Implementation of a piritramide based patient-controlled analgesia (PCA) as a standard of care for pain control in late abortion induction: A prospective cohort study from a patient perspective.

Objective: To assess whether the implementation of patient-controlled analgesia (PCA) with piritramide using an automatic pump system under routine conditions is effective to reduce pain in late abortion inductions. Study design: Prospective observational cohort study. Setting: Patients requiring medically indicated abortion induction from 14 weeks of pregnancy onwards between July 2019 and July 2020 at the department of Obstetrics and Prenatal Medicine of the Bonn University Hospital in Germany. Methods: Evaluation of pain management after implementation of a PCA system compared with previous nurse-controlled tramadol-based standard under routine conditions. Patients answered a validated pain questionnaire and requirement of rescue analgesics was assessed. Pain intensity and satisfaction were measured on a ten-point numeric rating scale. Main Outcome Measure Maximal pain intensity. Results: Forty patients were included. Patients using Piritramide-PCA complained of higher pain sores than those in the standard group (6.90 (± 2.34) vs. 4.83 (± 2.87), (p < 0.05)). In both groups the level of satisfaction with the analgesia received was comparable (8.00 (± 2.45) vs 7.67 (± 2.62), (p = 0.7)). Patients in the PCA group suffered more nausea (63.2 % vs 30 % respectively, OR 4.0, 95 % CI 1.05-15.20, p < 0.05) and expressed more the desire for more analgesic support compared to the control group (OR 5.7 (1-33.25), p = 0.05). Conclusion: Women with abortion induction after 14 weeks of gestation suffer from relevant severe pain, which requires adequate therapy. However, addition of PCA does not seem to bring any advantage in patients undergoing this procedure.

[Hypoglossal nerve palsy after follicle puncture]. / Hypoglossusparese nach Follikelpunktion.

A 42-year-old female patient suffered an infranuclear hypoglossal nerve paresis with right-sided swelling and weakness of the tongue following a short duration mask anesthesia for a follicle puncture. This resulted in dysarthria and dysphagia persisting for more than 3 months. A return to work was initially impossible. Etiopathogenetically, a mechanical compression of the peripheral hypoglossal nerve by positioning or reclination during mask ventilation is discussed. Conclusion for clinical practice: In order to protect against lesions of the hypoglossal nerve, the pre-anaesthesiological examination should ask specifically about cervical problems as an indication of individual sensitivity to reclination. In such cases, special attention should be paid to careful patient positioning. Even shorter periods of reclination or compression of the soft tissues of the neck can result in lesions, therefore tolls such as a Wendl or Guedel tube should be used accordingly.

Is internal jugular vein extensibility associated with indices of fluid responsiveness in ventilated patients?

BACKGROUND: Ultrasound of the inferior vena cava provides rapid and non-invasive assessment of fluid responsiveness. We hypothesized that the extensibility of the internal jugular vein (IJV) as well reflects intravascular volume state. We assessed IJV dimensions together with pulse pressure variation (PPV) as dynamic index for fluid responsiveness in mechanically ventilated patients. METHODS: Of 50 patients after cardiac surgery were assessed. Ultrasound of IJV dimensions as well as collection of hemodynamic data were performed in 30° and horizontal (0°) position, and the ventilator- and position-induced IJV extensibilities (E-IJV) were calculated. RESULTS: Mean ventilator-induced E-IJV in 30° position was 56%, and mean PPV in 30° position was 13.7%. Changing the patient's position from 30° to 0° significantly reduced ventilator-induced E-IJV as well as PPV. Pearson's correlation test revealed significant association between ventilator-induced E-IJV and fluid responsiveness deduced from PPV in 0° position (r = 0.43, P < 0.005). An E-IJV threshold >5% identified patients with significantly elevated PPV values. CONCLUSION: Ultrasound of the IJV and PPV as a dynamic index for fluid responsiveness can be associated under certain defined conditions. Whether or not ultrasound of the IJV can be useful to predict patient intravascular volume state should be further studied using invasive cardiac output monitoring.

Pre-conditioning with synthetic CpG-oligonucleotides attenuates myocardial ischemia/reperfusion injury via IL-10 up-regulation.

The aim of the study was to investigate whether pre-conditioning with CpG-oligodeoxynucleotides (CpG-ODN) may change cardiac ischemia/reperfusion (I/R)-dependent inflammation and modulates infarct size and cardiac performance. WT and TLR9-deficient mice were pre-treated with 1668-, 1612- and H154-thioate or D-Gal as control. Priming with 1668-thioate significantly induced inflammatory mediators in the serum and a concomitant increase of immune cells in the blood and spleen of WT mice. Furthermore, it induced myocardial pattern recognition receptors and pro-inflammatory cytokines peaking 2 h after priming and a continuous increase of IL-10. 16 h after pre-conditioning, myocardial ischemia was induced for 1 h. Infarct size determined after 24 h of I/R was reduced by 75 % due to pre-conditioning with 1668-thioate but not in the other groups. During reperfusion, cytokine expression in 1668-thioate primed mice increased further with IL-10 exceeding the other mediators by far. These changes were observed neither in animals pre-treated with 1612- or H154-thioate nor in TLR9-deficient mice. The 1668-thioate-dependent increase of IL-10 was further supported by results of a micro-array analysis 3 h after begin of reperfusion. Block of IL-10 signaling increased I/R size and prevented influence of priming. In the group pre-treated with 1668-thioate, cardiac function was preserved 24 h, 14 days and 28 days after I/R, whereas animals without pre-conditioning exhibited impaired heart function 24 h and 14 days after I/R. The excessive 1668-thioate-dependent IL-10 up-regulation during pre-conditioning and after I/R seems to be the key factor for reducing infarct size and improving cardiac function. This is in agreement with the finding that IL-10 block prevents cardioprotection by pre-conditioning.

Detection and differentiation of in vitro-spiked bacteria by real-time PCR and melting-curve analysis.

We introduce a consensus real-time PCR protocol for the detection of bacterial DNA from laboratory-prepared specimens such as water, urine, and plasma. This prototype detection system enables an exact Gram stain classification and, in particular, screening for specific species of 17 intensive care unit-relevant bacteria by means of fluorescence hybridization probes and melting-curve analysis in a one-run experiment. One strain of every species was tested at a final density of 10(6) CFU/ml. All bacteria examined except Staphylococcus aureus and Staphylococcus epidermidis could be differentiated successfully; S. aureus and S. epidermidis could only be classified as "Staphylococcus species." The hands-on time for preparation of the DNA, performance of the PCR, and evaluation of the PCR results was less than 4 h. Nevertheless, this prototype detection system requires more clinical validation.

Increased susceptibility to apoptosis in circulating lymphocytes of critically ill patients.

BACKGROUND AND AIMS: Lymphocyte apoptosis may influence immune responsiveness in systemic inflammation. Therefore, we investigated whether early signs of apoptosis (i.e., annexin-V binding and cell shrinkage) in peripheral lymphocytes were different among patients with severe sepsis, critically ill, nonseptic patients after major surgery, and healthy individuals. PATIENTS/METHODS: Ten patients with severe sepsis and ten critically ill, nonseptic patients after major surgery admitted to a surgical intensive care unit in a university hospital were included in the study. In addition, ten healthy blood donors were included for comparison. We investigated early signs of apoptosis using flow cytometric measurement of annexin-V binding to the cell surface and cell shrinkage of peripheral lymphocytes. RESULTS: The percentage of apoptotic lymphocytes determined as annexin-V positive and propidium iodide negative cells was increased in freshly prepared cells of patients with severe sepsis (11.4 +/- 0.5%) and critically ill, nonseptic patients after major surgery (18.5 +/- 2.0%) relative to healthy blood donors (4.4 +/- 0.5%) (P < 0.05). No significant difference between patients with severe sepsis and patients after major surgery were found. Annexin-V binding increased significantly after OKT-3 stimulation of lymphocytes in patients with severe sepsis (34.4 +/- 1.6%), patients after major surgery (33.8 +/- 3.4%), and healthy blood donors (21.1 +/- 2.8%). No significant difference among groups was detected following OKT-3 stimulation. Furthermore, freshly isolated peripheral lymphocytes of patients with severe sepsis and critically ill, nonseptic patients after major surgery revealed a significantly higher proportion of cell shrinkage than in healthy blood donors (55.0 +/- 2.2%, 21.5 +/- 2.4% vs 3.6 +/- 0.7%; P < 0.05). CONCLUSION: Circulating lymphocytes of critically ill patients show a high degree of early signs of cellular apoptosis. This may contribute to hyporesponsiveness of immune cells in systemic inflammation.

Dynamic breast MR imaging: are signal intensity time course data useful for differential diagnosis of enhancing lesions?

PURPOSE: To assess the relevance of the signal intensity time course for the differential diagnosis of enhancing lesions in dynamic magnetic resonance (MR) imaging of the breast. MATERIALS AND METHODS: Two hundred sixty-six breast lesions were examined with a two-dimensional dynamic MR imaging series and subtraction postprocessing. Time-signal intensity curves of the lesions were obtained and classified according to their shapes as type I, which was steady enhancement; type II, plateau of signal intensity; or type III, washout of signal intensity. Enhancement rates and curve types of benign and malignant lesions were compared. RESULTS: There were 101 malignant and 165 benign lesions. The distribution of curve types for breast cancers was type I, 8.9%; type II, 33.6%; and type III, 57.4%. The distribution of curve types for benign lesions was type I, 83.0%; type II, 11.5%; and type III, 5.5%. The distributions proved significantly different (chi 2 = 139.6; P < .001). The diagnostic indices for signal intensity time course were sensitivity, 91%; specificity, 83%; and diagnostic accuracy, 86%. The diagnostic indices for the enhancement rate were sensitivity, 91%; specificity, 37%; and diagnostic accuracy, 58%. CONCLUSION: The shape of the time-signal intensity curve is an important criterion in differentiating benign and malignant enhancing lesions in dynamic breast MR imaging. A type III time course is a strong indicator of malignancy and is independent of other criteria.

Do T2-weighted pulse sequences help with the differential diagnosis of enhancing lesions in dynamic breast MRI?

In this study, our purpose was to determine whether T2-weighted images are a useful diagnostic adjunct for lesion characterization in dynamic breast MRI. On a 1.5-T system, 205 enhancing benign and malignant breast tumors were examined. The standardized protocol consisted of a T2-weighted turbo spin echo (TSE) pulse sequence with and without spectral fat suppression (SPIR), followed by a two-dimensional dynamic series with subtraction postprocessing. In 59 cases, T2*-weighted gradient-echo images also were obtained. Two independent radiologists visually rated the lesions (101 malignant, 104 benign) as having either a low or a high signal with respect to the adjacent glandular tissue. To assess age dependency of lesion enhancement velocities and T2-TSE signal intensities, we compared the results for patients at or below the age of 50 (group A), between 40 and 50 (group B), and beyond the age of 50 (group C). In T2-weighted TSE images, breast cancers were iso- or hypointense with respect to breast parenchyma in 87% of cases, whereas fibroadenomas were hyperintense in 71%. Visual assessment of lesion appearance in T2-weighted TSE images allowed to distinguish between fibroadenomas and breast cancers, with a respective sensitivity, specificity, positive predictive value, and negative predictive value of 72%, 75%, 46%, and 90% for young patients; 94%, 66%, 78%, and 89% for the patients between 40 and 50; and 89%, 62%, 85%, and 68% for the patients over 50 years of age. No significant difference was found for the distribution of signal intensities of lesions in T2*-weighted images or in fat-suppressed images. In a contrast-enhancing breast lesion, careful analysis of T2-weighted TSE images can improve differential diagnosis. The accuracy of this criterion varies with age.