Comparison of Enk Fibreoptic Atomizer with translaryngeal injection for topical anaesthesia for awake fibreoptic intubation in patients at risk of secondary cervical injury: A randomised controlled trial.

BACKGROUND: Two methods of topical anaesthesia for awake fibreoptic intubation (FOI) in patients at risk of secondary cervical injury were compared: the translaryngeal injection (TLI) technique and the Enk Fibreoptic Atomizer. OBJECTIVE: The objective of this study was to determine which system of topical anaesthesia provides the fastest and most comfortable awake FOI, using the oral approach. DESIGN: A randomised controlled study. SETTING: A single centre trial between 2009 and 2011. PATIENTS: One hundred and twenty patients (63 women, 57 men) who underwent neurosurgery of the spine at Klinikum St. Georg Leipzig were randomly allocated into two groups (group TLI, 61 patients; group ENK-ATOMIZER, 59 patients). Inclusion criteria were an American Society of Anesthesiology (ASA) physical status of 1 to 3, age 18 to 80 years, and those who met any one of three indications for FOI - cervical instability, predicted difficult airway, a BMI greater than 40 kg m(-2), and who gave written informed consent.Exclusion criteria were emergency awake FOI, mental disability/delirium, polytrauma and contraindication to TLI. INTERVENTIONS: Two anaesthesiologists experienced in both techniques performed all anaesthesia procedures within the study. MAIN OUTCOME MEASURES: The primary outcome was the timing sequence of awake FOI. The incidence of coughing/gagging, ease of tracheal tube placement, mucosal bleeding, cardiopulmonary stability and postoperative outcomes were also investigated. RESULTS: Awake FOI was significantly faster using the TLI technique (mean, 191 s; range, 123 to 447 s; SD, 83.5) than the Enk Fibreoptic Atomizer [mean, 430 s; range, 275 to 773 s; SD, 124.9; (P = 0.0001)]. Patients in group TLI exhibited significantly less gagging (P = 0.047) but more mucosal bleeding (P <  .001). CONCLUSION: Awake FOI using the TLI technique was faster and provided better topical anaesthesia with less gagging during endoscopic intubation. However, the TLI technique was also more invasive. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00948350.

Psychiatric comorbidity as predictor of costs in back pain patients undergoing disc surgery: a longitudinal observational study.

BACKGROUND: Psychiatric comorbidity is common in back pain patients undergoing disc surgery and increases economic costs in many areas of health. The objective of this study was to analyse psychiatric comorbidity as predictor of direct and indirect costs in back pain patients undergoing disc surgery in a longitudinal study design. METHODS: A sample of 531 back pain patients was interviewed after an initial disc surgery (T0), 3 months (T1) and 15 months (T2) using the Composite International Diagnostic Interview to assess psychiatric comorbidity and a modified version of the Client Sociodemographic and Service Receipt Inventory to assess resource utilization and lost productivity for a 3-month period prior interview. Health care utilization was monetarily valued by unit costs and productivity by labour costs. Costs were analysed using random coefficient models and bootstrap techniques. RESULTS: Psychiatric comorbidity was associated with significantly (p < 0.05) increased direct (+664 Euro) and indirect costs (+808 Euro) at T0. The direct cost difference predominantly resulted from medical health care utilization and was nearly unchanged at T2. Further important cost predictors were clinical variables like the presence of chronic medical disease, the number of previous disc surgeries, and time and gender. CONCLUSION: Psychiatric comorbidity presents an important predictor of direct and indirect costs in back pain patients undergoing disc surgery, even if patients do not utilize mental health care. This effect seems to be stable over time. More attention should be given to psychiatric comorbidity and cost-effective treatments should be applied to treat psychiatric comorbidity in back pain patients undergoing disc surgery to reduce health care utilization and costs associated with psychiatric comorbidity.

Affective, anxiety, and substance-related disorders in patients undergoing herniated disc surgery.

PURPOSE: At present only a small number of studies have investigated psychiatric comorbidity in disc surgery patients. Objectives of this study are (1) to examine the prevalence rate of comorbid affective, anxiety, and substance-related disorders in nucleotomy patients in comparison to the German general population and (2) to investigate associations between psychiatric comorbidity and socio-demographic and illness-related characteristics. METHODS: The study refers to 349 consecutive disc surgery patients (response rate 87%) between the age of 18 and 55 years. The final study sample consists of 239 lumbar and 66 cervical nucleotomy patients. Face-to-face interviews were conducted approximately 3.45 days (SD 3.170) after disc surgery, during hospital stay. Psychiatric comorbidity was assessed by means of the Composite International Diagnostic Interview (CIDI-DIA-X). The corresponding data of the German general population were derived from the German National Health Interview and Examination Survey (GHS). RESULTS: 12-Month prevalence rates of any affective, anxiety or substance-related disorders range between 33.7% in cervical and 23.5% in lumbar disc surgery patients. Four-week prevalence rates of any affective, anxiety or substance disorder vary between 13.2% in cervical and 14.0% in lumbar nucleotomy patients. Disc surgery patients suffer more often from affective disorders and illicit substance abuse than the general population. Significant associations were found between psychiatric comorbidity and gender, as well as pain intensity. CONCLUSIONS: Disc surgery patients show a higher risk to suffer from mental disorders than the general population. The assessment of psychiatric distress and the assistance by mental health professionals should be considered during hospital and rehabilitation treatment.

The impact of psychiatric comorbidity on the return to work in patients undergoing herniated disc surgery.

INTRODUCTION: This study examines (1) return to work (RTW) and ability to work (ATW) rates, and the association with (2) psychiatric comorbidity and (3) socio-demographic, illness-related, vocational and rehabilitation-related characteristics in herniated disc surgery patients. METHODS: In this longitudinal observational study 305 consecutive patients took part in face-to-face interviews during hospital stay. 277 patients also participated in a 3-month follow-up survey via telephone (drop-out rate 9%). Psychiatric comorbidity was assessed with the Composite International Diagnostic Interview (CIDI-DIA-X). Calculations were conducted via Chi-Square tests, independent T-tests and binary logistic regression analyses. RESULTS: 40.1% of the herniated disc patients in this study were able to RTW, 44.4% had regained their ATW 3 months after surgery. Psychiatric comorbidity appeared to be an important risk factor for RTW and ATW. Other risk factors were lower educational qualification, unemployment status, a lower subjective prognosis of gainful employment, a higher number of herniated discs in medical history, cervical disc surgery, and the existence of other chronic diseases, a longer hospital stay and higher pain intensity. Patients who did not RTW, or did not regain their ATW participated more often in inpatient rehabilitation. CONCLUSIONS: Identifying a high risk group for RTW and ATW at an early age is of utmost importance for the purpose of improving rehabilitation effects and to make a return to the work place easier. Specific interventions, such as social-medical counselling, pain therapy and management, as well as the assistance of mental health professionals during hospital and rehabilitation treatment are recommended for this risk group.

Melanotic Neuroectodermal Tumour of Infancy: Clinical Courses and Therapeutic Options-A Review of Three Cases.

BACKGROUND: Melanotic neuroectodermal tumour of infancy (MNTI) is a rare benign neoplasm. MNTI appears most often during the first year of life, arises predominantly in the maxilla and tends to recur. We discuss possible therapeutic options given in the literature and within our experience in three cases. PATIENTS: In our recent case, we used an intraoral approach to perform resection of the right-sided maxilla. Despite tumour-positive margins, there was no recurrence over the course of one year. In a previous case of MNTI, two recurrences occurred and 6 months after last resection patient received a rib graft for maxillary reconstruction. However, at the age of 7 years, the infant displayed severe maxillary hypoplasia. In a third case of MNTI, the patient was followed up after initial therapy for two decades and underwent multiple reconstruction procedures to achieve successful rehabilitation. CONCLUSION: Surgical treatment of MNTI should respect vital anatomic structures to avoid gross mutilation. The need for extended and repetitive tumour resection in early childhood can lead to growth disturbances and to further multiple reconstruction procedures in adulthood. Because of the rarity of MNTI, an international database is warranted to evaluate therapies and clinical courses over decades.

Choosing the right rehabilitation setting after herniated disc surgery: Motives, motivations and expectations from the patients' perspective.

OBJECTIVES: This study aims to investigate (1) motives, motivations and expectations regarding the choice for a specific rehabilitation setting after herniated disc surgery and (2) how rehabilitation-related motivations and expectations are associated with rehabilitation outcome (ability to work, health-related quality of life and satisfaction with rehabilitation) three months after disc surgery. METHODS: The longitudinal cohort study refers to 452 disc surgery patients participating in a subsequent rehabilitation. Baseline interviews took part during acute hospital stay (pre-rehabilitation), follow-up interviews three months later (post-rehabilitation). Binary logistic regression and multiple linear regression analyses were applied. RESULTS: (1) Motives, motivations and expectations: Inpatient rehabilitation (IPR) patients stated "less effort/stress" (40.9%), more "relaxation and recreation" (39.1%) and greater "intensity of care and treatment" (37.0%) regarding their setting preference, whereas outpatient rehabilitation (OPR) patients indicated "family reasons" (45.3%), the wish for "staying in familiar environment" (35.9%) as well as "job-related reasons" (11.7%) as most relevant. IPR patients showed significantly higher motivation/expectation scores regarding regeneration (p < .001), health (p < .05), coping (p < .001), retirement/job (p < .01), psychological burden (p < .05) and physical burden (p < .001) compared to OPR patients. (2) Associations with rehabilitation outcome: Besides other factors (e.g. age, gender and educational level) rehabilitation-related motivations/expectations were significantly associated with rehabilitation outcome measures. For example, patients with less motivations/expectations to achieve improvements regarding "physical burden" showed a better health-related quality of life (p < .01) three months after disc surgery. Less motivations/expectations to achieve improvements regarding "psychological burden" was linked to a better mental health status (p < .001) and a greater satisfaction with rehabilitation (OR = .806; p < .05). CONCLUSION: Rehabilitation-related motivations and expectations differed substantially between IPR and OPR patients before rehabilitation and were significantly associated with rehabilitation outcome. Taking motivational and expectation-related aspects into account may help to improve allocation procedures for different rehabilitation settings and may improve rehabilitation success.

Risk Factors for Postoperative Pain Intensity in Patients Undergoing Lumbar Disc Surgery: A Systematic Review.

OBJECTIVES: Pain relief has been shown to be the most frequently reported goal by patients undergoing lumbar disc surgery. There is a lack of systematic research investigating the course of postsurgical pain intensity and factors associated with postsurgical pain. This systematic review focuses on pain, the most prevalent symptom of a herniated disc as the primary outcome parameter. The aims of this review were (1) to examine how pain intensity changes over time in patients undergoing surgery for a lumbar herniated disc and (2) to identify socio-demographic, medical, occupational and psychological factors associated with pain intensity. METHODS: Selection criteria were developed and search terms defined. The initial literature search was conducted in April 2015 and involved the following databases: Web of Science, Pubmed, PsycInfo and Pubpsych. The course of pain intensity and associated factors were analysed over the short-term (≤ 3 months after surgery), medium-term (> 3 months and < 12 months after surgery) and long-term (≥ 12 months after surgery). RESULTS: From 371 abstracts, 85 full-text articles were reviewed, of which 21 studies were included. Visual analogue scales indicated that surgery helped the majority of patients experience significantly less pain. Recovery from disc surgery mainly occurred within the short-term period and later changes of pain intensity were minor. Postsurgical back and leg pain was predominantly associated with depression and disability. Preliminary positive evidence was found for somatization and mental well-being. CONCLUSIONS: Patients scheduled for lumbar disc surgery should be selected carefully and need to be treated in a multimodal setting including psychological support.

The Course of Pain Intensity in Patients Undergoing Herniated Disc Surgery: A 5-Year Longitudinal Observational Study.

OBJECTIVES: The aims of this study are to answer the following questions (1) How does the pain intensity of lumbar and cervical disc surgery patients change within a postoperative time frame of 5 years? (2) Which sociodemographic, medical, work-related, and psychological factors are associated with postoperative pain in lumbar and cervical disc surgery patients? METHODS: The baseline survey (T0; n = 534) was conducted 3.6 days (SD 2.48) post-surgery in the form of face-to-face interviews. The follow-up interviews were conducted 3 months (T1; n = 486 patients), 9 months (T2; n = 457), 15 months (T3; n = 438), and 5 years (T4; n = 404) post-surgery. Pain intensity was measured on a numeric rating-scale (NRS 0-100). Estimated changes to and influences on postoperative pain by random effects were accounted by regression models. RESULTS: Average pain decreased continuously over time in patients with lumbar herniated disc (Wald Chi² = 25.97, p<0.001). In patients with cervical herniated disc a reduction of pain was observed, albeit not significant (Chi² = 7.02, p = 0.135). Two predictors were associated with postoperative pain in lumbar and cervical disc surgery patients: the subjective prognosis of gainful employment (p<0.001) and depression (p<0.001). CONCLUSION: In the majority of disc surgery patients, a long-term reduction of pain was observed. Cervical surgery patients seemed to benefit less from surgery than the lumbar surgery patients. A negative subjective prognosis of gainful employment and stronger depressive symptoms were associated with postoperative pain. The findings may promote multimodal rehabilitation concepts including psychological and work-related support.

Clinical course and implications of congenital nasal pyriform stenosis and solitary median maxillary central incisor in a newborn: a case report.

INTRODUCTION: Congenital nasal pyriform aperture stenosis and solitary median maxillary central incisor are uncommon anomalies and are associated with further malformations. Solitary median maxillary central incisor itself has initially no impact on a child's health, but congenital nasal pyriform aperture stenosis is a potentially life-threatening condition. CASE PRESENTATION: A Caucasian baby boy showed severe dyspnoea and was intubated orotracheally. Multiple anomalies were detected, including urogenital and craniofacial malformations. Computed tomography scans revealed congenital nasal pyriform aperture stenosis with a diameter of 4.9mm and a solitary median maxillary central incisor. A 3.0mm tube was inserted in his left nasal cavity, and the baby was able to breathe sufficiently and spontaneously. The nasal tube was removed after seven days, and the baby was discharged under application of decongestant drops. After seven months, the baby was readmitted with respiratory distress, and surgery was carried out using an intraoral sublabial approach. The stenotic area of the pyriform aperture was widened, and 3.0mm tubes were inserted in both nasal cavities for 10 days. Over a period of six months, no further respiratory distress has occurred. CONCLUSIONS: The decision to perform surgery was delayed since the baby's nasal breathing was adequate as a result of the insertion of a nasal tube. Since treatment depends on the severity of symptoms, it is appropriate in some cases to take a conservative approach at first, and to keep surgery as a last resort. Once a conservative approach has been selected for congenital nasal pyriform aperture stenosis, awareness of the life-threatening nature of the condition should be kept in mind, and a surgical approach must still be taken into account.

Mucoepidermoid carcinoma of the palate in a 5-year-old girl: case report and literature review.

BACKGROUND: Minor salivary gland tumors in children are uncommon. However, despite the low overall incidence, there is a high incidence of malignancy in these young patients which is reported to be above 50 %, with mucoepidermoid carcinoma (MEC) predominating. We hope that this case report will contribute to the enlightenment of the behavior and prognosis of pediatric MEC of palatal minor salivary gland tumors. CASE REPORT: A 5-year-old girl was admitted to our center with a histologically confirmed MEC of the left hard palate. Primary incision for drainage of a supposed abscess and secondary biopsy had been performed elsewhere 14 days before. After further workup, we excised the tumor and the adjacent bone; clear margins of 10 mm were revealed. Adjuvant therapy was not necessary. The defect was allowed to undergo secondary wound healing. As of the 1-year follow-up, there had been no recurrences. CONCLUSION: For differential diagnosis, MEC should be considered in cases of soft, slow-growing, painless, pale bluish-purple lumps of the palate even in young patients. Especially for nonresponders to initial treatment, early biopsy is recommended for histological confirmation or exclusion of a minor salivary gland tumor.

Inpatient or outpatient rehabilitation after herniated disc surgery? - Setting-specific preferences, participation and outcome of rehabilitation.

OBJECTIVE: To examine rehabilitation preferences, participation and determinants for the choice of a certain rehabilitation setting (inpatient vs. outpatient) and setting-specific rehabilitation outcomes. METHODS: The longitudinal observational study referred to 534 consecutive disc surgery patients (18-55 years). Face-to-face baseline interviews took place about 3.6 days after disc surgery during acute hospital stay. 486 patients also participated in a follow-up interview via telephone three months later (dropout-rate: 9%). The following instruments were used: depression and anxiety (Hospital Anxiety and Depression Scale), pain intensity (numeric analog scale), health-related quality of life (Short Form 36 Health Survey), subjective prognosis of gainful employment (SPE-scale) as well as questions on rehabilitation attendance, return to work, and amount of sick leave days. RESULTS: The vast majority of patients undergoing surgery for a herniated disc attended a post-hospital rehabilitation treatment program (93%). Thereby two-thirds of these patients took part in an inpatient rehabilitation program (67.9%). Physical, psychological, vocational and health-related quality of life characteristics differed widely before as well as after rehabilitation depending on the setting. Inpatient rehabilitees were significantly older, reported more pain, worse physical quality of life, more anxiety and depression and a worse subjective prognosis of gainful employment before rehabilitation. Pre-rehabilitation differences remained significant after rehabilitation. More than half of the outpatient rehabilitees (56%) compared to only one third of the inpatient rehabilitees (33%) returned to work three months after disc surgery (p<.001). CONCLUSION: The results suggest a "pre-selection" of patients with better health status in outpatient rehabilitation. Gaining better knowledge about setting-specific selection processes may help optimizing rehabilitation allocation procedures and improve rehabilitation effects such as return to work.

The course of depression and anxiety in patients undergoing disc surgery: a longitudinal observational study.

OBJECTIVE: This study examines longitudinal depression and anxiety rates in disc surgery patients in comparison to the general population, the change and associated determinants of depression and anxiety over time. METHODS: The longitudinal observational study refers to 305 consecutive disc surgery patients (age range: 18-55 years). Depression and anxiety was assessed with the Hospital Anxiety and Depression Scale. Random effects regression models for unbalanced panel data were used. RESULTS: Depression and anxiety decreases significantly during nine months after surgery. Depression rates vary between 23.6% (T0), 9.6% (T1) and 13.1% (T2). Only at T0 the depression rate differs significantly from the general population. Anxiety rates range between 23.7% (T0), 10.9% (T1) and 11.1% (T2). Compared to the general population anxiety rates are significantly higher at all three assessment points. Risk factors for anxiety or depression at the time of the surgery are psychiatric comorbidity before surgery, higher age, female gender, lower educational level, lower physical health status and higher pain intensity. Regarding depression and anxiety in the course of time significant time interactions were found for the existence of other chronic diseases, higher pain intensity and vocational dissatisfaction. CONCLUSIONS: Compared to the general population patients undergoing herniated disc surgery are often affected by depression and anxiety during hospital treatment and also in the course of time. Multimodal diagnostics regarding psychological well-being, pain and physical health status may help to identify this risk group. The assistance by mental health professionals during hospital and rehabilitation treatment may reduce poor postoperative outcome.

A rare association: basal cell carcinoma in a vitiliginous macula.

BACKGROUND: Today, no proven significant association was detected between sun-exposed vitiliginous patches and non-melanotic skin cancers. In fact, the occurrence of a basal cell carcinoma (BCC) in vitiliginous patches seems to be extremely rare. CASE REPORT: We present a case of a 33-year-old female patient suffering from BCC in a vitiliginous patch on the cheek. This is the first report of the occurrence of a sclerodermiform type of BCC in a vitiliginous macula. CONCLUSION: Our case report challenges the long-standing belief that the occurrence of BCC in vitiligo is nearly impossible. However, even if this association is apparently fortuitous, our report contributes to the awareness of the risk of BCC in young patients with vitiligo.

Effects of psychiatric comorbidity on costs in patients undergoing disc surgery: a cross-sectional study.

BACKGROUND CONTEXT: Back pain presents a significant cause of health care costs and lost productivity. In most cases, conservative treatment will be sufficient, but in the most severe cases, disc surgery is indicated. PURPOSE: To analyze the effect of psychiatric comorbidity on health care costs and lost productivity in patients with back pain undergoing disc surgery. STUDY DESIGN: A cross-sectional study design was used. PATIENT SAMPLE: A sample of 305 disc surgery patients (lumbar, 239; cervical, 66). OUTCOME MEASURES: Patients were interviewed using the German version of the Composite International Diagnostic Interview to assess psychiatric comorbidity and a questionnaire to assess resource utilization and lost productivity for a 3-month period prior disc surgery. Health care resources were monetarily valued by unit costs, whereas productivity was valuated by labor costs. METHODS: Cost differences between patients with and without psychiatric comorbidity were analyzed using bootstrap regression techniques. RESULTS: Back pain was associated with mean 3-month direct health care costs ranging from €5,534 (lumbar disc herniation without psychiatric comorbidity) to €8,507 (cervical disc herniation with psychiatric comorbidity), of which between 51% and 79% were caused by disc surgery. Mean indirect costs ranged from €7,589 to €8,492. Psychiatric comorbidity was significantly associated with increased direct costs in lumbar disc herniation (€7,042 vs. €5,534). Regression analysis showed increments of €851 (p=.043) in direct costs and €1,636 (p=.058) in total costs for psychiatric comorbidity, which predominantly resulted from nonpsychiatric health care utilization. CONCLUSIONS: Severe back pain is associated with high direct and indirect costs, which are influenced by the presence of psychiatric comorbidity. We found a lack of treatment for psychiatric comorbidity indicated by low mental health care utilization in affected individuals. More attention should be given to psychiatric comorbidity in the treatment of patients undergoing disc surgery. Clinicians should be aware of the high prevalence rates of psychiatric comorbidity in this patient group. They should consider the assessment of psychiatric distress and support of mental health professionals if applicable.

A strategy to avoid facial mutilation in orbital embryonal rhabdomyosarcoma.

INTRODUCTION: An orbital embryonal rhabdomyosarcoma (RMS) is a rare malignancy in children, but clinical findings are typical. We detail the case of an 8-year-old female with orbital RMS and discuss the therapeutic options. CASE REPORT: Orbital RMS was apparent with painless exophthalmos of the right globe and diplopia. Head MRI showed tumor masses behind and inferior to the globe. Open biopsy led to the histological diagnosis. Metastasis or infiltration of orbital bone was not observed. Chemotherapy was carried out in accordance with the Cooperative Weichteilsarkom Studie (CWS) 2002 protocol. Tumor regression was detected after the first course of chemotherapy; we decided to excise the residual tumor with preservation of the globe. The CWS 2002 protocol was subsequently completed. Radiotherapy was not done. One year after treatment, RMS recurrence was not observed. CONCLUSION: After interdisciplinary treatment, mutilation was avoided after exenteration of the orbit or radiation treatment to the growing facial skeleton. That was possible due to excision of the residual tumor in a second step, leading to down-staging of the RMS.

Complications after nasal skin repair with local flaps and full-thickness skin grafts and implications of patients' contentment.

PURPOSE: The range of complications after plastic surgical repair of nasal skin defects is not clearly known. The aim of this study was to identify complications after reconstruction of nasal skin defects to determine what typical complications occur after standard surgical options including full-thickness skin graft (FTSG) and local flap plastics (LFP). MATERIALS AND METHODS: In 210 patients with defects of the nasal tip, the nasal ala or dorsum of the nose (average diameter 1.1 +/- 0.3 cm) surgical skin repair was performed with LFP or FTSG. Complications within 6 months after surgery were recorded. RESULTS: Some 41 patients (19.5%) suffered complications; there was no significant difference in total complication rate between LFP (20.5%) and FTSG (18.3%). However, FTSG patients had significantly more infections postoperatively than LFP patients (5.4% vs. 2.6%). LFP patients presented a significantly higher rate of wound or suture dehiscence (FTSG 2.2%, LFP 5.9%). FTSG patients exhibited a significantly higher rate of partial or complete loss (total rate FTSG 8.5%, LFP 5.2%). The LFP technique led to significantly more aesthetic deficits (FTSG 2.1%, LFP 6.8%). CONCLUSIONS: LFP showed advantages with regard to infection and loss rates but with a higher rate of aesthetic deficits compared to FTSG. It remains an individual decision as to which procedure is used to repair defects of the nose, depending on patient and surgical variables.