) and various parameters derived from this measurement [median or lowest value of measured VCs during hospitalization, VC values < 20 ml/kg body weight (BW) or < 13 ml/kg BW, or an index assessing the variability of VC values during the whole ICU stay] could predict the need for intubation and mechanical ventilation (MV), as has been shown in other neuromuscular diseases with respiratory failure. DESIGN: Retrospective study with medical chart revision of all the patients with MG and respiratory failure admitted to our intensive care unit between 1985 and 1993. SETTING: Medical intensive care unit (15 beds) of a university hospital. PATIENTS AND METHODS: Five patients suffering from ten episodes of acute respiratory failure due to their decompensated MG. Repeated measurements of arterial blood gases and VC by trained respiratory therapists, at least every 4 h. RESULTS: There was no difference in any of these parameters between patients eventually requiring MV (four episodes) and those in whom mechanical ventilation was not necessary (six episodes). CONCLUSIONS: VC repeated measurements is a poor predictor of the need for further MV in MG patients. This can probably be ascribed to the erratic nature of MG, a disease whose course is largely influenced by many parameters (infection, treatment modifications, initiation of corticosteroid therapy, stress, psychological factors, etc.). Early admissions to the ICU of MG patients with respiratory dysfunction is thus recommended.

[Optimization of filtration and lighting parameters in pictures of the hand using digital luminescence radiography]. / Optimierung der Filterung und Belichtungsparameter von Aufnahmen der Hand mit der digitalen Lumineszenzradiographie.

The appearance of digital radiographs were markedly influenced by post-processing. To optimise images of the hand, radiographs of 7 patients with arthritis were modified by various filters. 6 observers evaluated the presence or absence of erosive changes during an ROC study and the advantages of low filtration were demonstrated. Further images were prepared of anatomical preparations in which para-articular defects had been made and of a hand phantom covered in perforated plexiglass. Limited filtration and low enhancement factors again provided the best results. Dose reduction of 50% resulted in a significant deterioration in the ability to recognise erosions and artificial lesions.

[Ozone, ventilatory function and bronchial reactivity]. / Ozone, fonction ventilatoire et réactivité bronchique.

Forty adult hospital workers were followed prospectively in 1989 by monthly assessment of the lung function and bronchial responsiveness to methacholine in a rural region in Switzerland. No correlation was demonstrated between these values and the concentrations of tropospheric ozone. Nevertheless, this is not incompatible with previous studies showing impairment of ventilatory function in subjects exposed to ozone, for several reasons: ozone levels in 1989 were low, the indoor concentrations were lower than outdoors and the volunteers performed little or no physical activity.

[Pathologic dens fracture in irradiated malignant neurofibroma]. / Pathologische Densfraktur beim bestrahlten malignen Neurofibrom.

A pathological dens fracture in a 47 year old patient with malignant neurofibroma is described. These tumours are very rare but the prognosis is very poor because of rapid proliferation and early metastatic progression. In the described case, bone osteolysis remained unnoticed until manifestation of clinical symptoms. The pathological fracture occurred despite irradiation of the dens.

Intravenous DSA and dynamic computed tomography for postoperative follow-up of type A aortic dissections.

We undertook a direct comparison of intravenous digital subtraction angiography and dynamic computed tomography in a follow-up study on 37 patients who had undergone surgery on the thoracic aorta for acute or chronic type A dissections. These are minimally invasive and complementary procedures: IV-DSA provides a clear angiographic image of the dissection, with visualization of the true and false channels, their distal extension and the supra-aortic and abdominal vessels they supply. Dynamic CT best demonstrates the proximal extension of the disease; it visualizes clotting in the false lumen and permits a more accurate measurement of the aortic width, and thus early recognition of a developing aneurysm.

[Percutaneous transluminal irradiation of biliary tract cancer using iridium]. / Perkutan transluminale Bestrahlung von Gallenwegskarzinomen mit Iridium.

In ten patients with biliary carcinomas, percutaneous biliary drainage was instituted and intracavitary irradiation performed, using 192iridium with a dose of 40 to 80 Gy. Eight of these patients had been found to be inoperable at laparotomy and two had had a recurrence. In half the patients there was a reduction in the degree of stenosis due to the tumour, but in only one patient was it possible to remove the draining catheter. Survival time in eight patients was between one and eight months, average 5 months. Two patients survived for eleven and twelve months respectively. The relatively poor results are due to extensive metastases. On the other hand, there can be no doubt about the effectiveness of this treatment on locally confined tumours, in view of the reduction in the obstruction caused by the tumour.

[Suitability and comparison of compensating filters for thoracic diagnosis]. / Eignung und Vergleich von Ausgleichsfiltern für die Thoraxdiagnostik.

The effect of three types of filter on the quality of radiographs of the chest was compared. These filters improve visualization of mediastinal structures without significantly reducing the quality of the pulmonary image. In practice the Du Pont filter proved best; the quality of the central and peripheral portions of the lung image is equal to that of an ordinary radiograph and visualization of the mediastinum is improved. The Agfa-Gevaert filter showed no significant disadvantages compared with the ordinary techniques but the improvement in mediastinal visualization is not that marked. The 3 M filter yields poor images of the central portions of the lung and its type of construction prevents the retrocardiac structures from being pictured as well as with the other filters.

[Comparison of a standard x-ray film with a high-latitude film in thoracic diagnosis]. / Vergleich eines Standard-Röntgen-Films mit einem "high latitude"-Film in der Thoraxdiagnostik.

A comparison of chest radiographs using two films of different gradation (Cronex 4 and Cronex L (R)) shows that the relevant structures are visualized if the technique is optimal, and that the assessment speed is not prolonged. For visualizing the peripheral vessels it seems to be particularly important to employ a technique that provides rich contrasts. However, the less contrasty film makes it definitely easier to visualize the mediastinal structures and the retrocardial vessels. Imaging of the costopleural marginal zone was hardly improved by the L film type, using the technique employed here.