Effects of steep Trendelenburg position for robotic-assisted prostatectomies on intra- and extrathoracic airways in patients with or without chronic obstructive pulmonary disease.

BACKGROUND: The use of the steep Trendelenburg position and abdominal CO2-insufflation during surgery can lead to significant reduction in pulmonary compliance and upper airway oedema. The postoperative time course of these effects and their influence on postoperative lung function is unknown. Therefore, we assessed intra- and extrathoracic airway resistance and nasal air flow in patients with or without chronic obstructive pulmonary disease (COPD) during robotic-assisted prostatectomy. METHODS: In 55 patients without and 20 patients with COPD spirometric measurements and nasal resistance were obtained before operation, 40 and 120 min, and 1 and 5 days after operation. We measured vital capacity (VC), forced expiratory volume in 1 s (FEV1), maximal mid-expiratory and inspiratory flow (MEF50, MIF50), arterial oxygen saturation, and nasal flow. The occurrence of postoperative conjunctival oedema (chemosis) was also assessed. RESULTS: In patients without COPD, MEF50/MIF50 increased and nasal flow decreased significantly after surgery (P<0.0001) and normalized within 24 h. VC and FEV1 decreased after operation with a nadir at 24 h and recovered to normal until the fifth day (P<0.0001). In patients with COPD, changes in MEF50/MIF50 and nasal flow were similar, while changes in VC and FEV1 lasted beyond the fifth day (P<0.0001). CONCLUSIONS: Robotic-assisted prostatectomy in the steep Trendelenburg position led to an increase in upper airway resistance directly after surgery that normalized within 24 h. The development of chemosis can be indicative of increased upper airway resistance. In patients without COPD, VC and FEV1 were reduced after surgery and recovered within 5 days, while in patients with COPD, the alteration lasted beyond 5 days.

Tracheal intubation in patients with odentogenous abscesses and reduced mouth opening.

BACKGROUND: Odentogenous abscesses with involvement of the facial or cervical spaces can be life-threatening and often have to be drained under general anaesthesia. Trismus and swelling can make intubation with a Macintosh laryngoscope difficult or even impossible. However, indirect laryngoscopy has been successful when conventional direct laryngoscopy has failed. Therefore, we evaluated the efficacy of the Glidescope laryngoscope in patients with odentogenous abscesses and the improvement in mouth opening after neuromuscular block. METHODS: After approval of the ethics committee, 100 patients with odentogenous abscesses were randomized to undergo tracheal intubation with the Glidescope or Macintosh laryngoscope. Success rate, visualization of the glottis, intubation duration, and need for supporting manoeuvres were evaluated. RESULTS: Intubation with the Glidescope was always successful, while conventional intubation failed in 17 out of 50 patients (P<0.0001). In all patients in whom conventional tracheal intubation failed, a subsequent attempt with the Glidescope was successful. The view at the glottis (according to Cormack and Lehane; P<0.0001), intubation duration [34 s (CI 27-41) vs 67 s (CI 52-82), mean (95% confidence interval); P=0.0001], and need for supporting manoeuvres (P<0.0001) were significantly different. The inter-incisor distance improved overall with induction of anaesthesia from 2.0 cm (CI 1.8-2.2) to 2.6 cm (CI 2.3-2.9; P<0.0001) and was correlated with the duration of symptoms. CONCLUSIONS: In patients with odentogenous abscesses, the use of a Glidescope laryngoscope was associated with significantly faster tracheal intubation, with a better view, fewer supporting manoeuvres, and a higher success rate than with a conventional laryngoscope. Improvement of the inter-incisor distance after induction of anaesthesia correlated with the duration of symptoms.

Giant cell tumor of distal phalanx in an adolescent with Goltz-Gorlin syndrome.

We report on a unique case of a young female patient with the Goltz-Gorlin syndrome who developed a giant cell tumor of bone in the distal phalanx of the thumb. This case is noteworthy because of the combination of some unusual features. Firstly, it is only the fifth case report on the association of giant cell tumor of bone and the Goltz-Gorlin syndrome. Also the localization of the lesion in the bones of the hand and the presentation at adolescent age is rarely seen.

Chemical and toxicological evaluation of transformation products during advanced oxidation processes.

The entry of pharmaceuticals into the water cycle from sewage treatment plants is of growing concern because environmental effects are evident at trace levels. Ozonation, UV- and UV/H(2)O(2)-treatment were tested as an additional step in waste water treatment because they have been proven to be effective in eliminating aqueous organic contaminants. The pharmaceuticals carbamazepine, ciprofloxacin, diclofenac, metoprolol and sulfamethoxazole as well as the personal care products galaxolide and tonalide were investigated in terms of degradation efficiency and by-product formation in consideration of toxic effects. The substances were largely removed from treatment plant effluent by ozonation, UV- and UV/H(2)O(2)-treatment. Transformation products were detected in all tested treatment processes. Accompanying analysis showed no genotoxic, cytotoxic or estrogenic potential for the investigated compounds after oxidative treatment of real waste waters. The results indicate that by-product formation from ozonation and advanced oxidation processes does not have any negative environmental impact.

Long-term follow-up of the three-ligament tenodesis for scapholunate ligament lesions: 9-year results.

We report on a retrospective cohort of 50 cases of three-ligament tenodesis for scapholunate instability. Fifteen cases (30% of our cohort) needed salvage surgery (11 proximal row carpectomies, 2 partial and 2 total wrist fusions) at an average of 33 months and are considered "failures". Of the 35 remaining cases ("success"), 16 (32% of our cohort) were reviewed at average 111 months and had good functional outcomes (QuickDASH 18/100, PRWE 11/100, pain 1/10, satisfaction 9/10). Return to work was 81% and grip strength was 80% of the opposite side. Radiological review found no significant correction in the short-term: scapholunate angle (SLA) from 72° to 69° (p = 0.544), scapholunate distance (SLD) from 3.4 mm to 3.4 mm (p = 0.833) and radiolunate angle (RLA) from 17° to 13° (p = 0.253). A significant deterioration in SLA from 72° to 80° (p = 0.014), not correlated to function, was seen at final follow-up. Radiographic progression to wrist degeneration was seen in 63% of successful cases. In failed cases, we noticed inferior radiographic parameters in the short-term: SLD of 4.6 mm in failed versus 3.4 mm in successful cases (p = 0.038) and RLA of 22° in failed versus 13° in successful cases (p = 0.046). Complication rate was 10% (2 scaphoid necroses, 1 septic arthritis and 2 complex regional pain syndromes). Despite radiological deterioration of SLA and development of degeneration in most cases, three-ligament tenodesis can give satisfactory wrist function in some patients, but we observed a significant number of failures and a high complication rate. LEVEL OF EVIDENCE: IV.

Expected difficult tracheal intubation: a prospective comparison of direct laryngoscopy and video laryngoscopy in 200 patients.

BACKGROUND: The Berci-Kaplan video laryngoscope was developed to improve the visualization of the glottis and ease tracheal intubation. Whether this technique is also effective in patients with an expected difficult intubation is unclear. We have prospectively evaluated the conditions and success rate of tracheal intubation in patients with a Mallampati score of III or IV. METHODS: Two hundred patients, undergoing general anaesthesia, were randomized to be intubated using direct laryngoscopy (n=100) or video laryngoscopy (n=100). Visualization of the vocal cords, success rate, time for intubation, and the need for additional manoeuvres (laryngeal manipulations, head positioning, and Eschmann stylet) were evaluated. RESULTS: Video laryngoscopy produced better results for the visualization of the glottis using Cormack and Lehane criteria (P<0.001), success rate (n=92 vs 99, P=0.017), and the time for intubation [60 (77) vs 40 (31) s, P=0.0173]. In addition, the number of optimizing manoeuvres was also significantly decreased [1.2 (1.3) vs 0.5 (0.7), P<0.001]. CONCLUSIONS: Video laryngoscopy, when compared with direct laryngoscopy for difficult intubations, provides a significantly better view of the cords, a higher success rate, faster intubations, and less need for optimizing manoeuvres. Therefore, we feel that the video laryngoscopy leads to a clinically relevant improvement of intubation conditions and can be recommended for difficult airway management.

Disposition of ampiroxicam, a prodrug of piroxicam, in man.

1. Ampiroxicam, a prodrug of the effective anti-inflammatory agent piroxicam, was completely converted to piroxicam after oral administration to man. 2. At clinical doses there was no detectable portal or systemic exposure of man to ampiroxicam, indicating that conversion to piroxicam was complete during the absorption process. 3. The pharmacokinetics of piroxicam from ampiroxicam were essentially the same as those after piroxicam itself except that Cmax was slightly lower and tmax was slightly longer after administration of ampiroxicam.