RESUMEN
BACKGROUND: There is no universally accepted treatment standard for idiopathic toe walking patients (ITW) in the current literature. None of the established methods provide homogenous satisfying results. In our department we treat ITW patients with lower leg orthoses with a circular foot unit for a total of 16 weeks. In this study we reviewed our database to evaluate the success of our treatment protocol for a 24 months follow up period. RESULTS: Twenty-two patients were included in this study. Age at the beginning of treatment was 7.0 years +/- 2.9 (range 2.5-13.1). Percentage of ITW at the beginning of treatment according to the perception of the parents was 89% +/- 22.2 (range 50-100). Immediately after the treatment with our device, percentage of ITW dropped to 11% +/- 13.2 (range 0-50). After 12 months, 73% of the patients (16/22) walked completely normal or showed ITW less than 10% of the day. After 24 months, 64% of the patients kept a normal gait (14/22). CONCLUSION: This study provides evidence that the treatment of idiopathic toe walking with lower leg orthoses with a circular foot unit results in satisfying long-term results in two thirds of the patients.
Asunto(s)
Pierna , Caminata , Adolescente , Niño , Preescolar , Marcha , Humanos , Aparatos Ortopédicos , Dedos del PieRESUMEN
PURPOSE: The purpose of this study was to utilize data from the German Cartilage Registry (KnorpelRegister DGOU) to examine the hypothesis that degenerative cartilage defects of the patellofemoral joint are associated with more severe clinical symptoms compared to trauma-related defects. METHODS: All patients with isolated focal cartilage defects of the patellofemoral joint registered in the German Cartilage Registry until May 2017 were included in the study. Patients with previous surgery of the ipsilateral knee were excluded. Baseline data including etiology (traumatic, degenerative), size, location and ICRS grade of the cartilage defects as well as the duration of symptoms were analyzed. Clinical symptoms were evaluated by means of the numeric analog scale (NAS) for pain and the Knee injury and Osteoarthritis Outcome Score (KOOS). Group comparisons were performed using the Mann-Whitney-U test along with the Chi-squared test and Fisher's exact test. A bivariate correlation analysis and a multivariable linear regression analysis were performed to investigate the association between the defect characteristics and the clinical scores. RESULTS: A total of 423 patients (203 traumatic and 220 degenerative defects) were included. Isolated degenerative cartilage defects were found to have significantly more trochlear locations (28% vs. 18%; p = 0.006), significantly less ICRS grade 4 lesions (50% vs. 73%; p = 0.002) and a significantly smaller defect size [median 300 (IQR 105-400) vs. 300 (200-400) mm2] when compared to those from traumatic etiology. Traumatic defects showed significantly better KOOS-ADL [77 (60-90) vs. 69 (56-82); p = 0.005], KOOS-pain [69 (56-81) vs. 61 (47-75); p = 0.001] and NAS [2 (1-5) vs. 4 (1-6); p = 0.005] scores compared to degenerative defects. The correlation analysis revealed only weak correlations between the quantitative defect characteristics and clinical scores. CONCLUSIONS: Degenerative isolated cartilage defects in the patellofemoral joint are associated with more severe clinical symptoms in comparison to trauma-related defects. Additionally, they show a larger variance regarding their location with more trochlear defects. LEVEL OF EVIDENCE: III.
Asunto(s)
Enfermedades de los Cartílagos/epidemiología , Traumatismos de la Rodilla/epidemiología , Articulación Patelofemoral/patología , Sistema de Registros/estadística & datos numéricos , Adulto , Enfermedades de los Cartílagos/patología , Enfermedades de los Cartílagos/cirugía , Cartílago Articular , Femenino , Alemania , Humanos , Traumatismos de la Rodilla/patología , Traumatismos de la Rodilla/cirugía , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Adulto JovenRESUMEN
Background: Perioperative chemotherapy is an established treatment of advanced gastric cancer patients. Treatment selection is based on clinical staging (cT). We aimed to establish and validate a prognostic score including clinical and molecular factors, to optimize treatment decisions for these patients. Patients and methods: We analyzed 626 carcinomas of the stomach and of the gastro-esophageal junction from two academic centers including primarily resected and pre-/perioperatively treated patients. Patients were divided into a training (N = 269) and validation (N = 357) set. Expression of 11 target genes was measured by quantitative PCR in resected tumors. A risk score to predict overall survival (OS) was generated and validated. Intra-tumoral heterogeneity was assessed by analyzing 50 tumor areas from 10 patients. Results: A risk score including the expression of CCL5, CTNNB1, EXOSC3 and LZTR1 and the clinical parameters cT, tumor localization and histopathologic type suggested two groups with a significant difference in OS [hazard ratio (HR) 0.30; 95% confidence interval (CI) 0.17-0.52]. The risk score was successfully validated in an independent cohort (HR 0.32; 95% CI 0.21-0.51; P < 0.001) as well as in subgroups of primarily resected (HR 0.30; 95% CI 0.17-0.54; P < 0.001) and pre-/perioperatively treated patients (HR 0.37; 95% CI 0.17-0.81; P = 0.009). A significant difference in OS of high- and low-risk patients was also found in primarily resected patients with intestinal (HR 0.45; 95% CI 0.23-0.90; P = 0.020) and nonintestinal-type carcinomas (HR 0.1; 95% CI 0.02-0.42; P < 0.001). Intra-tumor heterogeneity analysis indicated a classification reliability of 95% for a supposed analysis of three biopsies. Conclusion: The identified risk score could substantially contribute to an improved management of gastric cancer patients in the context of perioperative chemotherapy.
Asunto(s)
Neoplasias Gástricas/genética , Neoplasias Gástricas/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Perfilación de la Expresión Génica , Predisposición Genética a la Enfermedad , Humanos , Pronóstico , Neoplasias Gástricas/tratamiento farmacológico , Neoplasias Gástricas/cirugíaRESUMEN
BACKGROUND: In the Ponseti treatment of idiopathic clubfoot, children are generally provided with a standard foot abduction orthosis (FAO). A significant proportion of these patients experience irresolvable problems with the FAO leading to therapeutic non-compliance and eventual relapse. Accordingly, these patients were equipped with a unilateral lower leg orthosis (LLO) developed in our institution. The goal of this retrospective study was to determine compliance with and the efficacy of the LLO as an alternative treatment measure. The minimum follow-up was 5 years. RESULTS: A total of 45 patients (75 ft) were retrospectively registered and included in the study. Compliance with the bracing protocol was 91% with the LLO and 46% with the FAO. The most common problems with the FAO were sleep disturbance (50%) and cutaneous problems (45%). Nine percent of patients experienced sleep disturbance, and no cutaneous problems occurred with the LLO. Thirteen percent of patients being treated with an FAO until the age of four (23 patients; 40 ft) underwent surgery because of relapse, defined by rigid recurrence of any of the components of a clubfoot. Fourteen percent of patients being treated with an LLO (22 patients; 35 ft), mostly following initial treatment with an FAO, experienced recurrence. CONCLUSION: Changing from FAO to LLO at any point during treatment did not result in an increased rate of surgery and caused few problems.
Asunto(s)
Tirantes/tendencias , Pie Equinovaro/diagnóstico por imagen , Pie Equinovaro/terapia , Ortesis del Pié/tendencias , Hospitales Pediátricos/tendencias , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Cooperación del Paciente , Proyectos Piloto , Factores de Tiempo , Resultado del TratamientoRESUMEN
Pathogenic microbes may colonize the female genital tract via sexual transmission and cause health issues like inflammation or malignancy, summarized as sexually transmitted disease (STD). A major representative of such pathogens is Trichomonas vaginalis (T.v.), whose role in the etiology of cervical cancer remains elusive. Traditional morphologic screening of cervical smears is able to detect T.v., although its identification may be complicated by look-alikes such as degenerated granulocytes and basal cells. In addition, the parasite's endosymbiont Mycoplasma hominis (M.h.) cannot be detected in the Pap test. This investigation was aimed at designing a PCR-based method to detect specific pathogenic germs by using cervical cytology slides to overcome morphologic uncertainty and increase diagnostic accuracy. To test our molecular screening method on T.v., M.h., and HPV in archival smears, we elaborated a multiplex PCR approach based on microdissection. This assay was applied to a minute quantity of starting material which harbored or was suspected to harbor T.v.; the resulting isolated DNA was used for subsequent molecular analyses of T.v., M.h., and HPV. We clarified the diagnosis of genital T.v. infection in 88 and 1.8% of morphologically suspicious and T.v.-negative cases, respectively. We also revealed a tendency of M.h. co-infection in high-risk HPV cases. In conclusion, a microdissection-based approach to detect pathogenic microbes such as T.v., HPV, and M.h. is a molecular tool easy to implement and may help to better understand the interactivity of these germs with respect to pathogenesis.
Asunto(s)
Infecciones por Mycoplasma/diagnóstico , Mycoplasma hominis/genética , Papillomaviridae/genética , Infecciones por Papillomavirus/diagnóstico , Vaginitis por Trichomonas/diagnóstico , Trichomonas vaginalis/genética , Adolescente , Adulto , Coinfección , ADN Bacteriano/análisis , ADN Protozoario/análisis , ADN Viral/análisis , Femenino , Humanos , Reacción en Cadena de la Polimerasa Multiplex/métodos , Infecciones por Mycoplasma/microbiología , Mycoplasma hominis/aislamiento & purificación , Prueba de Papanicolaou/métodos , Papillomaviridae/aislamiento & purificación , Infecciones por Papillomavirus/virología , Vaginitis por Trichomonas/parasitología , Trichomonas vaginalis/aislamiento & purificación , Neoplasias del Cuello Uterino/etiología , Frotis Vaginal/métodosRESUMEN
BACKGROUND: Excessive workload may impact the anaesthetists' ability to adequately process information during clinical practice in the operation room and may result in inaccurate situational awareness and performance. This exploratory study investigated heart rate (HR), linear and non-linear heart rate variability (HRV) metrics and subjective ratings scales for the assessment of workload associated with the anaesthesia stages induction, maintenance and emergence. METHODS: HR and HRV metrics were calculated based on five min segments from each of the three anaesthesia stages. The area under the receiver operating characteristics curve (AUC) of the investigated metrics was calculated to assess their ability to discriminate between the stages of anaesthesia. Additionally, a multiparametric approach based on logistic regression models was performed to further evaluate whether linear or non-linear heart rate metrics are suitable for the assessment of workload. RESULTS: Mean HR and several linear and non-linear HRV metrics including subjective workload ratings differed significantly between stages of anaesthesia. Permutation Entropy (PeEn, AUC=0.828) and mean HR (AUC=0.826) discriminated best between the anaesthesia stages induction and maintenance. In the multiparametric approach using logistic regression models, the model based on non-linear heart rate metrics provided a higher AUC compared with the models based on linear metrics. CONCLUSIONS: In this exploratory study based on short ECG segment analysis, PeEn and HR seem to be promising to separate workload levels between different stages of anaesthesia. The multiparametric analysis of the regression models favours non-linear heart rate metrics over linear metrics.
Asunto(s)
Anestesia General , Anestesistas/estadística & datos numéricos , Frecuencia Cardíaca/fisiología , Carga de Trabajo/estadística & datos numéricos , Adulto , Competencia Clínica , Femenino , Humanos , Masculino , Quirófanos , Personal de Hospital/estadística & datos numéricos , Estudios ProspectivosRESUMEN
BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a treatment strategy for patients with severe aortic stenosis. Although general anaesthesia (TAVI-GA) and sedation (TAVI-S) have previously been described for TAVI, the difference in safety and efficacy of both methods has not been studied in a randomized trial. METHODS: The INSERT trial was a single centre, controlled parallel-group trial with balanced randomization. Sixty-six patients (68-94 yr) with acquired aortic stenosis undergoing transfemoral CoreValve™ were assigned to TAVI-GA or TAVI-S. Comparable operative risk was determined from risk-scores (EUROscore, STS-Score). Monitoring and anaesthetic drugs were standardized. Near-Infrared-Spectroscopy was used to monitor cerebral-oxymetry blinded. Primary outcome was the perioperative cumulative cerebral desaturation. As secondary outcomes, changes in neurocognitive function and respiratory and haemodynamic adverse events were evaluated. RESULTS: Of 66 included patients, 62 (TAVI-GA: n=31, TAVI-S: n=31) were finally analysed. Baseline characteristics were comparable. In 24 patients (39%) cerebral desaturation was observed. Cumulative cerebral desaturation was comparable (TAVI-GA:(median [IQR]) (0[0/1308] s%) vs. TAVI-S:(0[0/276] s%); P=0.505) between the groups. Neurocognitive function did not change within and between groups. Adverse events were more frequently observed in TAVI-S patients (P<0.001). Bradypnoea (n=16, 52%) and the need for airway manoeuvres (n=11, 36%) or bag-mask-ventilation (n=6, 19%) were the most common respiratory adverse events. CONCLUSIONS: Cerebral desaturation occurred in both patient groups, but there was no significant difference between the two groups. Based on primary outcome, both methods were shown to be comparable. Neurocognitive outcome was similar. The higher incidence of adverse events in the sedation group suggests a potential advantage of general anaesthesia. CLINICAL TRIAL REGISTRATION: NCT 01251328.
Asunto(s)
Anestesia General/efectos adversos , Encéfalo/efectos de los fármacos , Trastornos del Conocimiento/inducido químicamente , Sedación Profunda/efectos adversos , Oxígeno/sangre , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Válvula Aórtica/cirugía , Encéfalo/fisiopatología , Femenino , Humanos , Masculino , Pruebas Neuropsicológicas/estadística & datos numéricos , Oximetría/estadística & datos numéricos , Factores de Riesgo , Espectrofotometría Infrarroja , Resultado del TratamientoRESUMEN
PURPOSE: To establish normal values of the optic nerve sheath diameter (ONSD) in children and adolescents for transbulbar sonography and magnetic resonance imaging. MATERIALS AND METHODS: In 99 children and adolescents (age: 5.6 - 18.6 years, mean: 12 years) without neurologic or ophthalmologic disease, measurements of the ONSD with transbulbar sonography were performed. For comparison 59 children and adolescents (age: 5.1 - 17.4 years, mean 12.3 years) with a normal MR examination of the brain had measurements of the ONSD on a T2-weighted thin section sequence of the orbit. Besides establishing modality-related normal values, age dependency, accuracy and reproducibility of measurements were assessed. RESULTS: Overall the mean ONSD was 5.75 ± 0.52 mm for transbulbar sonography and 5.69 ± 0.31 mm for MRI. There was no statistical significance between the 95 % percentiles and age for both transbulbar sonography (p = 0.332) and MRI (p = 0.336). As a parameter for the reproducibility of measurements, the repeatability coefficient (RC) was between 0.34 mm and 0.46 mm. The concordance correlation coefficient (CCC) values revealed a high agreement between readers both for transbulbar sonography (0.868) and MRI (0.796). CONCLUSION: Normal values for ONSD in children and adolescents found in this study are significantly higher than assumed. The values found for transbulbar sonography are confirmed by comparable results for MR measurements. A precise sonographic measurement technique and the consideration of normal values found hereby are essential for correct interpretation of ONSD measurements in children and adolescents.
Asunto(s)
Imagen por Resonancia Magnética/métodos , Vaina de Mielina , Nervio Óptico/anatomía & histología , Ultrasonografía/métodos , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , Órbita/anatomía & histología , Valores de Referencia , Sensibilidad y EspecificidadRESUMEN
Due to their well-established fracture risk reduction, bisphosphonates are the most frequently used therapeutic agent to treat osteoporosis. Bisphosphonates reduce fracture risk by suppressing bone resorption, but the lower bone turnover could have a negative impact on bone quality at the tissue level. Here, we directly assess the structural and mechanical characteristics of cancellous bone from the lumbar vertebrae (L5) in non-treated osteoporotic controls (n=21), mid-term alendronate-treated osteoporotic patients (n=6), and long-term alendronate-treated osteoporotic patients (n=7). The strength and toughness of single trabeculae were evaluated, while the structure was characterised through measurements of microdamage accumulation, mineralisation distribution, and histological indices. The alendronate-treated cases had a reduced eroded surface (ES/BS, p<0.001) and a higher bone mineralisation in comparison to non-treated controls (p=0.037), which is indicative of low turnover associated with treatment. However, the amount of microdamage and the mechanical properties were similar among the control and treatment groups. As the tissue mineral density (TMD) increased significantly with alendronate treatment compared to non-treated osteoporotic controls, the reduction in resorption cavities could counterbalance the higher TMD allowing the alendronate-treated bone to maintain its mechanical properties and resist microdamage accumulation. A multivariate analysis of the possible predictors supports the theory that multiple factors (e.g., body mass index, TMD, and ES/BS) can impact the mechanical properties. Our results suggest that long-term alendronate treatment shows no adverse impact on mechanical cancellous bone characteristics.
Asunto(s)
Alendronato/farmacología , Conservadores de la Densidad Ósea/farmacología , Calcificación Fisiológica/efectos de los fármacos , Vértebras Lumbares/efectos de los fármacos , Osteoporosis Posmenopáusica/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Alendronato/efectos adversos , Alendronato/uso terapéutico , Fenómenos Biomecánicos , Conservadores de la Densidad Ósea/efectos adversos , Conservadores de la Densidad Ósea/uso terapéutico , Resorción Ósea/tratamiento farmacológico , Femenino , Humanos , Vértebras Lumbares/metabolismo , Vértebras Lumbares/patologíaRESUMEN
BACKGROUND: Radial artery applanation tonometry technology can be used for continuous non-invasive measurement of arterial pressure (AP). The purpose of this study was to evaluate this AP monitoring technology in intensive care unit (ICU) patients in comparison with invasive AP monitoring using a radial arterial catheter. METHODS: In 24 ICU patients (German university hospital), AP values were simultaneously recorded on a beat-to-beat basis using radial artery applanation tonometry (T-Line system; Tensys Medical, San Diego, CA, USA) and a radial arterial catheter (contralateral arm). The primary endpoint of the study was to investigate the accuracy and precision of the non-invasively assessed AP measurements with the Bland-Altman method based on averaged 10 beat AP epochs (n=2993 10 beat epochs). RESULTS: For mean AP (MAP), systolic AP (SAP), and diastolic AP (DAP), we observed a bias (±standard deviation of the bias; 95% limits of agreement; percentage error) of +2 mm Hg (±6; -11 to +15 mm Hg; 15%), -3 mm Hg (±15; -33 to +27 mm Hg; 23%), and +5 mm Hg (±7; -9 to +19 mm Hg; 22%), respectively. CONCLUSIONS: In ICU patients, MAP and DAP measurements obtained using radial artery applanation tonometry show clinically acceptable agreement with invasive AP determination with a radial arterial catheter. While the radial artery applanation tonometry technology also allows SAP measurements with high accuracy, its precision for SAP measurements needs to be further improved.
Asunto(s)
Presión Arterial/fisiología , Cuidados Críticos/métodos , Manometría/métodos , Monitoreo Fisiológico/métodos , Arteria Radial/fisiología , Adulto , Anciano , Determinación de Punto Final , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: The T-Line TL-200pro (TL-200pro) device (Tensys Medical, Inc., San Diego, CA, USA), based on radial artery tonometry, provides an arterial pressure (AP) waveform and beat-to-beat values of systolic arterial pressure (SAP), mean arterial pressure (MAP), and diastolic arterial pressure (DAP). The aim of the study was to evaluate this non-invasive technique for continuous AP monitoring in medical intensive care unit (ICU) patients. METHODS: Arterial pressure measurements obtained using the TL-200pro technology were compared using Bland-Altman analysis with values measured directly from a femoral arterial catheter in 34 ICU patients. RESULTS: Arterial pressure values were analysed and compared in 4502 averaged 10-beat epochs. A bias of +0.72 mm Hg (95% limits of agreement -9.37 to +10.82 mm Hg) was observed for MAP. For SAP and DAP, there was a mean difference of -1.39 mm Hg (95% limits of agreement -18.74 to +15.96 mm Hg) and +4.36 mm Hg (95% limits of agreement -8.66 to +17.38 mm Hg), respectively. The percentage error for MAP, SAP, and DAP was 12%, 14%, and 21%, respectively. CONCLUSIONS: Arterial pressure measurement based on radial artery tonometry using the TL-200pro technology is feasible in medical ICU patients. The TL-200pro system is capable of providing MAP values with high accuracy (low mean difference) and precision (narrow limits of agreement) compared with MAP measured invasively using a femoral arterial catheter. The TL-200pro technology is promising for the measurement of SAP and DAP but further development is necessary to improve accuracy and precision.
Asunto(s)
Determinación de la Presión Sanguínea/instrumentación , Monitores de Presión Sanguínea , Cuidados Críticos/métodos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Monitoreo Fisiológico/instrumentación , Arteria Radial/fisiología , Anciano , Presión Sanguínea/fisiología , Determinación de la Presión Sanguínea/métodos , Femenino , Humanos , Masculino , Manometría/métodos , Persona de Mediana Edad , Monitoreo Fisiológico/métodosRESUMEN
BACKGROUND: Once aprotinin was no longer available for clinical use, ε-aminocaproic acid (EACA) and tranexamic acid became the only two options for antifibrinolytic therapy. We compared aprotinin and EACA with respect to their blood-sparing efficacy and other major clinical outcome criteria in infants undergoing cardiac surgery. METHODS: We retrospectively analysed data from a large consecutive cohort of infants (n=227) aged 31-365 days undergoing primary cardiac surgery requiring cardiopulmonary bypass encompassing the transition from aprotinin to EACA (aprotinin n=88, EACA n=139); all other aspects including the medical team and departmental protocols remained unchanged. The primary outcome was postoperative blood loss measured as chest tube output (CTO). Secondary outcome parameters were transfusion requirements, reoperation due to bleeding, renal, vascular, and neurological complications, and in-hospital mortality. RESULTS: CTO was significantly higher in the EACA patients {aprotinin 18 (13-27) ml kg(-1) 24 h(-1), EACA 23 (15-37) ml kg(-1) 24 h(-1) [mean (inter-quartile range)], P=0.001}, but transfusion requirements and donor exposures were not significantly different. A sensitivity analysis strengthened our finding that the increased blood loss in the EACA group was attributable to lower efficacy of EACA. There were no significant differences in the other clinical outcome measures. CONCLUSIONS: CTO was lower in aprotinin-treated patients. Nonetheless, EACA remains a suitable substitute without measurable differences in other clinical outcome criteria.
Asunto(s)
Ácido Aminocaproico/uso terapéutico , Aprotinina/uso terapéutico , Pérdida de Sangre Quirúrgica/prevención & control , Procedimientos Quirúrgicos Cardíacos/métodos , Hemostáticos/uso terapéutico , Transfusión Sanguínea/estadística & datos numéricos , Tubos Torácicos , Puente de Arteria Coronaria , Femenino , Mortalidad Hospitalaria , Humanos , Lactante , Masculino , Seguridad del Paciente , Complicaciones Posoperatorias/epidemiología , Ajuste de Riesgo , Resultado del TratamientoRESUMEN
The purpose of this study was to investigate characteristics of critically ill patients with Stenotrophomonas maltophilia (S. maltophilia) isolated from the respiratory tract, to identify risk factors for S. maltophilia-pneumonia and intensive care unit (ICU) mortality and to analyze antibiotic susceptibility of S. maltophilia. This was a retrospective analysis of 64 medical ICU patients with S. maltophilia in the respiratory tract. Thirty-six patients fulfilled the criteria for diagnosis of pneumonia. A significantly higher lung injury score (LIS) was observed in patients with pneumonia compared to patients with colonization (p=0.010). Independent risk factors for S. maltophilia-pneumonia were higher Sequential Organ Failure Assessment (SOFA) score (p=0.009) and immunosuppression (p=0.014). Patients with S. maltophilia-pneumonia had higher ICU mortality within a 28-day follow-up (p=0.040) and higher hospital mortality (p=0.018) than patients with colonization. The highest antibiotic susceptibility rates were observed to trimethoprim-sulfamethoxazole, tigecycline, and moxifloxacin. Higher SOFA score when S. maltophilia was isolated (p=0.001) and development of renal failure (p=0.021) were independent risk factors for ICU mortality. Higher SOFA score and immunosuppression are independent risk factors for S. maltophilia-pneumonia. Patients with S. maltophilia-pneumonia have a significantly higher ICU mortality within a 28-day follow-up, hospital mortality and LIS compared to patients with S. maltophilia-colonization.
Asunto(s)
Infecciones por Bacterias Gramnegativas/epidemiología , Neumonía Bacteriana/epidemiología , Sistema Respiratorio/microbiología , Stenotrophomonas maltophilia/aislamiento & purificación , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/farmacología , Femenino , Infecciones por Bacterias Gramnegativas/microbiología , Infecciones por Bacterias Gramnegativas/mortalidad , Infecciones por Bacterias Gramnegativas/patología , Humanos , Unidades de Cuidados Intensivos , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Neumonía Bacteriana/microbiología , Neumonía Bacteriana/mortalidad , Neumonía Bacteriana/patología , Estudios Retrospectivos , Factores de Riesgo , Stenotrophomonas maltophilia/efectos de los fármacos , Análisis de SupervivenciaRESUMEN
PURPOSE: To evaluate the accuracy of measurements of the optic nerve sheath diameter (ONSD) in children by comparing transbulbar sonography with magnetic resonance imaging (MRI). MATERIALS AND METHODS: 65 children (age: 3 mo- 17y; mean age: 11.3y) underwent MR imaging of the brain including a heavily T 2-w sequence of the orbit and transbulbar sonography using a 17âMHz linear array transducer. Measurements of the ONSD were performed retrospectively by two experienced readers and all images were evaluated regarding the image quality. Bland-Altman Plots were produced to assess the accuracy of measurements. The correlation between readers and between MR imaging and transbulbar sonography was calculated by the concordance correlation coefficient (CCC). RESULTS: Overall the mean values of the ONSD for MRI (5.86â±â0.66âmm) and transbulbar sonography (5.86â±â0.71âmm) were identical. There was a high correlation between readers for measurements of the ONSD both for transbulbar sonography (CCCâ=â0.93) as well as for MRI (CCCâ=â0.9). Comparing the measurement values between transbulbar sonography and MRI, the correlation of ONSD values was good to moderate with a high dependency on image quality (CCC [0.31, 0.68]). CONCLUSION: We were able to demonstrate that the ONSD values of transbulbar sonography in children correlate well with MRI if the relevant anatomic structures are depicted and the measuring points are set correctly. Based on the findings of our study, it seems necessary to define normal and cut-off values for the ONSD in children again to finally assess the clinical relevance of the ONSD as a noninvasive parameter for the evaluation of intracranial pressure.
RESUMEN
BACKGROUND: Workload assessment is an important tool for improving patient safety in anaesthesia. We tested the hypothesis that heart rate, pupil size, and duration of fixation increase, whereas saccade amplitude decreases with increased workload during simulated critical incidents. METHODS: Fifteen trainee anaesthetists participated in this randomized cross-over trial. Each participant used a head-mounted eye-tracking device (EyeSeeCam) during induction of general anaesthesia in a full-scale simulation during three different sessions. No critical incident was simulated in the first session. In a randomized order, workload was increased by simulation of a critical incident in the second or third session. Pupil size, duration of fixations, saccadic amplitude, and heart rate of each participant and the simulator conditions were recorded continuously and synchronized. The data were analysed by paired sample t-tests and mixed-effects regression analysis. RESULTS: The findings of the second and third sessions of 11 participants were analysed. Pupil diameter and heart rate increased simultaneously as the severity of the simulated critical incident increased. Allowing for individual effects, the simulator conditions explained 92.6% of the variance in pupil diameter and 93.6% of the variance in heart rate (both P<0.001). The duration of fixation decreased with increased workload. The saccadic amplitude remained unaffected by workload changes. CONCLUSIONS: Pupil size and heart rate reflect workload increase within simulator sessions, but they do not permit overall workload comparisons between individuals or sessions. Contrary to our assumption, the duration of fixation decreased with increased workload. Saccade amplitude did not reflect workload fluctuations.
Asunto(s)
Anestesia General , Movimientos Oculares/fisiología , Cuerpo Médico de Hospitales , Carga de Trabajo , Anafilaxia/terapia , Anestesiología/educación , Simulación por Computador , Estudios Cruzados , Educación de Postgrado en Medicina/métodos , Medidas del Movimiento Ocular , Fijación Ocular , Frecuencia Cardíaca/fisiología , Humanos , Simulación de Paciente , Proyectos Piloto , Pupila/fisiología , Movimientos SacádicosRESUMEN
BACKGROUND: Situation awareness (SA) is considered to be an important non-technical skill for delivering safe anaesthesia. The spatial distribution of visual attention (VA) is an underlying process for attaining adequate SA. In the present study, a novel technology was used to assess the distribution of VA in anaesthetists delivering anaesthesia. The impact of a critical incident on VA in relation to individual experience is analysed in a descriptive and exploratory manner. METHODS: Fifteen anaesthetists induced general anaesthesia in a full-scale simulator while wearing a head-mounted eye-tracking camera system. After an uneventful session, workload was increased in a randomized order by simulation of a critical incident in the second or third session. Eye tracking was used for the assessment of individual's distribution of VA to monitors, patient, and environment. A post hoc video analysis revealed information about the spatial distribution of VA. Descriptive statistics and exploratory analysis were used. RESULTS: Twenty per cent of VA was directed to the patient monitor (30% during critical incident scenarios, P=0.003). The more experienced anaesthetists (more than 2 yr of work experience) increased the amount of time dedicated to manual tasks from 21% to 25% during critical incidents, whereas the less experienced decreased from 20% to 14% (P=0.061). CONCLUSIONS: Distribution of attention is different during anaesthesia induction with critical incidents compared with uneventful anaesthesia induction. Less experienced anaesthesia providers spend more time on monitoring tasks. Further investigation in confirmatory designs is needed.
Asunto(s)
Anestesia General/normas , Atención/fisiología , Competencia Clínica , Percepción Espacial/fisiología , Anafilaxia/terapia , Concienciación/fisiología , Métodos Epidemiológicos , Medidas del Movimiento Ocular , Femenino , Alemania , Humanos , Complicaciones Intraoperatorias/terapia , Masculino , Monitoreo Intraoperatorio/normas , Simulación de Paciente , Desempeño Psicomotor , Análisis y Desempeño de Tareas , Carga de TrabajoRESUMEN
PURPOSE: We performed a cadaver study to evaluate the accuracy of measurements of the optic nerve and the optic nerve sheath for high resolution US (HRUS) and magnetic resonance imaging (MRI). MATERIALS AND METHODS: Five Thiel-fixated cadaver specimens of the optic nerve were examined with HRUS and MRI. Measurements of the optic nerve and the ONSD were performed before and after the filling of the optic nerve sheath with saline solution. Statistical analysis included the calculation of the agreement of measurements and the evaluation of the intraobserver and interobserver variation. RESULTS: Overall a good correlation of measurement values between HRUS and MRI can be found (mean difference: 0.02-0.97 mm). The repeatability coefficient (RC) and concordance correlation coefficient (CCC) values were good to excellent for most acquisitions (RC 0.2-1.11 mm; CCC 0.684-0.949). The highest variation of measurement values was found for transbulbar sonography (RC 0.58-1.83 mm; CCC 0.615/0.608). CONCLUSION: If decisive anatomic structures are clearly depicted and the measuring points are set correctly, there is a good correlation between HRUS and MRI measurements of the optic nerve and the ONSD even on transbulbar sonography. As most of the standard and cut-off values that have been published for ultrasound are significantly lower than the results obtained with MRI, a reevaluation of sonographic ONSD measurement with correlation to MRI is necessary.
Asunto(s)
Aumento de la Imagen/métodos , Imagen por Resonancia Magnética/métodos , Vaina de Mielina/diagnóstico por imagen , Nervio Óptico/anatomía & histología , Nervio Óptico/diagnóstico por imagen , Ultrasonografía/métodos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Valores de Referencia , Sensibilidad y Especificidad , Estadística como AsuntoRESUMEN
Mandibular reconstruction with a fibular free flap has become standard in specialised centres for head and neck reconstruction, particularly for defects with more than one osteotomy that are challenging even for experienced surgeons. Virtual surgical planning is a potential tool to facilitate harvesting of the fibula and the osteostomy. The purpose of this study was to compare the two methods of mandibular reconstruction - conventionally planned (conventional group) and "virtually" planned (virtual group) - with regard to accuracy, bony consolidation, complications, and operating time. Fifty patients who required mandibular reconstruction after segmental mandibulectomy were evaluated retrospectively, 24 virtually planned and 26 conventionally planned. The overall survival of flaps was 92% (46/50). The bony consolidation rate in the virtual group was significantly better than that in the conventional group (p=0.002). The difference between the angle of the mandible before and after was highly significant with a median of 11.5° (range 2°-75°) in the conventional group and 4.5° (range 0-18°) in the virtual group (p=0.0001). Operations were mean (SD) of 34 (21.2) minutes shorter in virtually-planned cases (p=0.12). The overall morbidity did not differ significantly between the groups. The use of virtual surgical planning in mandibular reconstruction by fibular free flap is beneficial for optimising accuracy, consolidation of bony segments, and operating time, while increasing the predictability of results for the surgeon. However, additional costs have to be carefully weighed against the benefits.
Asunto(s)
Colgajos Tisulares Libres , Imagenología Tridimensional , Osteotomía Mandibular , Reconstrucción Mandibular , Trasplante Óseo , Peroné , Humanos , Mandíbula , Procedimientos de Cirugía PlásticaRESUMEN
BACKGROUND AND AIMS: In spite of huge developments in liver surgery during the last decades, morbidity and mortality continue to pose problems in this field. The aim of this study was to identify preoperative predictors for postoperative mortality and morbidity in liver surgery. MATERIAL AND METHODS: In a single-center study, an extensive analysis of a prospective database, including clinical criteria and laboratory tests of patients undergoing liver surgery between July 2007 and July 2012 was performed. Cutoff values of selected laboratory tests were calculated. RESULTS: In all, 337 patients were included in the study. Univariate analysis showed a statistically significant association of preoperative bilirubin, lactate, hemoglobin levels, platelet count, and prothrombin time with postoperative morbidity and mortality. Multivariate analysis revealed preoperatively elevated serum bilirubin and lactate levels as independent predictors for increased postoperative morbidity and mortality after liver surgery. CONCLUSIONS: The identified laboratory values showed a statistically significant association with postoperative morbidity and mortality in liver surgery and might be helpful in preoperative patient selection.