Self-efficacy, quality of life, and weight loss in overweight/obese endometrial cancer survivors (SUCCEED): a randomized controlled trial.

OBJECTIVE: More patient-centered programming is essential for endometrial cancer (EC) survivors needing to lose weight to reduce cardiovascular disease risk (CVD). The purpose of this study was to improve self-efficacy (SE) and quality of life (QOL) using a lifestyle intervention program designed for weight loss. METHODS: Overweight and obese early-stage EC survivors, n = 75, were randomized into two groups: 1) Survivors of Uterine Cancer Empowered by Exercise and Healthy Diet (SUCCEED), a six-month lifestyle intervention or 2) a usual care group (UC). Participants completed the Weight Efficacy Lifestyle Questionnaire (WEL) to assess SE and the Functional Assessment of Cancer Therapy-General (FACT-G) to measure QOL, and their body mass index (BMI) was calculated at baseline, 3, 6, and 12 months. Mixed, repeated-measures ANCOVA models with baseline covariates were employed using SPSS 20.0. RESULTS: Positive effects in every WEL domain, including the total score, were statistically significant in the SUCCEED group versus the UC group. A linear regression model demonstrated that, if BMI decreased by 1 unit, the total WEL score increased by 4.49 points. Significant negative correlations were found in the total WEL score and a change in BMI of R = -0.356 (p = 0.006). Between-group differences in the FACT-G were significant from baseline in the fatigue domain at three months (p = .008) and in the physical domain at six months (p = .048). No other significant differences were found. CONCLUSION: Overall, this study shows promise for targeted interventions to help improve SE, thus improving BMI.

[Current clinical practice among German Internists regarding the prophylaxis of gastroduodenal ulcers associated with NSAIDs, aspirin and Helicobacter pylori]. / Klinische Praxis der Prophylaxe gastroduodenaler Ulzera.

OBJECTIVE: Rapidly growing information on adverse gastrointestinal effects of non-steroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori (Hp) causes continuous changes in clinical patient management. Decisions on the prevention of gastroduodenal ulcers in individual patients often do not follow guidelines. We aimed to assess the current management of gastroduodenal ulcers by internists in southern Germany. METHODS: All 965 members of the Association of Bavarian Internists, a German province with about 8000 internists, were invited to participate in answering a 12-item questionnaire. The questions addressed different clinical scenarios regarding ulcer disease associated with traditional NSAIDs (tNSAIDs), aspirin and Hp. Particularly, we asked for the clinical approach to patients with NSAID-/aspirin-associated ulcers and prophylactic measures before the beginning of a potentially ulcerogenic medication. RESULTS: N = 225 (23.3 %) physicians returned completed questionnaires. In patients with Hp-negative, NSAID-/aspirin-associated ulcers, > 80 % of respondents would initiate long-term proton pump inhibitor (PPI) therapy, whereas 20 % and 17.8 % would prescribe COX-2 selective inhibitors or opiates instead of non-selective NSAIDs and clopidogrel instead of aspirin. The management of Hp-positive ulcers, especially in cases with additional use of aspirin or NSAIDs, was very heterogenous, including Hp-eradication only, eradication +  long-term PPI, eradication +  clopidogrel or COX-2-inhibitors/opiates. CONCLUSION: This survey depicts individual discrepancies in the clinical management of patients receiving NSAIDs and/or aspirin, regarding the prophylaxis of gastroduodenal ulcer disease.

Randomised clinical trial: the effect of baclofen in patients with gastro-oesophageal reflux--a randomised prospective study.

BACKGROUND: Baclofen, a GABA(B) agonist, has been shown to reduce transient lower oesophageal sphincter relaxations (TLESRs), a major cause of gastro-oesophageal reflux disease (GERD). AIM: To examine the effect and tolerability of baclofen in GERD patients over a 2-week period. METHODS: Forty-three GERD patients with abnormal 24-h pH tests were prospectively randomised to receive baclofen or placebo in a double-blind fashion for 2 weeks. Oesophageal manometry, 24-h pH monitoring, and a standard questionnaire was administered, before and after treatment. RESULTS: Thirty-four patients completed the study. In the baclofen group there were significant decreases in 24-h pH score (P = 0.020), percent of upright reflux episodes (P = 0.016), percent total time pH <4 (P = 0.003), number of reflux episodes (P = 0.018), number of reflux episodes longer than 5 min (P = 0.016), number of postprandial reflux episodes (P = 0.045), and percentage of time pH <4 (P = 0.003). No significant changes in reflux parameters were noted in the placebo group. Patients receiving baclofen had significantly less belching (P = 0.038), regurgitation (P = 0.036) and overall symptom score (P = 0.004) whereas placebo patients had less heartburn (P = 0.001), chest pain (P = 0.002), regurgitation (P = 0.017) and overall symptom score (P = 0.000). However, there were no significant differences in changes of reflux parameters or symptoms when comparing the two groups. Drowsiness did not limit baclofen use. CONCLUSIONS: Baclofen was associated with a significant decrease in percent upright reflux by 24-h pH monitoring and a significant improvement in belching, regurgitation and overall symptom score. Baclofen may be more effective in patients with predominantly upright reflux and belching.

Effect of Xenon on elevated intracranial pressure as compared with nitrous oxide and total intravenous anesthesia in pigs.

BACKGROUND: Xenon in low concentrations has been investigated in neuroradiology to measure cerebral blood flow (CBF). Several reports have suggested that inhalation of Xenon might increase intracranial pressure (ICP) by increasing the cerebral blood flow and blood volume, raising concerns about using Xenon as an anesthetic in higher concentrations for head-injured patients. A porcine study is presented in which the effects of inhaled 75% Xenon on elevated ICP, cerebral perfusion pressure and the efficacy of hyperventilation for ICP treatment were compared with nitrous oxide anesthesia and total intravenous anesthesia (TIVA). METHODS: Twenty-one pentobarbital-anesthetized pigs (age: 12-16 weeks) were randomly assigned to three groups to receive either 4 h of Xenon-oxygen ventilation, nitrous oxide-oxygen ventilation or air-oxygen (75%/25%) ventilation, respectively. After instrumentation for parenchymal ICP measurement and ICP manipulation, an epidurally placed 6-F balloon catheter was inflated until a target ICP of 20 mmHg was achieved. After 4 h of anesthesia hyper- and hypoventilation maneuvers were performed and consecutive ICP and CBF changes were investigated. RESULTS: Intracranial pressure and CBF increased significantly in the nitrous oxide group as compared with the controls. There was no increase of ICP or CBF in the Xenon or control group. Intracranial pressure changed in all three groups corresponding to hyper- and hypoventilation. CONCLUSIONS: During Xenon anesthesia, elevated ICP is not increased further and is partially reversible by hyperventilation. Our study suggests that inhalation of 75% Xenon seems not to be contraindicated in patients with elevated ICP.

Hepatic function during xenon anesthesia in pigs.

BACKGROUND: Inhalation anesthetics decrease liver perfusion and oxygen consumption by changing the distribution pattern of perfusion between the hepatic artery and the portal vein and by direct effects on liver cells. The effects of xenon on liver perfusion and function have been not investigated until now. METHODS: Fourteen pigs were randomly assigned to two groups to receive either 73-78% xenon or 75% nitrogen in oxygen with additional supplementation of pentobarbital and buprenorphine. Microspheres were used to determine the arterial perfusion of the liver and splanchnic organs. Oxygen contents were measured by catheterization of the portal and a liver vein. Lactate and glucose plasma concentrations were measured in hepatic, mixed venous and arterial blood. Alanine aminotransferase (ALT) and lactate dehydrogenase (LOH) plasma concentrations were measured in arterial blood. Urea production rates were calculated to assess hepatic metabolic function. RESULTS: Significant higher oxygen contents were found in the liver venous blood during xenon anesthesia. No differences were found in any other investigated parameters. CONCLUSION: Higher oxygen content in liver venous blood observed during xenon anesthesia was not induced by changes in hepatic perfusion distribution or by an impairment of liver metabolic capacity. However, it can be explained by similar results known from inhalation anesthesia. Additionally, the effect can be caused by the reduction of plasma catecholamine concentrations during xenon anesthesia.

Cerebral and regional organ perfusion in pigs during xenon anaesthesia.

Little is known about the haemodynamic effects of inhaled xenon on regional organ perfusion. The aim of this study was to investigate the effect of 79% xenon ventilation on organ perfusion in pigs. We investigated 10 pigs, which were randomly allocated to receive either xenon 79% or total intravenous anaesthesia (TIVA)/oxygen anaesthesia. Microspheres were used to determine organ perfusion. The following regions of interest were investigated: cerebral cortex, medulla oblongata, brainstem, cerebellum, liver, kidney, small intestine, colon, muscle, skin and heart. The results demonstrated a significant increase in regional perfusion in the brainstem (+63%), cerebral cortex (+38%), medulla oblongata (+35%) and cerebellum (+34%). All other organs showed no significant change in regional perfusion. We conclude that xenon should be used with caution in clinical situations associated with pathological increases in intracranial pressure, e.g. neurosurgical procedures, head injury, cerebral mass lesions or stroke.

Analgesic effect of butorphanol and levomethadone in detomidine sedated horses.

The analgesic potency of butorphanol 25 microg/kg bodyweight (BW) and levomethadone 100 microg/kg BW, administered together with detomidine 10 microg/kg BW, was measured in twelve Warmblood horses in a randomized, blinded cross-over study. Detomidine with saline 10 ml 0.9% was used as placebo. The nociceptive threshold was determined using a constant current and a pneumatic pressure model for somatic pair Detomidine alone and in combination with butorphanol or levomethadone caused a significant temporary increase (P < 0.05) of the nociceptive threshold with a maximum effect within 15 min and a return to baseline levels within 90 min. Butorphanol and levomethadone increased the nociceptive threshold and prolonged the duration of anti-nociception significantly from 15 to 75 min (P < 0.05) after drug administration compared with detomidine alone to both test methods. No significant difference between butorphanol and levomethadone was registered. It is concluded that the addition of butorphanol or levomethadone to detomidine increases the nociceptive threshold to somatic pain and prolongs the analgesic effect of detomidine in the horse.

The use of esmolol as an alternative to remifentanil during desflurane anesthesia for fast-track outpatient gynecologic laparoscopic surgery.

We compared esmolol and remifentanil infusions with respect to their effect on intraoperative hemodynamic stability and early recovery after outpatient laparoscopic surgery when administered as IV adjuvants during desflurane anesthesia. After premedication with midazolam 2 mg IV, anesthesia was induced with propofol 2 mg. kg(-1) IV in combination with either esmolol 1 mg. kg(-1) IV (n = 27) or remifentanil 1 microg. kg(-1) IV (n = 26) and succinylcholine 1 mg. kg(-1) IV according to a randomized, double-blinded protocol. Anesthesia was initially maintained with desflurane 2.5% (subsequently titrated to maintain an electroencephalogram-bispectral index value of 60) and nitrous oxide 65% in oxygen. Before skin incision, an infusion of either esmolol (5 microg. kg(-1). min(-1)) or remifentanil (0.05 microg. kg(-1). min(-1)) was started and titrated to maintain the heart rate within 25% of the baseline value. Mivacurium, 0.04 mg/kg IV, bolus doses were administered to maintain a stable peak inspiratory pressure. Esmolol (12.8 +/- 13.1 microg. kg(-1). min(-1)) and remifentanil (0.04 +/- 0.02 microg. kg(-1). min(-1)) infusions were equally effective in maintaining a stable heart rate during these laparoscopic procedures. Although the mivacurium requirement was larger in the Esmolol group (7 +/- 5 vs 3 +/- 4 mg), the Esmolol group reported a smaller incidence of postoperative nausea and vomiting (4% vs 35%). Both drugs were associated with frequent "postanesthesia care unit bypass" rates (78-81%), short times to "home readiness" (119-120 min), excellent patient satisfaction (81-85%), and rapid resumption of normal activities (2.6-3.2 d). Fast-tracked patients were ready for discharge home significantly earlier (112 +/- 46 vs 151 +/- 50 min). We concluded that esmolol infusion is an acceptable alternative to remifentanil infusion for maintaining hemodynamic stability during desflurane-based fast-track anesthesia for outpatient gynecologic laparoscopic surgery.

Fast-tracking after immersion lithotripsy: general anesthesia versus monitored anesthesia care.

UNLABELLED: Both monitored anesthesia care (MAC) and general anesthesia (GA) offer advantages over epidural anesthesia for immersion lithotripsy. We compared propofol-based MAC and desflurane-based GA techniques for outpatient lithotripsy. After receiving midazolam 2 mg IV, 100 subjects were randomly assigned to one of two anesthetic treatment groups. In the MAC group, propofol 50-100 microg. kg(-1). min(-1) IV was titrated to maintain an observer's assessment of alertness/sedation score of 2-3 (5 = awake/alert to 1 = asleep). Remifentanil 0.05 microg.kg(-1). min(-1) IV supplemented with 0.125 microg/kg IV boluses, was administered for pain control. In the GA group, anesthesia was induced with propofol 1.5 mg/kg IV and remifentanil 0.125 microg/kg IV and maintained with desflurane (2%-4% inspired) and nitrous oxide (60%). Tachypnea (respiratory rate >20 breaths/min) was treated with remifentanil 0.125 microg/kg IV boluses. In the GA group, droperidol (0.625 mg IV) was administered as a prophylactic antiemetic. Recovery times and postoperative side effects were assessed up to 24 h after the procedure. Compared with MAC, the use of GA reduced the opioid requirement and decreased movements and episodes of desaturation (<90%) during the procedure. Although the GA group took longer to return to an observer's assessment of alertness/sedation score of 5, discharge times were similar in both groups. We conclude that GA can provide better conditions for outpatient immersion lithotripsy than MAC sedation without delaying discharge. IMPLICATIONS: A desflurane-based general anesthetic technique using the cuffed oropharyngeal airway device was found to be a highly acceptable alternative to propofol-based monitored anesthesia care sedation for outpatient immersion lithotripsy.

Use of the intubating laryngeal mask airway to facilitate awake orotracheal intubation in patients with cervical spine disorders.

Airway management in patients with unstable cervical spines remains a challenge for anesthesia providers. Because neurologic evaluations may be required following tracheal intubation and positioning for the surgical procedure, an awake intubation technique is desirable in this patient population. In this report, we describe the use of an intubating laryngeal mask airway (ILMA) to facilitate awake tracheal intubation in two patients with cervical spine disorders. After topical local analgesia, the ILMA was inserted easily, and a tracheal tube was passed through the glottic opening without complications. Thus, the ILMA may be an acceptable alternative to the fiberoptic bronchoscope for awake tracheal intubation.

Comparison of ketorolac and morphine for postoperative pain after major surgery.

This study was designed to determine the relative analgesic efficacy and safety of single intramuscular injections of ketorolac (10 mg or 30 mg) and morphine (10 mg) in patients of either sex with moderate to severe pain after major surgery. In a single-dose, randomised, double-blind study of parallel design, pain was assessed immediately before injection of test medication and at regular intervals for 8 h thereafter. One hundred and seventeen patients (109 undergoing cardiac surgery; 8 lung surgery) were randomized to one of the three treatment groups. Pain intensity was assessed using a 5-point verbal scale before administration of study drugs. Postadministration, at 30 min and hourly for 8 h, pain intensity and pain relief were assessed, again using the 5-point verbal scale. Additionally, as a measure of analgesia, forced expiratory volume (FEV1) was obtained in all patients. Vital signs including blood pressure, pulse, temperature, respiratory rate and blood gases (PaCO2) were recorded prior to and after study medication. Based on hourly pain intensity differences and hourly pain relief observations, ketorolac 10 mg was generally more effective than morphine 10 mg, and ketorolac 30 mg was generally more effective than ketorolac 10 mg. The results of this study show that ketorolac is an effective and safe (with regard to arterial pressure, blood gases and lung function) analgesic for relief of postoperative pain after major surgery in stable patients. No clinically significant adverse effects occurred during the study. One cannot exclude an influence on patients with organ system dysfunction or on parameters not measured in this study.

Safety and efficacy of xenon in routine use as an inhalational anaesthetic.

40 patients (24 male, 16 female, aged 21-59 years) of American Society of Anesthesiologists class I or II who were undergoing routine surgery took part in a randomised, double-blind comparison of the anaesthetic efficacy and potency of xenon and nitrous oxide and their effects on the circulatory and respiratory systems. During anaesthesia, for each rise in blood pressure of more than 20% of the preanaesthetic (baseline) value, the patient received 0.1 mg fentanyl. The total amount of fentanyl required per patient was used as an index of the anaesthetic potency of the study gases. Patients in the xenon group required on average only 0.05 mg fentanyl, whereas those in the nitrous oxide group required 0.24 mg fentanyl; the duration of anaesthesia was similar in the two groups. Changes in blood pressure were significantly greater throughout the study in the nitrous oxide than in the xenon group. Thorax-lung compliance fell during the study period in the nitrous oxide group but not in the xenon group. Thus, xenon is a potent and effective anaesthetic which can be safely used under routine conditions.

Online measurements of SaO2, Ht and Hb using a micro transmission cell.

Recently a Micro Transmission Cell has been developed based on spectrophotometry for in vivo monitoring of SaO2 together with Hb. A study in pigs was performed to compare the cell with standard methods for measuring SaO2, Hb and Ht. The results show that the cell is capable of following the trends of SaO2, Hb and Ht at different Hb concentrations and/or O2 saturations.

Volume-controlled ventilation with superimposed high frequency ventilation during expiration in healthy and surfactant-depleted pig lungs.

In the healthy and surfactant-depleted lungs of five pigs the influence of different forms of high frequency ventilation superimposed on conventional mechanical ventilation during the expiratory phase of the ventilatory cycle (SHFVE) on gas exchange and cardiocirculatory parameters was investigated. Subsequently the effects of end-expiratory flushing (EF), i.e. cleaning the large airways and connecting tubes from the ventilator free from end-expiratory CO2, with a volume greater than the dead space of the large airways and connecting tubes was investigated. SHFVE and EF resulted in a significant improvement in CO2 elimination in both healthy and surfactant-depleted lungs. Furthermore, in stiff lungs, at a certain level of oxygenation and CO2 elimination, SHFVE produced the lowest peak and mean airway pressure without any additional depression of cardiocirculatory parameters.