Acute mesenteric ischemia following cardiovascular surgery--A nested case-control study.

INTRODUCTION: Acute mesenteric ischemia is a rare but often fatal complication following cardiovascular surgery. Early suspicion may reduce overall mortality. This retrospective study aims to identify predictors and risk factors that may determine the onset and evolution of acute mesenteric ischemia. METHODS: In a retrospective case-control study, we compared co-morbidities and peri-operative risk factors of patients with or without mesenteric ischemia following cardiac surgery using univariate and logistic regression analyses. RESULTS: Of 9385 patients, 108 (1.15%) were diagnosed with acute mesenteric ischemia within two weeks after cardiac surgery. In-hospital mortality was 68% for this group. Patients with ischemia and controls were matched in regard to patient's age and type of surgical intervention and showed similar pre-operative parameters. Only liver cirrhosis (OR 13.3, CI95% 3.6-49.3), and emergency operation (OR 2.6, CI95% 1.3-5.2) remained independent pre-operative predictors for acute mesenteric ischemia in multivariate analysis. In contrast, early postoperative parameters revealed a higher correlation with the occurrence of mesenteric ischemia including the use of norepinephrine (OR 3.5 CI95% 1.6-7.8), epinephrine (OR 2.0, CI95% 1.1-3.7), and serum lactate levels >3 mmol/L (OR 2.9, CI95% 1.5-5.6). A set of key markers of regression analysis was evaluated in a ROC curve analysis. The area under curve was 0.835, which indicates moderate to good prognostic accuracy. CONCLUSION: Early identification of pre- and post-operative predictors including liver cirrhosis, emergency operation, serum lactate >3 mmol/L, and the use of norepinephrine and epinephrine may help facilitate early diagnosis of acute mesenteric ischemia following cardiac surgery, and thus may allow immediate adequate treatment, leading to a reduction in mortality rates.

Occupation and cancer of the larynx: a systematic review and meta-analysis.

The aim of the study was to explore the relationship between occupational exposure, defined by occupational categories and job title, and laryngeal cancer. A systematic review and meta-analysis of 21 tobacco and alcohol-adjusted case-control studies including data from 6,906 exposed cases and 10,816 exposed controls was performed to investigate the frequency of laryngeal cancer in different occupations. Job classifications were harmonized using the International Standard Classification of Occupations. Pooled odds ratios (OR [95 % confidence intervals (CI)]) were calculated for the different occupational groups. A significantly increased risk of laryngeal cancer was observed for the occupational category of 'production-related workers, transport equipment operators, and laborers' (OR=1.3 [1.2-1.4]); particularly at risk were occupations as: miners (OR=1.6 [1.2-2.1]), tailors (OR=1.7 [1.2-2.3]), blacksmith and toolmakers (OR=1.5 [1.2-1.7]), painters (OR=1.4 [1.1-1.9]), bricklayers and carpenters (OR=1.3 [1.2-1.5]), and transport equipment operators (OR=1.3 [1.2-1.5]). Individuals working as 'professional, technical, and related workers' (OR=0.7 [0.6- 0.8]), 'administrative and managerial workers' (OR=0.6 [0.4-0.7]), or 'clerical and related workers' (OR=0.8 [0.7-0.9]) had laryngeal cancer less frequently. Occupational exposure, defined by occupational categories and job title, is likely to be an independent risk factor for laryngeal cancer. Further research on specific occupations with increased risk of laryngeal cancer is warranted to explore the underlying mechanisms.

[Changes in Incidence and Mortality Trends of Head and Neck Cancer in Rhineland-Palatinate, 2000-2009]. / Veränderung von Inzidenz und Mortalität von Kopf-Hals-Malignomen in Rheinland-Pfalz, 2000-2009.

BACKGROUND: Epidemiological data on HNC are often reported aggregated despite their anatomical and histological heterogeneity. In Germany, few studies have analyzed incidence and mortality trends separately for specific anatomic sites. Furthermore, little is known about whether the incidence of HPV-associated tumour entities of the head and neck region has increased. METHODS: Based on cancer registry data from Rhineland-Palatinate from 2000 to 2009, age-standardized incidence and mortality rates were calculated for all HNC sites and localisation groups that might be HPV-associated according to the literature. Trends were analyzed by Joinpoint regression and reported as the annual percentage change (APC). RESULTS: Throughout the study period, 8 055 incident cases and 3 177 deaths were identified. The incidence rates of overall HNC increased among women (APC:+2.2%) and declined slightly among men (- 0.9%). Significantly increasing incidence rates among women were seen for tumours of the oral cavity (+2.7%) and the oropharynx (+3.6%). Among men, a significant decrease in incidence rates for tumours of the hypopharynx (-3.4%) and the larynx (-2.7%) are noteworthy. Cancers at HPV-associated sites showed increased incidence rates in men (+3.3%) and women (+4.3%). A decrease in mortality was found for tumours of the larynx in both sexes (-5.8% men,-9.1% women). CONCLUSIONS: A detailed analysis by localisation of HNC showed significant and often opposing trends for men and women regarding incidence and mortality.

[The golden hour of sepsis: initial therapy should start in the prehospital setting]. / Die goldene Stunde der Sepsis : Frühzeitiger präklinischer Therapiebeginn.

BACKGROUND: Sepsis is a common, time-urgent emergency that is still associated with a high mortality and morbidity rate. A strong correlation between the onset of therapy and survival has been shown. With every hour of delay, survival decreases by 7.6 %. In 2001, four treatment goals that should be performed in the first 6 h of treatment were developed. These form the basis of early goal-directed therapy (EDGT) which is accepted as the standard of treatment for sepsis in the emergency department. OBJECTIVES: More than half of patients are admitted to the hospital by medical emergency services. Up to 40 % receive prehospital therapy with i.v. fluids and stabilization of vital signs according to the goals of EDGT. The diagnosis of sepsis is difficult if characteristic symptoms or parameters such as in the ST segment elevation myocardial infarction are lacking. However, 90 % of patients present with fever. CONCLUSIONS: Body temperature should always be assessed by paramedics. In addition, sepsis must always be considered as part of the differential diagnosis. If the suspicion cannot be ruled out, immediate therapy has to be initiated. Concerning the prehospital use of antibiotics, preliminary results of a study from the center of sepsis control and care in Jena, Germany, showed that this therapy form seems to be safe and effective, but further evaluation is necessary.

[Management of patients with the cardinal symptom dizziness or vertigo]. / Versorgungssituation von Patienten mit dem Leitsymptom Schwindel.

BACKGROUND: Vertigo and dizziness are common symptoms leading patients to consult a physician. The nationally representative "2003 Health Survey" depicts the epidemiology of the symptoms vertigo and dizziness across all of Germany. A breakdown of the data by region is not available. METHODS: Routine data of the Bavarian Association of Statutory Health Insurance Physicians accounting centre ("Kassenärztliche Vereinigung Bayerns", KVB) from 2008 were analysed using multilevel models to investigate individual and regional factors and the relevance of nonspecific regional heterogeneity. RESULTS: Altogether, 866,086 of 9,269,729 (9.34%) inhabitants received an ambulatory diagnosis of vertigo or dizziness, including 1.77 times as many women as men. Visits to the doctor because of vertigo or dizziness increased with age. After adjustments for age and sex, a North-South divide and a higher prevalence in the urban centres were apparent within Bavaria. The majority of patients were seen by their GP and nearby doctors. This held especially true for women. Also older patients were less likely to go to specialists further afield. CONCLUSION: This analysis of the KVB data of patients with vertigo or dizziness underlines the central role that is played by GPs in diagnosis and treatment. In order to correctly diagnose the underlying causes, treat patients or send them to specialists effectively, all doctors need to be trained about this relevant clinical symptom. The insufficient representation of clinically established vertigo disorders by the ICD-10 was problematic. The most frequently coded diagnosis was N95.1 "postmenopausal dizziness".

Fruit and vegetable consumption and BMI change in primary school-age children: a cohort study.

BACKGROUND/OBJECTIVES: Healthy eating behaviours, such as increasing fruit and vegetable consumption (FVC), are frequently used as a target or outcome measure in obesity prevention interventions. The goal of this study was to demonstrate replacement of high-caloric foods/drinks by FVC and changes in body mass index (BMI) z-score associated with FVC. SUBJECTS/METHODS: Anthropometric measurements of 1252 children (51.0% girls) were taken before school entrance (age 6 years) and repeated in the fourth grade (age 10 years). At the same time, parents were asked about their children's diet using a questionnaire. RESULTS: In longitudinal analysis, changes in FVC were not significantly correlated with changes of other nutritional habits, such as consumption of sweets and high-caloric drinks. BMI gain tended to be lower (nonsignificant) in children with increasing fruit consumption compared to those with decreasing fruit consumption. An opposite (nonsignificant) tendency was observed for vegetable consumption and BMI gain. CONCLUSIONS: Although beneficial for other health outcomes, the evidence for FVC replacing high-energy foods and thereby reducing BMI gain is weak and could not be substantiated in this study. This might be partially due to the limitation in dietary assessment.

[Cardinal symptom vertigo from the neurologist's perspective]. / Leitsymptom Schwindel aus Sicht des Neurologen.

In most patients with vertigo, the first and clinically most important question posed to neurologists is whether it is a central or a peripheral syndrome. In more than 90 % of cases, this differentiation is made possible by systematically recording the patient history (asking about the type of vertigo, the duration, triggers and accompanying symptoms) and conducting a physical examination. Particularly in the case of acute vertigo disorders, a five-step procedure has proven useful: 1. A cover test to look for vertical divergence (skew deviation) as a central sign and component of the ocular tilt reaction (OTR); 2. Examination with and without Frenzel goggles to differentiate between peripheral vestibular spontaneous nystagmus and central fixation nystagmus; 3. Examination of smooth pursuit; 4. Examination of the gaze-holding function (particularly gaze-evoked nystagmus beating in the opposite direction to spontaneous nystagmus); 5. The head impulse test to look for a deficit in the vestibulo-ocular reflex (VOR). Considerable advances have been made in the pharmacotherapy of vertigo disorders during the last 10 years, including cortisone for the treatment of acute vestibular neuritis, betahistine as a high-dose long-term treatment for Menière's disease, carbamazepine to treat vestibular paroxysmia and aminopyridine for down- and upbeat nystagmus and episodic ataxia type 2.

Increase in prevalence of adiposity between the ages of 7 and 11 years reflects lower remission rates during this period.

UNLABELLED: What is already known about this subject? A considerable increase in the prevalence of overweight during the primary school years (7-11 years) has been reported. What this study adds? This reflects lower remission rates of excess body fat (i.e. the proportion of shifts from excess to normal body fat) between the ages of 7 and 11 years as compared with nearly balanced incidence and remission rates of excess body fat between the ages of 3 and 7 years. OBJECTIVE: This study aimed to compare the age-specific balance between incidence and remission of excess body fat between the ages of 3-7 and 7-11 years using the data from a longitudinal study. DESIGN: Longitudinal analysis based on the data from the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study, an ongoing, open cohort study in healthy children, conducted in Dortmund, Germany. Excess body fat was defined by the sum of triceps and subscapular skin-fold measurements above the 90th reference percentile of the new German standard; overweight was defined using different national and international standards. The main outcome parameters were incidence and remission rates of excess body fat (n = 496) and overweight (n = 518) between the ages of 3 and 7 years and between the ages of 7 and 11 years. RESULTS: The incidence rates of excess skin-fold thickness between the ages of 3 and 7 years (4.2 [2.4, 6.2]%) and between the ages of 7 and 11 years (4.3 [2.6, 6.2]%) were almost identical. By contrast, remission rates were significantly lower during the age period of 7-11 years (primary school age) than during the age period of 3-7 years (pre-school age): 37.5 (21.9, 53.1%) compared with 72.3 (59.6, 85.1%). CONCLUSIONS: These data point to the low remission of excess body fat as an important driving force for the increasing prevalence of excess body fat in children between the ages of 7 and 11 years. Public health initiatives in children should encompass both primary prevention and interventions targeted at children already overweight at school entry.

Outcome prediction in cardiac surgery: the first logistic scoring model for cardiac surgical intensive care patients.

BACKGROUND: In the process of risk stratification, a logistic calculation of mortality risk in percentage is easier to interpret. Unfortunately, there is no reliable logistic model available for postoperative intensive care patients. The aim of this study was to present the first logistic model for postoperative mortality risk stratification in cardiac surgical intensive care units. This logistic version is based on our previously presented and established additive model (CASUS) that proved a very high reliability. METHODS: In this prospective study, data from all adult patients admitted to our ICU after cardiac surgery over a period of three years (2007-2009) were collected. The Log-CASUS was developed by weighting the 10 variables of the additive CASUS and adding the number of postoperative day to the model. Risk of mortality is predicted with a logistic regression equation. Statistical performance of the two scores was assessed using calibration (observed/expected mortality ratio), discrimination (area under the receiver operating characteristic curve), and overall correct classification analyses. The outcome measure was ICU mortality. RESULTS: A total of 4054 adult cardiac surgical patients was admitted to the ICU after cardiac surgery during the study period. The ICU mortality rate was 5.8%. The discriminatory power was very high for both additive (0.865-0.966) and logistic (0.874-0.963) models. The logistic model calibrated well from the first until the 13th postoperative day (0.997-1.002), but the additive model over- or underestimated mortality risk (0.626-1.193). CONCLUSION: The logistic model shows statistical superiority. Because of the precise weighing the individual risk factors, it offers a reliable risk prediction. It is easier to interpret and to facilitate the integration of mortality risk stratification into the daily management more than the additive one.

Weight status of European preschool children and associations with family demographics and energy balance-related behaviours: a pooled analysis of six European studies.

This study aimed to (i) gain insight in the prevalence of overweight indices in European preschoolers (4-7 years); (ii) identify energy balance-related behaviours associated with overweight/obesity; and (iii) identify children at risk for overweight/obesity. Secondary analyses of six European data sets were conducted according to standardized protocols. Based on objectively measured height and weight, prevalence of overweight and obesity across the countries ranged from 8% to 30% and 1% to 13%, respectively, with highest rates in Southern European countries (i.e. Spain and Greece). Positive associations between sedentary behaviours and overweight indices were found. Physical activity and dietary behaviours were not associated, possibly because of methodological limitations. Children of parents with high body mass index or low socioeconomic status were at increased risk of overweight/obesity. In conclusion, large differences in prevalence of overweight and obesity among preschoolers across Europe were observed. Future obesity prevention interventions in preschoolers should target screen time giving specific attention to children from overweight and/or low socioeconomic status parents. There is a need for high methodological quality studies, preferably with a long-term prospective design using sensitive, valid and reliable measures of behaviours, assessing whether and which physical activity and dietary behaviours are associated with overweight in preschoolers.

Comparison between Sequential Organ Failure Assessment score (SOFA) and Cardiac Surgery Score (CASUS) for mortality prediction after cardiac surgery.

BACKGROUND: Our purpose was to evaluate and compare the accuracy of the "Sequential Organ Failure Assessment" score (SOFA) and the "Cardiac Surgery Score" (CASUS) for the prediction of mortality after cardiac surgery. METHODS: Between January 1, 2007 and December 31, 2008 we prospectively included all consecutive adult patients admitted to our intensive care unit (ICU) after cardiac surgery. Both scoring systems were calculated daily from the 1st day in the ICU (day of operation) until the 7th ICU day. We evaluated the ICU mortality prediction of both models using calibration and discrimination statistics. RESULTS: 2801 patients (29.6% females) were included. Mean age was 66.9 ± 10.7 years. Intensive care unit mortality was 5.2%. The calibration of the "Sequential Organ Failure Assessment Score" and "Cardiac Surgery Score" was reliable for all days (p ≥ 0.05). CASUS was more accurate in predicting survival and mortality compared to SOFA for all days, as evidenced by the larger areas under the Receiver Operating Characteristic curves. CONCLUSIONS: Both CASUS and SOFA are reliable mortality prediction tools after cardiac surgery. However, CASUS was more accurate in predicting the individual patient's risk of mortality. Thus, use of the CASUS in cardiac surgery intensive care units is recommended.

[Sleep duration and overweight]. / Schlafdauer und Übergewicht.

Sleep deprivation is considered a serious risk factor with a relevant public health impact due to its multiple effects, which we are just beginning to understand. This is underlined by the growing number of studies in recent decades that have investigated the association between sleep duration and overweight. This review gives an overview of the current state of research and potential biological mechanisms. Evidence from epidemiological studies suggests an association between short sleep duration and overweight in children as well as in adults. Different biological mechanisms have been discussed in this context with a special focus on hormonal changes as the potential mediator. To include sleep in a comprehensive strategy to prevent overweight, interventional studies that analyze the potentially protective effect of prolonged sleep duration are necessary.

Detection of tracheal malpositioning of nasogastric tubes using endotracheal cuff pressure measurement.

BACKGROUND: Insertion of a gastric tube (GT) in anaesthetized, paralyzed and intubated patients may be difficult. Tracheobronchial malposition of a GT may result in deleterious consequences. The purpose of this study was to determine the reliability of tracheal cuff pressure measurement to detect endobronchial malposition of GTs. We compared this new method with the measurement of exhaled CO(2) through the GT. METHODS: Thirty patients under general anesthesia and orotracheal intubation were analysed. First, the cuff pressure of the low-volume endotracheal tube (ET; ID 7.0-8.5 mm) was increased to 40 cmH(2)O. Then, in a randomized fashion, the GT (18 Charrière) was inserted consecutively into the trachea and oesophagus or vice versa. Cuff pressure was monitored continuously while advancing the GT. Furthermore, a capnograph was connected to the gastric tube and the aspirated PCO(2) was monitored. RESULTS: Advancement of the gastric tube into the oesophagus increased ET cuff pressure by 1 +/- 1 cmH(2)O, while endotracheal placement of the GT increased cuff pressure by 28 +/- 8 cmH(2)O (P < 0.001). Using an increase of >10 cmH(2)O in cuff pressure detected endotracheal malpositioning of the GT with 100% sensitivity and specificity. In 28 out of 30 cases, PCO(2) increased by more than 2.6 kPa. Thus, the PCO(2) approach failed to detect tracheal malpositioning in two cases resulting in a sensitivity of 93.3%. CONCLUSIONS: In intubated patients, cuff pressure measurement during insertion of a gastric tube is a new, simple and reliable bedside method to detect endotracheal malpositioning of a GT.

Saccades to moving targets.

The metrics and dynamics of saccades to stationary and moving targets were observed in monkeys (Macaca mulatta). To isolate the effects of target speed on the saccade from contributions of smooth pursuit, saccade velocity was corrected for intrasaccadic pursuit velocity on a trial-by-trial basis prior to analysis. The effects of presaccadic retinal error and target speed on the saccadic velocity profile were determined by analyzing the partial correlations computed as a function of time after saccade onset. The main results are: (1) Saccade amplitude is determined not only by the retinal error sampled before the saccade, but also by the speed of the target during the latency period. (2) The dynamics of saccades, even if compensated for smooth-pursuit components, differ between forward- and backward-moving targets. (3) Whereas the presaccadic retinal error affects the eye velocity throughout the saccade, target speed has no effect before peak velocity. These results are discussed in the context of current models of saccade generation and their physiological substrates, in particular the role of the cerebellum in the local feedback loop.

[Bilateral peripheral pulmonic stenosis due to tumor-compression (author's transl)]. / Symmetrische periphere Pulmonalstenose durch Tumorkompression.

Description of a case of bilateral peripheral pulmonic stenosis due to a retothel-sarcoma of the mediastinum. A temporary remission of the stenotic symptoms was achieved under betatron-radiation and combined cytostatic therapy.