Back to the future: breast surgery with tumescent local anesthesia (TLA)?

PURPOSE: Breast surgery is usually performed under general anesthesia. Tumescent local anesthesia (TLA) offers the possibility to anesthetize large areas with highly diluted local anesthetic. METHODS: In this paper, the implementation, and experiences with TLA in the field of breast surgery are discussed. CONCLUSION: For carefully selected indications, breast surgery in TLA represents an alternative to ITN.

An initial psychometric evaluation of the German PROMIS v1.2 Physical Function item bank in patients with a wide range of health conditions.

OBJECTIVES: To translate the PROMIS Physical Function (PF) item bank version 1.2 into German and to investigate psychometric properties of resulting full bank and seven derived short forms. DESIGN: Cross-sectional psychometric study. SETTING: Inpatient and outpatient clinics of the Department of Psychosomatic Medicine at Charité-Universitätsmedizin Berlin, Germany. SUBJECTS: A total of 10 adult patients with various chronic diseases participated in cognitive debriefing interviews. The final item bank was administered to n = 266 adult patients with a broad range of medical conditions. INTERVENTIONS: Patient-reported outcome assessment as part of routine care. MAIN MEASURES: PROMIS v1.2 PF bank; MOS SF-36 PF scale (PF-10). RESULTS: Cross-cultural adaptation of the item bank followed established guidelines. For the final German translation, the corrected item-total correlations ranged from 0.44 to 0.84. Cronbach's alpha was high for each PROMIS PF short form ( α = 0.88-0.96). The full PROMIS PF bank and most short forms correlated highly with the SF-36 PF-10 ( r = 0.85-0.90), with the exception of PROMIS Upper Extremity ( r = 0.64). PROMIS Upper Extremity showed ceiling effects and lower agreement with the full bank than other short forms. Unidimensionality was supported for all PROMIS PF measures using traditional factor analysis and nonparametric item response theory. CONCLUSION: The German PROMIS PF bank was found to be conceptually equivalent to the English version and fulfilled the psychometric requirements for use of short forms in clinical practice. Future studies should pay particular attention to samples with upper extremity functional limitations to further investigate the dimensional structure of PF as conceptualized according to PROMIS.

Course of self-reported symptoms of 342 outpatients receiving medium- versus long-term psychodynamic psychotherapy.

BACKGROUND: The course of self-reported symptoms during medium- versus long-term psychodynamic psychotherapy has rarely been documented for outpatient settings. This observational study describes routine practice of ambulatory treatment in Germany and explores self-reported symptoms of a broad patient sample undergoing one (medium-term) versus two years (long-term) of psychodynamic psychotherapy. METHODS: Over four and a half years, longitudinal self-report symptom data were collected from 342 outpatients as part of a standardized documentation system. Self-report data were compared between patients receiving either medium-term or long-term psychodynamic psychotherapy. RESULTS: Routine care significantly decreased disease burden as reported by patients by small to medium effect sizes (ES) for depression (ES = 0.58), anxiety (ES = 0.49), obsessive-compulsive disorder (ES = 0.54), somatoform disorder (ES = 0.32), eating disorder (ES = 0.38). The majority of patients completed treatment after one year and showed medium-size changes. For a subgroup of patients with depressive and/or obsessive-compulsive disorder symptoms for whom two years of therapy were deemed necessary, additional benefits were reported during the second year of treatment (ES = 0.61 and ES 0.47, respectively). CONCLUSIONS: Our findings suggest that both medium- and long-term psychodynamic psychotherapy decrease self-reported disease burden of patients with depression, anxiety, obsessive-compulsive, somatoform and/or eating disorders. For a subgroup of patients, additional benefits were gained in the second year of treatment.

On the validity of measuring change over time in routine clinical assessment: a close examination of item-level response shifts in psychosomatic inpatients.

OBJECTIVE: Significant life events such as severe health status changes or intensive medical treatment often trigger response shifts in individuals that may hamper the comparison of measurements over time. Drawing from the Oort model, this study aims at detecting response shift at the item level in psychosomatic inpatients and evaluating its impact on the validity of comparing repeated measurements. STUDY DESIGN AND SETTING: Complete pretest and posttest data were available from 1188 patients who had filled out the ICD-10 Symptom Rating (ISR) scale at admission and discharge, on average 24 days after intake. Reconceptualization, reprioritization, and recalibration response shifts were explored applying tests of measurement invariance. In the item-level approach, all model parameters were constrained to be equal between pretest and posttest. If non-invariance was detected, these were linked to the different types of response shift. RESULTS: When constraining across-occasion model parameters, model fit worsened as indicated by a significant Satorra-Bentler Chi-square difference test suggesting potential presence of response shifts. A close examination revealed presence of two types of response shift, i.e., (non)uniform recalibration and both higher- and lower-level reconceptualization response shifts leading to four model adjustments. CONCLUSIONS: Our analyses suggest that psychosomatic inpatients experienced some response shifts during their hospital stay. According to the hierarchy of measurement invariance, however, only one of the detected non-invariances is critical for unbiased mean comparisons over time, which did not have a substantial impact on estimating change. Hence, the use of the ISR can be recommended for outcomes assessment in clinical routine, as change score estimates do not seem hampered by response shift effects.

Timing and climate forcing of volcanic eruptions for the past 2,500 years.

Volcanic eruptions contribute to climate variability, but quantifying these contributions has been limited by inconsistencies in the timing of atmospheric volcanic aerosol loading determined from ice cores and subsequent cooling from climate proxies such as tree rings. Here we resolve these inconsistencies and show that large eruptions in the tropics and high latitudes were primary drivers of interannual-to-decadal temperature variability in the Northern Hemisphere during the past 2,500 years. Our results are based on new records of atmospheric aerosol loading developed from high-resolution, multi-parameter measurements from an array of Greenland and Antarctic ice cores as well as distinctive age markers to constrain chronologies. Overall, cooling was proportional to the magnitude of volcanic forcing and persisted for up to ten years after some of the largest eruptive episodes. Our revised timescale more firmly implicates volcanic eruptions as catalysts in the major sixth-century pandemics, famines, and socioeconomic disruptions in Eurasia and Mesoamerica while allowing multi-millennium quantification of climate response to volcanic forcing.

Mindful walking in psychologically distressed individuals: a randomized controlled trial.

Background. The aim of this randomized, controlled study was to investigate the effectiveness of a mindful walking program in patients with high levels of perceived psychological distress. Methods. Participants aged between 18 and 65 years with moderate to high levels of perceived psychological distress were randomized to 8 sessions of mindful walking in 4 weeks (each 40 minutes walking, 10 minutes mindful walking, 10 minutes discussion) or to no study intervention (waiting group). Primary outcome parameter was the difference to baseline on Cohen's Perceived Stress Scale (CPSS) after 4 weeks between intervention and control. Results. Seventy-four participants were randomized in the study; 36 (32 female, 52.3 ± 8.6 years) were allocated to the intervention and 38 (35 female, 49.5 ± 8.8 years) to the control group. Adjusted CPSS differences after 4 weeks were -8.8 [95% CI: -10.8; -6.8] (mean 24.2 [22.2; 26.2]) in the intervention group and -1.0 [-2.9; 0.9] (mean 32.0 [30.1; 33.9]) in the control group, resulting in a highly significant group difference (P < 0.001). Conclusion. Patients participating in a mindful walking program showed reduced psychological stress symptoms and improved quality of life compared to no study intervention. Further studies should include an active treatment group and a long-term follow-up.

[Outpatient rehabilitation after myocardial infarction or for heart failure]. / Ambulante Rehabilitation nach Herzinfarkt und bei Herzinsuffizienz.

Reducing cardiac mortality and improving quality of life are the main objectives of cardiac rehabilitation. In recent years, outpatient rehabilitation within easy patient reach has achieved the same status as inpatient rehabilitation. Outpatient rehabilitation permits close involvement of the patient's family and social environment, thus easing reintegration into everyday life. However, the health care system is not yet utilizing outpatient rehabilitation to its full potential. This contribution illustrates the principles of rehabilitation following myocardial infarction or for heart failure in an outpatient setting, as well as its potential and future development.

Key issues in clinical and epidemiological research in complementary and alternative medicine--a systematic literature review.

BACKGROUND: In the last 2 decades there has been a large increase in publications on complementary and alternative medicine (CAM). However, CAM research methodology was heterogeneous and often of low quality. The aim of this systematic review was to investigate scientific publications with regards to general issues, concepts and strategies. We also looked at research priorities and methods employed to evaluate the clinical and epidemiological research of CAM in the past to identify the basis for consensus-based research strategies. METHODS: We performed a systematic literature search for papers published between 1990 and 2010 in 7 electronic databases (Medline, Web of Science, PsychArticles, PsycInfo, CINAHL, EMBASE and Cochrane Library) on December 16 and 17, 2010. In addition, experts were asked to nominate relevant papers. Inclusion criteria were publications dealing with research methodology, priorities or complexities in the scientific evaluation of CAM. All references were assessed in a multistage process to identify relevant papers. RESULTS: From the 3,279 references derived from the search and 98 references contributed by CAM experts, 170 papers fulfilled the criteria and were included in the analysis. The following key issues were identified: difficulties in past CAM research (e.g., randomisation, blinding), utility of quantitative and qualitative research methods in CAM, priority setting in CAM research and specific issues regarding various CAM modalities. CONCLUSIONS: Most authors vote for the use of commonly accepted research methods to evaluate CAM. There was broad consensus that a mixed methods approach is the most suitable for gathering conclusive knowledge about CAM.

[Hereditary hemochromatosis, alpha-1-antitrypsin deficiency and Wilson's disease. Pathogenesis, clinical findings and pathways to diagnosis]. / Hereditäre Hämochromatose, Alpha-1-Antitrypsin-Mangel und Morbus Wilson: Pathogenese, Klinik und Wege zur Diagnose.

Primary hemochromatosis, alpha-1-antitrypsin (AAT) deficiency, and Wilson's disease are the most common hereditary causes of unclear hepatopathy. Classical primary hemochromatosis (type I) on the basis of a homozygous mutation of the HFE gene, usually presents in adults with increasing hepatocellular siderosis and chronic progressive necroinflammatory liver disease. Homozygous AAT deficiency type PiZZ becomes manifest in newborns as a giant cell hepatitis or findings similar to bile duct atresia, in adults as chronic hepatitis or "cryptogenic cirrhosis". The heterozygous PiZ mutation can lead to PAS-positive hepatocellular AAT deposits increasing over the life time. Immunohistochemical detection of AAT deposits by specific PiZ antibodies is a highly sensitive and specific supplementary method. Molecular analysis of AAT and HFE genes in paraffin-embedded tissue or blood can confirm the diagnosis and allows the zygosity status to be defined. Wilson's disease has to be considered in children and young adults with unexplained histologic findings of chronic hepatitis or steatohepatitis. Rhodanin staining is the most effective histochemical method to detect free copper deposits, but negative staining results do not exclude Wilson's disease. In cases suspected of Wilson's disease further clinical exploration must be initiated. The diagnosis is based on a combination of clinical and biochemical findings, which can be supplemented by mutation analysis of the ATP7B gene.

Crack healing in alumina bioceramics.

OBJECTIVES: Microscopic cracks can occur at the surface of oxide ceramic restorations as a result of the manufacturing process and mainly due to the final mechanical preparation in the dental laboratory. A method is presented to heal up such microscopic cracks by a glass infiltration process. METHODS: Bar specimens made of high purity bio-alumina were manufactured. On two batches of specimens microscopic cracks were induced using the Vickers indentation technique. The small microscopic cracks at the tip of the resulting half-penny-shape cracks were extended by the bridge loading method. The indentation pattern of the specimens of one batch was subsequently glass-infiltrated. The surface layers of the specimens with the Vickers indentation were removed by grinding as far as only the extended microscopic cracks (with and without glass) remained at the surface. The strengths of untreated, micro-damaged, and micro-damaged and glass-infiltrated specimens were determined. The microstructure of the fracture surfaces was analyzed using SEM. RESULTS: The characteristic strength of the specimens decreased from sigma(0)=378 to 196 MPa and the Weibull modulus from m=13.7 to 2.3 due to the micro-damaging. The strength and the scatter-in-strength were significantly improved by the glass infiltration process. The strength of the "healed" specimens (sigma(0)=434 MPa, m=17.3) was even better than that of the untreated samples. SIGNIFICANCE: Microscopic cracks that can occur at the surface of dental restorations made of alumina like abutments or cores of crowns and bridges during the manufacturing and preparation process could reliably be healed by a glass infiltration process.

[Drug- and toxin-induced hepatotoxicity]. / Medikamenten- und fremdstoffbedingte Hepatotoxizität.

The liver is essential for metabolism of drugs and exogenous toxins. Therefore, liver toxicity due to natural, domestic and industrial toxins or drugs is common but rarely recognised. Although thorough epidemiological data are missing, the number of cases with drug-induced liver toxicity is increasing, parallel to the growing number of drugs. Adverse hepatic reactions may present as acute or chronic liver damage. Independent from the cause and mechanism of liver damage, the clinical presentation may be either cytolytic or cholestatic. In addition, liver damage may be accompanied by a systemic hypersensitivity reaction against the applied agent. Drug- or toxin-induced liver damage includes vascular damage, induction of liver tumours and development of liver cirrhosis. The prerequisite for specialised treatment of drug-induced adverse hepatic reactions is establishing the diagnosis which is obtained by a thorough medical history taken by an experienced physician with a special emphasis on drug or toxin exposure. The diagnosis may be confirmed by additional diagnostic measures (e. g. liver biopsy) or the clinical course after exposure to the causing agent has been stopped. Only in a minority of cases a definite treatment may be available. Therefore, the main aim is to prevent chronic liver damage through early and correct diagnosis. Due to the extensive variety of possibly liver toxic drugs and chemical agents this aspect is a major challenge to physicians.

Lifetime prediction of all-ceramic bridges by computational methods.

There has been limited use of ceramic materials for all-ceramic posterior bridges. Major reasons are the low strength, the strength scatter, and the time-dependent strength decrease of ceramics due to slow crack growth. The objective of this study was to predict the long-term failure probability and loading capability of all-ceramic bridges (Empress 1, Empress 2, In-Ceram Alumina, and ZrO(2)) by computational techniques. The lifetimes of different bridge model designs were predicted by means of the NASA post-processor CARES. Bridges made of zirconia showed a very high mechanical long-term reliability. Empress I and InCeram Alumina seem to be insufficient as posterior bridge materials based on this prediction. The lifetime of the all-ceramic bridges can be significantly increased by improving the design in the connector area. We conclude that computational techniques can help to judge a ceramic material and a specific ceramic bridge design with respect to mechanical reliability before clinical use.

R-curve behavior of dental ceramic materials.

Some technical ceramics exhibit the R-curve effect, i.e., an increasing fracture resistance with crack extension which is a desirable material property because more energy is necessary to propagate a microscopic crack. The objective of this study was to prove whether dental ceramic materials exhibit R-curve behavior. Nine dental ceramics were examined by the indentation-strength method. It was found that all of the tested ceramic materials exhibit a rising R-curve with crack extension. The R-curve behavior was more pronounced for the high-strength materials In-Ceram Alumina, monolithic alumina, and especially Empress 2. We conclude from our results that the mechanical behavior of a dental ceramic material can be judged more comprehensively, if the R-curve of the respective material is known.

Nondestructive estimation of the strength of dental ceramic materials.

OBJECTIVES: The aim of this study was to prove a nondestructive method to evaluate the strength of dental ceramic materials with respect to its potentiality and limitations. METHODS: The Young's moduli of 13 dental ceramic materials were determined by the resonance frequency method. Additionally, the flexural strengths of eight of these materials were evaluated by the four-point bending test. Strength values for the other five ceramic materials were taken from the literature. The Young's moduli were correlated with the strength values by Hook's law, respectively. RESULTS: Young's modulus for ceramics can be determined using a resonance frequency method. Fracture strain values of the ceramic materials tested (with the exception of Empress 2) have fracture strain values between 0.08 and 0.15%. A mean strain can be calculated (0.11%) and used with the value of Young's modulus to estimate fracture strength of ceramics. For the materials evaluated, predicted strength was within 39% of the measured values. SIGNIFICANCE: A non-destructive method to estimate strength of dental ceramic materials is possible, even though the accuracy of the predicted values is not very high. Nevertheless, the method permits new materials proposed for dental ceramic restorations to be screened for probable clinical success. Expensive and time-consuming testing would only need to be done on those materials which pass this initial criterion.

Neutral endopeptidase and alcohol consumption, experiments in neutral endopeptidase-deficient mice.

Alcohol consumption was investigated in mice which were rendered deficient in the peptide-degrading enzyme neutral endopeptidase (EC 3.4.24.11) (NEP-/-) by gene targeting and compared to alcohol consumption in corresponding wild type mice (NEP+/+). Mice were offered a free choice to drink tap water or 10% alcohol. The NEP-/- mice consumed significantly more alcohol ( approximately 42%) than the NEP+/+ mice, whereas no significant differences were observed in the total fluid consumption. The daily food consumption of alcohol naive NEP-/- animals was elevated ( approximately 29%). Furthermore, the activities of peptidases closely related to neutral endopeptidase were analysed ex vivo in several brain regions from NEP-/- and NEP+/+ mice not treated with alcohol. There was no obvious compensation for the total loss of neutral endopeptidase by the functionally related peptidases angiotensin-converting enzyme and aminopeptidase N. In vitro, the degradation of exogenously applied [Leu(5)]enkephalin was not reduced in membrane preparations of those brain regions assayed in NEP-/- mice. A small reduction in [Leu(5)]enkephalin degradation was detected in striatal membrane preparations of NEP-/- mice, if aminopeptidase N was additionally blocked by bestatin or amastatin.

Phenotype and functions of brain dendritic cells emerging during chronic infection of mice with Toxoplasma gondii.

During chronic infection of mice with Toxoplasma gondii, gene message for IL-12p40, CD86, and the potassium channel Kv1.3 was detected in brain mononuclear cells, suggesting the presence of dendritic cells (DC) in the CNS. Consistently, cells bearing the DC markers CD11c and 33D1 were localized at inflammatory sites in the infected brain. The number of isolated CD11c+ brain cells increased until peak inflammation. The cells exhibited the surface phenotype of myeloid DC by coexpressing 33D1 and F4/80, little DEC-205, and no CD8alpha. These brain DC were mature, as indicated by high-level expression of MHC class II, CD40, CD54, CD80, and CD86. They triggered Ag-specific and primary allogeneic T cell responses at very low APC/T cell ratios. Among mononuclear cells from encephalitic brain, DC were the main producers of IL-12. Evidence for a parasite-dependent development of DC from CNS progenitors was obtained in vitro: after inoculation of primary brain cell culture with T. gondii, IL-12-secreting dendriform cells emerged, and DC marker genes were expressed. Different stimuli elicited the generation and maturation of brain DC: neutralization of parasite-induced GM-CSF prevented outgrowth of dendriform cells and concomitant release of IL-12. IL-12 production was up-regulated by external IFN-gamma but was stopped by inhibiting parasite replication. Consistently, DC isolated from GM-CSF-treated brain cell culture were activated to secrete IL-12 by exposure to parasite lysate. In sum, these results demonstrate T. gondii-induced expansion and functional maturation of DC in the CNS and, thus, highlight a mechanism that may contribute to the chronicity of the host response.

Three new NifA-regulated genes in the Bradyrhizobium japonicum symbiotic gene region discovered by competitive DNA-RNA hybridization.

The so-called symbiotic region of the Bradyrhizobium japonicum chromosome (C. Kündig, H. Hennecke, and M. Göttfert, J. Bacteriol. 175:613-622, 1993) was screened for the presence of genes controlled by the nitrogen fixation regulatory protein NifA. Southern blots of restriction enzyme-digested cosmids that represent an ordered, overlapping library of the symbiotic region were competitively hybridized with in vitro-labeled RNA from anaerobically grown wild-type cells and an excess of RNA isolated either from anaerobically grown nifA and rpoN mutant cells or from aerobically grown wild-type cells. In addition to the previously characterized nif and fix gene clusters, we identified three new NifA-regulated genes that were named nrgA, nrgB, and nrgC (nrg stands for NifA-regulated gene). The latter two probably form an operon, nrgBC. The proteins encoded by nrgC and nrgA exhibited amino acid sequence similarity to bacterial hydroxylases and N-acetyltransferases, respectively. The product of nrgB showed no significant similarity to any protein with a database entry. Primer extension experiments and expression studies with translational lacZ fusions revealed the presence of a functional -24/-12-type promoter upstream of nrgA and nrgBC and proved the NifA- and RpoN (sigma(54))-dependent transcription of the respective genes. Null mutations introduced into nrgA and nrgBC resulted in mutant strains that exhibited wild-type-like symbiotic properties, including nitrogen fixation, when tested on soybean, cowpea, or mung bean host plants. Thus, the discovery of nrgA and nrgBC further emphasizes the previously suggested role of NifA as an activator of anaerobically induced genes other than the classical nitrogen fixation genes.

[Coronary angiography and change in antioxidative status]. / Koronarangiographie und Veränderung des antioxidativen Status.

PATIENTS AND METHODS: In a prospective study in 53 patients with stable angina pectoris symptoms the antioxidant status (glutathione peroxidase, glutathione, superoxid dismutase, malondialdehyde and selenium in serum and whole blood) was determined before and 4 to 6 hours after coronary angiography. According to the results of the coronary angiography the patients were classified in a group with "severe" (n = 16) and another with "moderate" coronary alterations. RESULTS: In both groups there was a significant reduction of selenium in serum and whole blood. The enzymes glutathione peroxidase and superoxide dismutase as well as glutathione and malondialdehyde changed only slightly. CONCLUSION: These results can be the cause of an increase of the formation of free radicals during coronary reperfusion (PTCA, implantation of stents in the group with "severe" coronary alterations) but could also be seen as a sign of formation of radicals by the method itself (in patients with "moderate" coronary alterations). Further investigations are indicated. Furthermore the amelioration of the antioxidant status of the organism by scavenger substances (vitamins A, B, C and selenium) should be discussed.

Interferon/antioxidant combination therapy for chronic hepatitis C--a controlled pilot trial.

The effects of two forms of antioxidative co-therapy were analyzed in 24 interferon-alpha (IFN)-naive patients with chronic hepatitis C who were randomized to either receive IFN monotherapy (3 x 4.5 million units IFN-alpha 2a per week), (group A), or IFN and N-acetylcysteine (N-acetylcysteine (NAC) 1.800 mg/day) plus sodium selenite (400 microg/day) supplementation (group B), or treatment as in group B plus vitamin E (544 IU/day) (group C), over 24 weeks. Changes in histology, normalization of ALT, reduction of viral RNA, serum levels of glutathione, selenium, vitamin E, erythrocyte glutathione peroxidase, trolox equivalent antioxidative capacity (TEAC), thiobarbituric acid reactive substances (TBARS) and protein carbonyl groups were measured. Low baseline TEAC and elevated TBARS indicated increased oxidative stress before therapy, which was not affected by antioxidant supplementation. At the end of treatment complete responses were found in 3/8, 2/8 and 6/8 patients in groups A, B and C, respectively, but liver histology had not significantly improved. Vitamin E treated patients had a 2.4 greater chance (95% CI: 1.05-5.5) of obtaining a complete response and had significantly greater reduction in viral load (P = 0.028) than patients without vitamin E. Relapses, i.e. re-appearance of detectable hepatitis C virus (HCV) RNA and/or re-elevation of ALT-activity occurred in 7 out of the 11 responders within 6 months after termination of therapy (group A: 2/3, group B: 1/2 and group C: 4/6). Thus, no overall beneficial effect of antioxidant/IFN therapy was detected. However, the apparent trend towards a more favorable outcome with vitamin E supplementation warrants to further study this substance as an adjuvant to IFN therapy in chronic hepatitis C.