Topical anaesthetic patches for postoperative wound pain in laparoscopic gynaecological surgery: a prospective, blinded and randomised trial.

PURPOSE: Aim of this prospective study was to investigate the effectiveness of eutectic mixture of local anaesthetic (EMLA) patches on every abdominal incision for pain relief after gynaecologic laparoscopic surgery. METHODS: A total of 121 women were prospectively randomised to receive either placebo (control group) or EMLA (study group) patches on all abdominal incisions. Postoperative pain was assessed 24 and 48 h after surgery using the short form of the McGill Pain Questionnaire (SF-MPQ). The amount of analgesic pain medication on demand was assessed in both groups. RESULTS: Sixty women were allocated to the study group and 61 patients to the control group before laparoscopic surgery. There were no statistically significant differences regarding age, body mass index (BMI), duration of surgery and blood loss comparing both groups. There were no statistically significant differences between both groups with regard to postoperative total pain scores 24 h (McGill total score: 31.77 ± 27.95 vs. 36.80 ± 31.39, p = 0.3535) and 48 h (McGill total score: 19.18 ± 20.09 vs. 26.61 ± 27.70, p = 0.0942) after surgery. Time to mobilisation after surgery (hours) was significantly shorter in the study group (5.01 ± 3.72 vs. 5.78 ± 3.04, p = 0.0423). CONCLUSION: Despite of a significant reduction of time for mobilisation transdermal anaesthetic patches after gynaecologic laparoscopic surgery did not lead to decreased postoperative pain scores.

The risk of infections in hematologic patients treated with rituximab is not influenced by cumulative rituximab dosage - a single center experience.

BACKGROUND: Rituximab, a monoclonal antibody directed against CD20, is approved for the treatment of CD20-positive B-cell Non-Hodgkin's lymphoma and rheumatologic disorders. Due to its potent activity in depleting CD20-positive lymphocytes, the influence on opportunistic infections is still under discussion. Thus, we analyzed the impact of rituximab either as monotherapy or in combination with other chemotherapeutic regimens to elucidate its role in contributing to infectious complications. METHODS: The records of consecutive patients (n = 125, 141 treatment episodes) treated with rituximab alone or in combination with chemotherapy and corticosteroids were analyzed retrospectively for the incidence, spectrum and outcome of infections during treatment and 6 months after the last course of rituximab. Univariate analysis of cofactors such as steroid medication, antiinfective prophylaxis, underlying disease and remission status were performed. RESULTS: Altogether 80 therapy episodes were associated with infections, the median number of infections per patient being 1 (range 1-7). The number of infectious complications was significantly higher in patients receiving a combination of rituximab and chemotherapy compared to rituximab monotherapy (p < 0.001). There was no statistically significant difference regarding number of rituximab courses or cumulative rituximab dosage between episodes with and without infections, respectively.Mean cumulative prednisone dosage between the cohort with infections and the one without infections showed a trend towards higher dosage of prednisone in the patients with infections (mean difference 441 mg, p > 0.14). CONCLUSIONS: Rituximab in induction treatment, either as monotherapy or combined with chemotherapy by itself does not increase the incidence or change the spectrum of infections in hematologic patients. However the possible influence of higher dosages of concomitant steroid medication on frequency of infections suggests that a heightened awareness of the potential for infectious complications should be applied to patients receiving higher doses of glucocorticoids in combination with other therapeutic regimens.

Solo surgery--early results of robot-assisted three-dimensional laparoscopic hysterectomy.

OBJECTIVE: Report of our initial experience in laparoscopic hysterectomy by a solo surgeon using a robotic camera system with three-dimensional visualisation. MATERIAL AND METHODS: This novel device (Einstein Vision®, B. Braun, Aesculap AG, Tuttlingen, Germany) (EV) was used for laparoscopic supracervical hysterectomy (LASH) performed by one surgeon. Demographic data, clinical and surgical parameters were evaluated. Our first 22 cases, performed between June and November 2012, were compared with a cohort of 22 age-matched controls who underwent two-dimensional LASH performed by the same surgeon with a second surgeon assisting. RESULTS: Compared to standard two-dimensional laparoscopic hysterectomy, there were no significant differences regarding duration of surgery, hospital stay, blood loss or incidence of complications. The number of trocars used was significantly higher in the control group (p <.0001). All hysterectomies in the treatment group were performed without assistance of a second physician. CONCLUSION: Robot-assisted solo surgery laparoscopic hysterectomy is a feasible and safe procedure. Duration of surgery, hospital stay, blood loss, and complication rates are comparable to a conventional laparoscopic hysterectomy.

Influence of bag volume on reproducibility of inert gas rebreathing pulmonary blood flow measurements in patients with pulmonary diseases.

PURPOSE: Non-invasive inert gas rebreathing (IGR) has shown promising results in the determination of pulmonary blood flow. The volume of the rebreathing bag (V bag) is proposed by the system. However, elderly patients or those with severe pulmonary disease may be unable to rebreathe this volume entirely. We evaluated the effect of adapting V bag on the reproducibility of IGR. METHODS: A total of 270 valid measurements were obtained from 45 patients with obstruction (group A), restriction (group B), and in healthy controls (group C). Two measurements for each of three different V bag of 1,200, 1,700, and 2,200 ml were conducted in the supine position. RESULTS: We found no statistically significant difference of the repeated measurements neither between the different V bag in groups A to C nor between the three groups for identical V bag. There was a weak yet significantly worse coefficient of variation between a V bag of 2,200 ml in group A compared with group C with 2,200 and 1,200 ml, respectively. Intraclass correlation coefficient and repeatability coefficient yielded significantly worse values in group A for a V bag of 2,200 ml compared with healthy controls and lower bag volumes. No difference could be found intraclass nor interclass in groups B and C. CONCLUSIONS: V bag can be altered between 1,200 and 2,200 ml in most situations without affecting the reproducibility. Attention has to be paid to extreme volumes in obstructive patients. Nevertheless, V bag should be chosen as large as possible and therefore has to be carefully adapted, particularly in patients with obstruction or restriction.

Are mammographic changes in the tumor bed more pronounced after intraoperative radiotherapy for breast cancer? Subgroup analysis from a randomized trial (TARGIT-A).

Intraoperative radiotherapy (IORT) with low-energy x-rays is increasingly used in breast-conserving therapy (BCT). Previous non-randomized studies have observed mammographic changes in the tumor bed to be more pronounced after IORT. The purpose of this study was to reassess the postoperative changes in a randomized single-center subgroup of patients from a multicenter trial (TARGIT-A). In this subgroup (n = 48) 27 patients received BCT with IORT, 21 patients had BCT with standard whole-breast radiotherapy serving as controls. Overall 258 postoperative mammograms (median follow-up 4.3 years, range 3-8) were retrospectively evaluated by two radiologists in consensus focusing on changes in the tumor bed. Fat necroses showed to be significantly more frequent (56% versus 24%) and larger (8.7 versus 1.6 sq cm, median) after IORT than those in controls. Scar calcifications were also significantly more frequent after IORT (63% versus 19%). The high incidence of large fat necroses in our study confirms previous study findings. However, the overall higher incidence of calcifications in the tumor bed after IORT represents a new finding, requiring further attention.

Is arterial pulse contour analysis using Nexfin a new option in the noninvasive measurement of cardiac output?--A pilot study.

OBJECTIVES: A growing interest in monitoring cardiac output (CO) noninvasively has emerged; however, its determination has been difficult using the standard approaches. The aim of this study was to evaluate the accuracy and precision of pulse contour analysis (PCA) compared with cardiac magnetic resonance imaging (CMR). DESIGN: A single-center prospective study. SETTING: A university hospital. PARTICIPANTS: Thirty-nine consecutive stable patients undergoing CMR. INTERVENTIONS: CO was determined twice by PCA using the Nexfin monitoring system (BMEYE BV, Amsterdam, The Netherlands). Measurements were performed after 10 minutes of rest in a stable supine position immediately before or after the CMR examination. MEASUREMENTS AND MAIN RESULTS: There was a mean bias of 0.2 ± 1.9 L/min between CMR and PCA and a reproducibility of 0.2 ± 0.6 L/min for PCA. Between 4.8 and 6.3 L/min (second quartile of COCMR), there was a good agreement (mean bias = -0.2 ± 1.3 L/min). Comparing quartile 1 (-1.3 ± 2.0 L/min) overestimating and quartiles 3 (1.4 ± 0.9 L/min) and 4 (0.9 ± 2.0 L/min) underestimating CO, a statistically significant difference was found. The reproducibility was not affected by the quartile (p = 0.23, analysis of variance), whereas there was a significant difference between the nonoutlier and outlier group when using the Mann-Whitney U test (p = 0.02). CONCLUSIONS: Noninvasive PCA allows the safe and economic measurement of CO, yet it still has major limitations. Although the agreement with CMR was acceptable, there was a clinically unacceptable variation; absolute values should not be used interchangeably. These results suggest that therapeutic interventions and clinical decisions should not be based on noninvasive PCA measurements at the present time.

Is the assessment of the central skeleton sufficient for osseous staging in breast cancer patients? A retrospective approach using bone scans.

OBJECTIVE: By analyzing bone scans we aimed to determine whether the assessment of the central skeleton is sufficient for osseous staging in breast cancer patients. This might be of interest for future staging modalities, especially positron emission tomography/computed tomography, usually sparing the peripheral extremities, as well as the skull. MATERIALS AND METHODS: In this retrospective study, a total of 837 bone scans for initial staging or restaging of breast cancer were included. A total of 291 bone scans in 172 patients were positive for bone metastases. The localization and distribution of the metastases were re-evaluated by two readers in consensus. The extent of the central skeleton involvement was correlated to the incidence of peripheral metastases. RESULTS: In all 172 patients bone metastases were seen in the central skeleton (including the proximal third of humerus and femur). In 34 patients (19.8 %) peripheral metastases of the extremities (distally of the proximal third of humerus and femur) could be detected. Sixty-four patients (37.2 %) showed metastases of the skull. Summarizing the metastases of the distal extremities and skull, 79 patients (45.9 %) had peripheral metastases. None of the patients showed peripheral metastases without any affliction of the central skeleton. The incidence of peripheral metastases significantly correlated with the extent of central skeleton involvement (p<0.001). CONCLUSIONS: Regarding bone scans, an isolated metastatic spread to the peripheral skeleton without any manifestation in the central skeleton seems to be the exception. Thus, the assessment of the central skeleton should be sufficient in osseous breast cancer staging and restaging. However, in case of central metastases, additional imaging of the periphery should be considered for staging and restaging.

Right- versus left-sided congenital diaphragmatic hernia: postnatal outcome at a specialized tertiary care center.

OBJECTIVE: To systematically investigate the impact of the location of the defect in congenital diaphragmatic hernia on neonatal mortality and morbidity with a special focus on survival at discharge, extracorporeal membrane oxygenation requirement, and the development of chronic lung disease. DESIGN: Retrospective tertiary care center study with a matched-pair analysis of all fetuses that were treated for congenital diaphragmatic hernia between 2004 and 2009. SETTING: A specialized tertiary care center for fetuses with congenital diaphragmatic hernia. PATIENTS: Complete sets of data were available for 106 patients with congenital diaphragmatic hernia. For 17 of 18 infants with right-sided congenital diaphragmatic hernia we were able to allocate infants with left-sided congenital diaphragmatic hernia with no relevant difference in previously described prognostic factors, such as pulmonary hypoplasia and liver herniation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There was a strong trend toward better survival in infants with right-sided congenital diaphragmatic hernia than with left-sided congenital diaphragmatic hernia (94% vs. 70%; p = .07). More neonates with left-sided congenital diaphragmatic hernia died of severe pulmonary hypertension despite extracorporeal membrane oxygenation. Fewer neonates with right-sided congenital diaphragmatic hernia died, yet higher degrees of pulmonary hypoplasia and oxygen requirement were observed despite extracorporeal membrane oxygenation. CONCLUSIONS: In congenital diaphragmatic hernia, the location of the defect has a substantial impact on postnatal survival and the development of chronic lung disease. In left-sided congenital diaphragmatic hernia, pulmonary hypertension resistant to therapeutic management, including extracorporeal membrane oxygenation, is more common and is associated with a higher rate of neonatal demise. Right-sided congenital diaphragmatic hernia infants have an increased benefit from extracorporeal membrane oxygenation but the better survival entails a higher rate of chronic lung disease.

Donor Deferral Rates after the Implementation of a New German Blood Donor Questionnaire.

BACKGROUND: The implementation of a new national German blood donor questionnaire was proposed to improve donor and recipient safety. METHODS: We compared deferral/exclusion rates of whole blood donors before (May 2010, n = 64,735) and after (May 2011, n = 71,687) the implementation of a new blood donor questionnaire. Considering seasonal variations, analysis was performed with respect to collection site (mobile vs. fixed), sex, donor status (first-time vs. repeat), age, and the frequencies of sexual risk behavior and other reasons for deferral. RESULTS: We observed a statistically significant increase (p < 0.001) of the overall deferral/exclusion rate from 6.2 to 8.1%, irrespective of type of collection site (fixed: from 6.0 to 8.5%; mobile: from 6.2 to 8.0%), sex (females: from 7.5 to 9.9%; males: from 5.1 to 6.6%), donor status (first-time donors: from 19.7 to 24.7%; repeat donors: from 4.6 to 6.3%) or age (18-29 years: from 9.1 to 11.7%; 60-71 years: from 5.1 to 6.6%). Confidential self-exclusion increased from 0.08 to 0.14% (p < 0.001). Besides risk behavior, various medical reasons could be identified that explain this increase. CONCLUSIONS: The new blood donor questionnaire resulted in an increased deferral/exclusion of all donor groups. Thus the impact on future blood supply must be considered carefully, and long-term studies and investigation of donor acceptance will be needed.

A single nucleotide polymorphism determines protein isoform production of the human c-FLIP protein.

The cellular FLICE-inhibitory protein (c-FLIP) is a modulator of death receptor-mediated apoptosis and plays a major role in T- and B-cell homeostasis. Three different isoforms have been described on the protein level, including the long form c-FLIP(L) as well as 2 short forms, c-FLIP(S) and the recently identified c-FLIP(R). The mechanisms controlling c-FLIP isoform production are largely unknown. Here, we identified by sequence comparison in several mammals that c-FLIP(R) and not the widely studied c-FLIP(S) is the evolutionary ancestral short c-FLIP protein. Unexpectedly, the decision for production of either c-FLIP(S) or c-FLIP(R) in humans is defined by a single nucleotide polymorphism in a 3' splice site of the c-FLIP gene (rs10190751A/G). Whereas an intact splice site directs production of c-FLIP(S), the splice-dead variant causes production of c-FLIP(R). Interestingly, due to differences in protein translation rates, higher amounts of c-FLIP(S) protein compared with c-FLIP(R) are produced. Investigation of diverse human cell lines points to an increased frequency of c-FLIP(R) in transformed B-cell lines. A comparison of 183 patients with follicular lymphoma and 233 population controls revealed an increased lymphoma risk associated with the rs10190751 A genotype causing c-FLIP(R) expression.

Role of fetal abdominal circumference as a prognostic parameter of perinatal complications.

OBJECTIVE: To evaluate the potential of fetal abdominal circumference (AC) measurement as predictor of perinatal complications in term newborns. MATERIALS AND METHODS: This prospective study included 324 consecutive term pregnancies within a 6-month period between February and August 2009. Inclusion criteria were a singleton pregnancy with at least 37 weeks of gestation, vertex presentation, absence of structural or chromosomal disorders and complete ultrasound examination within 3 days of delivery. Patients with elective caesarean sections were excluded. Vaginal deliveries were assessed with regard to the impact of fetal AC on the mode of delivery, the neonatal outcome (pH, base excess, APGAR score at 5 min) and the incidence of perineal injuries. When appropriate, U tests and χ (2) tests were performed for group comparisons. RESULTS: Complete data were obtained for 258 patients. Sixty-six patients were excluded because they underwent elective caesarean section. Only 12 of the 30 fetuses with an AC ≥ 36.0 cm weighed more than 4,000 g. There was no significant difference in relation to incidence of surgical delivery (instrumental delivery, P = 0.754 and caesarean section, P = 0.405), the neonatal outcome (pH, P = 0.527; base excess, P = 0.146; APGAR score at 5 min, P = 0.552), and the occurrence of perineal injuries (2nd and 3rd degree, P = 0.951). CONCLUSION: The results of the study could not demonstrate a significant relationship between AC ≥ 36.0 cm and perinatal complications. For this, measuring the fetal AC is of no help in finding the correct clinical management.

Application of DC beads in hepatocellular carcinoma: clinical and radiological results of a drug delivery device for transcatheter superselective arterial embolization.

AIM: Application of a drug delivery device for transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). Clinical and radiological treatment assessment. PATIENTS AND METHODS: 24 patients with liver cirrhosis and uni- or multifocal HCC underwent TACE with doxorubicin beads (DC Bead). The underly-ing cause of liver cirrhosis was hepatitis (A: n = 7; B: n = 10) or alcohol consumption (n = 7). Patients presented with Child Pugh stage A (n = 15) and B (n = 9). The mean intrahepatic tumor size, considering the sum of diameters of all lesions treated, was 3.83 cm (+/-2.4). Liver function and hematological parameters were documented before and after each TACE. Magnetic resonance imaging (MRI) was performed before and 4 weeks after TACE. The T1-w 3D volume-interpolated breathhold exam (VIBE) sequence was applied for evaluation of the therapy response. RESULTS: 24 patients received a total number of 69 TACE treatments with DC beads (mean dose 160 mg). The elevation of liver function parameters after treatment did not affect the patients' clinical condition. The T1-w VIBE sequence proved very valuable for assessment of the intrahepatic tumor spread. Post-contrast images enabled delineation of the viable HCC lesions, hence facilitating the selective transcatheter approach. The tumor marker a-fetoprotein (AFP), available in 19/24 patients, dropped from 347.5 to 299.5 ng/ml, without being a reliable predictor of treatment response. A decrease of tumor size after TACE from 3.83 (+/-2.40) to 3.01 cm (+/-2.67; p < 0.0001) was evident on the T1w-VIBE sequences. The mean follow-up period was 30 months. At the time of data analysis, 10 (42%) out of 14 patients were alive. CONCLUSION: TACE with DC beads in HCC offers a safe and efficient treatment resulting in tumor response within a very short time.

The impact of pulmonary disease on noninvasive measurement of cardiac output by the inert gas rebreathing method.

Cardiac output (CO) is an important parameter for diagnosis and therapy of heart diseases, but it is still difficult to determine. Innocor, a novel noninvasive inert gas rebreathing (IGR) system, has shown promising results. However, the impact of pulmonary diseases on IGR remains unclear. The aim of the study therefore was to assess the accuracy and reliability of IGR in patients with distinct chronic lung disease. A total of 96 patients were enrolled, including 48 consecutive patients with variant lung diseases (group A) and 48 pair-matched pulmonary healthy patients (group B). CO was measured with cardiac magnetic resonance imaging (CMR) and IGR. Lung function testing was done by spirometry [FEV(1)/FVC (forced expiratory volume in one second/forced vital capacity), VC (vital capacity)] and determination of the diffusing capacity of the lung for carbon monoxide divided by alveolar volume (DLCO/VA). In group A we found a mean CO of 4.7 ± 1.3 L/min by IGR and 4.9 ± 1.2 L/min by CMR. Group B showed a mean CO of 4.8 ± 1.4 L/min by IGR and 5.0 ± 1.3 L/min by CMR. Bland-Altman analysis revealed good correspondence between CMR and IGR, with an average deviation of 0.1 ± 1.0 L/min in group A and 0.1 ± 1.0 L/min in group B (p = 0.99). Multiple regression analysis for the pulmonary parameters did not show a statistically significant impact on the mean bias of CO measurements (FEV(1)/FVC: r = 0.01, p = 0.91; VC: r = -0.2, p = 0.13; and DLCO/VA: r = 0.04, p = 0.82). IGR allows a feasible determination of CO even in patients with lung diseases. The accuracy of the IGR method is not influenced by either pulmonary obstructive and restrictive diseases or a reduced DLCO.

Congenital diaphragmatic hernia: predictive value of MRI relative lung-to-head ratio compared with MRI fetal lung volume and sonographic lung-to-head ratio.

OBJECTIVE: The purpose of this study was to evaluate the prognostic accuracy of a new MRI-based relative lung-to-head ratio in regard to neonatal survival and need for extracorporeal membrane oxygenation (ECMO) in the care of fetuses with congenital diaphragmatic hernia (CDH) and to compare it with the previously described sonographic relative lung-to-head ratio and relative fetal lung volume assessed at antenatal MRI. MATERIALS AND METHODS: Sonographic lung-to-head ratio and MRI fetal lung volume were measured in 90 fetuses (mean gestational age, 31.4+/-4.1 weeks) with CDH. Sonographic relative lung-to-head ratio and MRI relative fetal lung volume were assessed by expressing the observed sonographic lung-to-head ratio and MRI fetal lung volume as a percentage of the expected parameter value. The new MRI relative lung-to-head ratio was assessed as a percentage of the expected MRI lung-to-head ratio based on MRI fetal lung volume and MRI head circumference measurements. Measurements for survival and ECMO requirement were determined with the area under the curve (AUC). Data were analyzed for left-sided defects, right-sided defects, and associated liver herniation. RESULTS: Among fetuses with left-sided CDH, all parameters were excellent in determining neonatal survival and need for ECMO therapy (p

Response to intravenous ajmaline: a retrospective analysis of 677 ajmaline challenges.

AIMS: The diagnostic type I ECG in Brugada syndrome (BS) is often concealed and fluctuates between the diagnostic and non-diagnostic pattern. Challenge with intravenous ajmaline is used to unmask the diagnostic Brugada ECG. The aim of this study was to evaluate the safety of the test and to identify predictors for the response to an intravenous ajmaline challenge. METHODS AND RESULTS: In four tertiary referral centres, 677 consecutive patients underwent an intravenous ajmaline challenge for diagnosis or exclusion of BS in accordance with the recommendations of the Brugada consensus conferences. Two hundred and sixty-two ajmaline challenges (39%) were positive. Male gender, familial BS, sudden cardiac arrest (SCA), first-degree AV-block, basal saddleback type ECG, and basal right bundle branch block were identified as predictors for a positive ajmaline challenge. A predictor for negative ajmaline test was the absence of ST-segment elevation at baseline. Six of 12 patients who had experienced SCA, and five of 25 patients with a familial sudden death exhibited a positive response to ajmaline. Only one patient (0.15%) developed sustained ventricular tachyarrhythmias (ventricular fibrillation) during ajmaline challenge, which was terminated by a single external defibrillator shock. CONCLUSION: Ajmaline challenge is a safe procedure to unmask the electrocardiographic pattern of BS. Electrocardiographic and clinical parameters were identified to predict patients' response to ajmaline. The results of this study guide the clinician in which setting an ajmaline challenge is an appropriate diagnostic step.

Interleukin-18 serum levels in inflammatory bowel diseases: correlation with disease activity and inflammatory markers.

BACKGROUND: An imbalance of cytokines is believed to contribute to the immunopathogenesis of inflammatory bowel diseases (IBD). Serum cytokine levels may correlate with disease activity and acute phase reactivity. AIM: To determine the correlation of systemic interleukin-18 (IL-18) levels with disease activity and other markers of inflammation using a crosssectional pilot study in outpatients with IBD. METHODS: Peripheral venous blood was obtained from 84 patients with Crohn's disease (CD) and from 46 patients with ulcerative colitis (UC). Serum levels of C-reactive protein (CRP), IL-8, IFN-gamma, IL-12p70 and IL-18 were assessed by ELISA. Disease activity was expressed by the Crohn's Disease Activity Index (CDAI) and the Clinical Activity Index (CAI), respectively. Statistical analysis comprised correlation coefficients and linear regression analysis. RESULTS: In CD IL-18 and other cytokine concentrations, CRP levels, leukocyte and platelet counts did not correlate with the CDAI. However, IL-18 as well as IL-8 and platelets positively correlated with CRP levels (p <0.001), while IFN-gamma and IL-12p70 did not. In contrast, in UC only the CAI and CRP levels showed a significant positive correlation. COMCLUSIONS: In CD IL-18 lacks significant correlation with the CDAI, as do serum acute phase protein and other cytokine markers of inflammation. As opposed to UC, IL-18 and IL-8 may, however, serve as indicators of acute phase reactivity in CD and should be explored in a larger study.

Can dynamic MR imaging predict response in patients with rectal cancer undergoing cetuximab-based neoadjuvant chemoradiation?

BACKGROUND: The aim of this study was to evaluate therapy response in patients undergoing cetuximab-CapIri-based chemoradiation for rectal cancer using dynamic magnetic resonance imaging (dMRI). PATIENTS AND METHODS: The volumetric degree of tumor regression and contrast media perfusion were compared to the results of the histopathologic ypTN staging. 33 patients were examined using a 1.5-T scanner with repetitive 2D FLASH sequences after contrast media application. All patients were examined twice - before therapy and immediately before surgery. RESULTS: In all patients, the tumor volume decreased (mean 72 +/- 16%). In 25/33 patients, the slope of the contrast media enhancement curve decreased (mean 31 +/- 20%). In histopathologically proven downstaging after therapy, the decrease in slope was significantly higher than in the group without downstaging, and the decrease in slope was better for distinguishing between 'responder' and 'non-responder' than the decrease in volume. CONCLUSION: Using dMRI helps to identify responders undergoing cetuximab-based chemoradiation better than volume decrease alone.

Non-invasive measurement of hemodynamic response to postural stress using inert gas rebreathing.

In postural stress, an increased preload volume leads to higher stroke volume (SV) according to the Frank-Starling law of the heart. The present study aimed to evaluate the hemodynamic response to postural stress using non-invasive inert gas rebreathing (IGR) in patients with normal as well as impaired left ventricular function. Hemodynamic measurements were performed in 91 patients undergoing cardiac magnetic resonance imaging (CMR). Mean cardiac output and SV determined by IGR were 4.4±1.3 l/min and 60±19 ml in the upright position, which increased significantly to 5.0±1.2 l/min and 75±23 ml in the supine position (P<0.01). Left ventricular systolic function was normal [ejection fraction (EF) ≥55%] in 42 patients as determined by CMR. In 21 patients, EF was mildly abnormal (45-54%), in 16 patients moderately abnormal (30-44%) and in 12 patients severely abnormal (<30%). An overall trend for a lower percentage change in SV (%ΔSV) was indicated with increasing impairment of ejection fraction. In patients with abnormal EF in comparison to those with normal EF, the %ΔSV was significantly lower (13% vs. 22%; P=0.03). Non-invasive measurement of cardiac function using IGR during postural changes may be feasible and detected significant difference in %ΔSV in patients with normal and impaired EF according to the Frank-Starling law of the heart. Several clinical scenarios including cases of heart rhythm disturbances or pulmonary or congenital heart disease are worthy of further investigation.

Extraction of diethylhexylphthalate by home total parenteral nutrition from polyvinyl chloride infusion lines commonly used in the home.

OBJECTIVES: Recently, our group detected that polyvinyl chloride (PVC) perfusion lines leach large amounts of the toxic plasticizer diethylhexylphthalate (DEHP) under conditions typical of intensive care units. In the present study, we investigated the extraction of DEHP from PVC connecting tubes that are commonly used for total parenteral nutrition (TPN) solutions. The aim of the study was to estimate the amount of DEHP to which children receiving home TPN are exposed for months and years. MATERIALS AND METHODS: 1000 mL of TPN, identical in constitution and amount to the home TPN of 1 of our patients, were perfused through 5 different connecting tube systems and collected in hexane-rinsed glass bottles. The concentration of DEHP in the TPN was analyzed before and after perfusion. RESULTS: Before perfusion of the lines, the solution had a DEHP concentration of 0.05 to 0.69 microg/mL (baseline value). After perfusion of the lines, the load of DEHP in the solution varied between 1.41 and 2.07 microg/mL. This TPN was established for children weighing 20 kg. The daily dosage is between 71 and 104 microg x kg(-1) x day(-1). TPN is administered at home for many months and years. The monthly charge of DEHP is between 42.3 and 62.1 mg. Children weighing 20 kg therefore receive a dosage between 2.1 and 3.1 mg x kg(-1) x month(-1). CONCLUSIONS: Diethylhexylphthalate and its metabolite monoethylhexylphthalate have been demonstrated to be carcinogenic, embryotoxic, hepatotoxic, pneumotoxic, and cardiotoxic and are known to disrupt endocrine pathways and liver detoxifying capacity in animals. They are suspected of having multiple effects in humans as well. The doses presented above should therefore be avoided in children receiving home TPN by the use of tubing systems that are completely free of DEHP. Such systems are available.

Prospective study of interleukin-6 and the risk of malignant ventricular tachyarrhythmia in ICD-recipients--a pilot study.

OBJECTIVE: We investigated the relationship between interleukin-6 (IL-6) and the risk of experiencing spontaneous ventricular tachyarrhythmia (VT/VF) in patients with an implantable cardioverter-defibrillator (ICD). BACKGROUND: Cytokine levels predict outcome in patients with advanced heart failure and are elevated in patients with coronary artery disease (CAD). Regarding heart rhythm disturbances, proinflammatory activity could predict the occurrence of atrial fibrillation. There is no data on cytokine levels and the risk of spontaneous VT/VF. METHODS: IL-6 serum concentrations were determined at baseline and follow-up in 47 consecutive ICD-patients with CAD and idiopathic dilated cardiomyopathy (IDC). Data were prospectively correlated with VT/VF-incidence. RESULTS: Thirty-six patients (76.6%) suffered from CAD and 11 (23.4%) from IDC. Mean serum concentrations of IL-6 at baseline and at 9 months follow-up were 6.12+/-4.98 and 4.63+/-6.97. 88 spontaneous VT/VF-events occurred in 13/47 patients (27.7%). Patients with VT/VF had significantly higher IL-6 levels as compared to patients without VT/VF (8.96+/-5.97 vs. 5.04+/-4.16pg/ml at baseline (p =0.03), 7.8+/-4.88 vs. 3.42+/-6.32pg/ml at follow-up (p =0.01)). CONCLUSIONS: Elevated IL-6 serum concentrations were prospectively associated with an increased risk of spontaneous VT/VF-events in ICD-patients with CAD or IDC. These preliminary findings support a possible association of proinflammatory activity and an increased susceptibility to spontaneous VT/VF-events.