Preoperative Nutrition and Postoperative Discomfort in an ERAS Setting: A Randomized Study in Gastric Bypass Surgery.

BACKGROUND: Many patients experience postoperative nausea and vomiting (PONV). Preoperative treatment with carbohydrate solutions seems to improve the course after different types of surgery. This study was undertaken to investigate the potential value of different models for preoperative hydration/nutrition, in addition to our ERAS (enhanced recovery after surgery) protocol. METHODS: Ninety non-diabetic women planned for elective laparoscopic gastric bypass and aged 18-65 years were included. All were on preoperative low-calorie diet (LCD). They were randomized into three arms, either a carbohydrate-rich drink, a protein-enriched drink, or tap water and instructed to drink 800 and 200 mL 16 and 2 h, respectively, prior to operation. Risk factors for PONV were recorded preoperatively. All patients were operated before lunch and received 1500-2000 mL of Ringer-Acetate solution during the 24-30-h postoperative hospital time. Four variables (nausea, pain, tiredness, and headache) were registered on 100-mm visual analog scales six times over 22 h. The need for additional medication was registered. RESULTS: Out of 90 patients, 73 complete datasets were obtained. Nausea peaked at 7 p.m. but with no statistically significant differences between groups for any of the variables. Pain peaked the first 2 h postoperatively, remained longer, and had not returned to baseline values at 6 a.m. the morning after surgery but with no difference between groups. CONCLUSIONS: Inside our ERAS protocol, additional preoperative carbohydrate- or protein-enriched fluid treatment did not further reduce immediate patient discomfort in laparoscopic gastric bypass surgery.

The influence of CSF on EEG sensitivity distributions of multilayered head models.

We examined how the cerebrospinal fluid (CSF) affects the distribution of electroencephalogram (EEG) measurement sensitivity. We used concentric spheres and realistic head models to investigate the difference between computed-tomography (CT) and magnetic resonance image (MRI) models that exclude the CSF layer. The cortical EEG sensitivity distributions support these phenomena and show that the CSF layer significantly influences them, thus identifying the importance of including the CSF layer inside the head volume conductor models. The results show that the highly conductive CSF channels the current, thus decreasing the maximum cortical current density relative to models that do not include the CSF. We found that the MRI and CT models yielded HSV results 20% and 45%, respectively, too small when compared with CSF-inclusive models.

Trichomonas vaginalis: evaluating capsid proteins of dsRNA viruses and the dsRNA virus within patients attending a sexually transmitted disease clinic.

Some isolates of Trichomonas vaginalis, the number one, non-viral sexually transmitted disease agent, are infected with one or several distinct double stranded (ds)-RNA virus. Immune rabbit anti-capsid serum (IRS) reacted with the capsid protein of purified dsRNA virus of a subset of the virus-infected T. vaginalis isolates. A monoclonal antibody (mAb) that recognized the capsid protein reactive with the IRS was generated. Analysis of the virus capsid protein of virus-infected isolates by probing nitrocellulose blots with mAb revealed diversity among immunoreactivity and in the size of the reactive capsid protein. Despite difficulties in visualizing virus within parasites by cross-section electron microscopy, gold-conjugated mAb readily labeled the cytoplasm of virus-positive trichomonads. Finally and importantly, isolates infecting patients attending an STD clinic, 75% of which were virus-positive isolates, had capsid protein of the same size detected by mAb present in all dsRNA viruses.

Use of urine polymerase chain reaction to define the prevalence and clinical presentation of Trichomonas vaginalis in men attending an STD clinic.

OBJECTIVE: To determine the prevalence and clinical features of Trichomonas vaginalis (TV) infection in men. METHODS: Men attending a public STD clinic in Baltimore, Maryland, were evaluated between March and July 2000. Clinicians recorded a standardised history and clinical examination. Urethral swab specimens were collected for Gram stain and Neisseria gonorrhoeae culture. First fraction urine samples were evaluated with TV culture and chlamydia and TV polymerase chain reaction (PCR). True positive TV was defined as a positive TV culture or a positive TV PCR confirmed with a second primer set. RESULTS: 355 men were evaluated in 363 visits. The prevalence of gonorrhoea, TV, and chlamydia were 19%, 13%, and 11%, respectively. In men over 28 years, the prevalence of TV was significantly higher than chlamydia. Age and urethritis by Gram stain were associated with a positive result on TV culture (p=0.03 and p=0.02, respectively) but not associated with TV infection as defined by a positive TV culture or a confirmed TV PCR. Discharge or dysuria was reported in 47% and 22% of men with TV, respectively. CONCLUSIONS: TV prevalence in an urban STD clinic setting was high. Older age and urethritis were not significantly associated with TV infection as defined by a positive TV culture or a confirmed TV PCR.

Paradoxical worsening of tuberculosis in HIV-infected persons.

OBJECTIVE: To determine the incidence of paradoxical worsening of tuberculosis (TB) in HIV-infected persons. DESIGN: Observational cohort study. SETTING: Public, urban TB clinic. PATIENTS: HIV-infected persons treated for TB between January 1, 1996, and December 31, 1999, and followed through June 30, 2000. INTERVENTION: Patients received standard anti-TB therapy. Antiretroviral therapy was provided by primary medical providers. Patients receiving antiretroviral therapy were given nucleoside reverse transcriptase inhibitors alone or highly active antiretroviral therapy (HAART; nucleoside reverse transcriptase inhibitors in combination with a protease inhibitor or a nonnucleoside reverse transcriptase inhibitor). MAIN OUTCOME MEASURE: Paradoxical worsening of TB. RESULTS: There were 82 TB cases in 76 patients. Paradoxical worsening was identified in 6 of 82 cases (7%; 95% confidence interval, 3 to 15%). Paradoxical worsening occurred in 3 of 28 cases (11%) in patients receiving HAART and in 3 of 44 cases (7%) in patients not receiving antiretroviral therapy (p = 0.67). Cases complicated by paradoxical worsening were more likely to have both pulmonary and extrapulmonary disease at initial diagnosis than cases without paradoxical worsening (83% vs 24%; p = 0.006). TB relapse occurred in 2 of 6 cases (33%) in patients with paradoxical worsening and in 4 of 76 cases (5%) in patients without paradoxical worsening (p = 0.06). CONCLUSIONS: Paradoxical worsening of TB occurred less frequently than in previous reports and was not associated with HAART. Paradoxical worsening also appeared to be associated with an increased risk of TB relapse. Further studies are warranted to better characterize the risk factors for paradoxical worsening and the appropriate duration of anti-TB therapy in patients in whom it occurs.

Anatomy of the internal branch of the superior laryngeal nerve.

The purpose of this study was to determine the length and distribution of the branches of the internal branch of the superior laryngeal nerve (ibSLN) and describe the initial afferent pathway for the laryngeal cough reflex (LCR). On 25 sides of 19 cadaver specimens, the ibSLN and its branches were dissected from the greater cornu of the hyoid to the mucosa of the larynx and laryngopharynx. The location of these terminal fibers were confirmed by direct observation and fiberoptic laryngoscopy. In 21 specimens, the ibSLN coursed 6.95+/-3.71 mm before piercing the thyrohyoid membrane and splitting into superior, middle, and inferior rami. Four specimens split proximal to the thyrohyoid membrane. The superior ramus distributed to the mucosa of the piriform recess. In this study the large, middle ramus was a new finding and distributed branches to the mucosa of the vestibule of the larynx, specifically the quadrangular membrane. The length of the ibSLN from the greater cornu to the end of the middle ramus at quadrangular membrane was 28.52+/-4.61 mm. The termination of these fibers were confirmed by observation and direct laryngoscopy. The middle ramus probably conveyed the afferent component of the laryngeal cough reflex. The inferior ramus did not distribute to the vestibular mucosa.

Topoisomerase II levels and drug sensitivity in adult acute myelogenous leukemia.

The topoisomerase (topo) II-directed agents etoposide, daunorubicin (DNR), and amsacrine (m-AMSA) are widely used in the treatment of acute myelogenous leukemia (AML). In the present study, multiple aspects of topo II-mediated drug action were examined in marrows from adult AML patients. Colony-forming assays revealed that the dose of etoposide, DNR, or m-AMSA required to diminish leukemic colony formation by 90% (LD90) varied over a greater than 20-fold range between different pretreatment marrows. Measurement of nuclear DNR accumulation in the absence and presence of quinidine revealed evidence of P-glycoprotein (Pgp) function in 8 of 82 samples at diagnosis and 5 of 36 samples at first relapse, but the largest quinidine-induced increment in DNR accumulation (< 2-fold) was too small to explain the variations in drug sensitivity. Restriction enzyme-based assays and sequencing of partial topo II alpha and topo II beta cDNAs from the most highly resistant specimens failed to demonstrate topo II gene mutations that could account for resistance. Western blotting of marrow samples containing greater than 80% blasts revealed that the content of the two topo II isoenzymes varied over a greater than 20-fold range, but did not correlate with drug sensitivity in vitro or in vivo. In addition, levels of topo II alpha and topo II beta in 46 of 47 clinical samples were lower than in human AML cell lines. Immunoperoxidase staining showed that these low topo II levels were accompanied by marked cell-to-cell heterogeneity, with topo II alpha being abundant in some blasts and diminished or absent from others. There was a trend toward increasing percentages of topo II alpha-positive cells in pretreatment marrows that contained more S-phase cells. Consistent with this observation, treatment of patients with granulocyte-macrophage colony-stimulating factor for 3 days before chemotherapy resulted in increases in topo II alpha-positive cells concomitant with increases in the number of cells traversing the cell cycle. These observations have implications for the regulation of topo II in AML, for the use of topo II-directed chemotherapy, and for future attempts to relate drug sensitivity to topo II levels in clinical material.

[A child-centered management concept for families of children with cancer in the terminal phase. Cooperation with the established physician]. / Kindzentriertes Betreuungskonzept für Familien krebskranker Kinder in der Sterbephase. Zusammenarbeit mit dem niedergelassenen Arzt.

For a period of more than a year children with incurable diseases and their families we observed at home during the final stage of the children's illness. The psychological assistance and the necessary medical care were guaranteed by the staff of the district attending clinic, the family doctors and the district home nurses. The results of this project show that the concept which takes into account the child's welfare at home, was practicable in all cases even in very serious disease right up to death.

[Therapy of hyperammonemia in carbamyl phosphate synthase deficiency with peritoneal dialysis and venovenous hemofiltration]. / Therapie der Hyperammonämie bei Carbamylphosphat-Synthetasemangel mittels Peritonealdialyse und venovenöser Hämofiltration.

Inborn errors of metabolism with hyperammonaemia cause emergency situations with unconsciousness, convulsion, hyperpnoea and hyperpyrexia. Therefore hyperammonaemia has to be treated immediately after diagnosis to avoid irreversible damage. Two newborns with carbamylphosphates synthetase deficiency are described. Both, continuous peritoneal dialysis and venovenous haemofiltration have proved to be effective methods to reduce serum ammonia concentration to values of less than 300 mu/l. Because of the severity of the enzyme defect in both cases, (carbamylphosphate synthetase was not detectable in liver tissue), treatment finally had to be stopped, and both patients died.

[Rhizospheric organism under the influence of environmental pollution. II. Physiologic efficiency of the microbial biocenosis in fungicide containing soil (author's transl)]. / Rhizosphärenorganismen unter dem Einfluss pestizider Umweltbelastungen. II. Physiologische Leistungen der mikrobiellen Biozönose in fungizid belasteten Böden.

Measuring the potential soil respiration according to the incubator method allows the physiological performance of the celluloytic microflora to be determined. Laboratory tests were carried out to analyse catabolic processes after soil samples had been enriched with native cellulose + fungides. As the temporary capacity of mineralization primarily induced by the substrate invariably gives rise to a substrate-specific "change in position" in the microbial biocenosis, the measured values cannot furnish a parameter for microbiological comparisons of the soil content. Preliminary analyses provided information on the processes of depolymerisation of various C-sources and characterized the celluloysis as well as the order of respiration of its monomer. The rising respiration curve markedly drops off after 12 days, because with the CO2 development at its maximum, total and partial respiration alternate, a phenomenon that was verified in soils incubated with glucose 14C (Keefer and Mortensen, 1963; Macura, 1963; Simonart and Mayaudon, 1958). The test results obtained with fungicide-treated soils (dithiocarbamine acid derivatives) allow the conclusion that the fungicides exercise a varying influence: in the cellulolysis the activity of the cellulase systems is reduced depending on the active substance and concentration, but what is surprising is that respiration is stimulated; this applies to amounts of pesticides being 0.75 and 1.5 times the practical quantity applied. Nor have the "dissociation tests" with cellobiose, which is supposed to be the final link of celluloysis, shown any inhibition of the 1.4--glucodimerase or high respiration values comparable with the glucose metabolism. Tests with cellulases (Cx with dimerase function, Messrs. Roehm and Haas, Darmstadt), which are at present being carried out, are expected to support these observations experimentally. Investigations intended to clarify whether an additional administration of Mn2+ and Fe3+ in the presence of Maneb and Ferbam permits interference with possible adsorption and exchange processes have not yet yielded any generally valid results. The results of the open-field investigations also tend to indicate that the mentioned dithio-carbamates determine the magnitude and the extent of the physiological and CO2-ecological processes to a varying degree; it can be seen that a remarkable "capacity fo compensation" is discernible in the succession of the investigated phases of soil-physiological processes which we tried to clarify.