National strategy for palliative care of severely ill and dying people and their relatives in pandemics (PallPan) in Germany - study protocol of a mixed-methods project.

BACKGROUND: In the SARS-CoV-2 pandemic, general and specialist Palliative Care (PC) plays an essential role in health care, contributing to symptom control, psycho-social support, and providing support in complex decision making. Numbers of COVID-19 related deaths have recently increased demanding more palliative care input. Also, the pandemic impacts on palliative care for non-COVID-19 patients. Strategies on the care for seriously ill and dying people in pandemic times are lacking. Therefore, the program 'Palliative care in Pandemics' (PallPan) aims to develop and consent a national pandemic plan for the care of seriously ill and dying adults and their informal carers in pandemics including (a) guidance for generalist and specialist palliative care of patients with and without SARS-CoV-2 infections on the micro, meso and macro level, (b) collection and development of information material for an online platform, and (c) identification of variables and research questions on palliative care in pandemics for the national pandemic cohort network (NAPKON). METHODS: Mixed-methods project including ten work packages conducting (online) surveys and qualitative interviews to explore and describe i) experiences and burden of patients (with/without SARS-CoV-2 infection) and their relatives, ii) experiences, challenges and potential solutions of health care professionals, stakeholders and decision makers during the SARS-CoV-2 pandemic. The work package results inform the development of a consensus-based guidance. In addition, best practice examples and relevant literature will be collected and variables for data collection identified. DISCUSSION: For a future "pandemic preparedness" national and international recommendations and concepts for the care of severely ill and dying people are necessary considering both generalist and specialist palliative care in the home care and inpatient setting.

Vital signs: Valid indicators to assess pain in intensive care unit patients? An observational, descriptive study.

Pain is a stressor for intensive care unit (ICU) patients, and inadequate pain assessment has been linked to increased morbidity and mortality. One hundred and twenty patients were evaluated during three periods: (T1) 1 min before, (T2) during, and (T3) 20 min after the nociceptive procedure. For each patient, data were obtained through at least two nociceptive procedures. Conscious patients' self-reports of pain were assessed using the Numerical Rating Scale and Visual Analog Scale. For unconscious patients, the Behavioral Pain Scale was used instead. Descriptive statistical methods, Friedman's test, and Spearman's rank correlation coefficient were used for the data analysis. Significant changes were observed in heart rate (HR), respiratory rate (RR), and peripheral oxygen saturation (SpO2 ) during nociceptive procedures. The HR, RR, and pain scores increased, while the SpO2 decreased. Positive correlation coefficients were observed between the pain intensity and HR and RR levels. According to our study findings, vital signs are not strong indicators for pain assessment in neurosurgery ICU patients. However, HR and RR can be used as cues when behavioral indicators are not valid in these unconscious patients.

Challenges in using allylthiourea and chlorate as specific nitrification inhibitors.

Allylthiourea (ATU) and chlorate (ClO3-) are often used to selectively inhibit nitritation and nitratation. In this work we identified challenges with use of these compounds in inhibitory assays with filter material from a biological rapid sand filter for groundwater treatment. Inhibition was investigated in continuous-flow lab-scale columns, packed with filter material from a full-scale filter and supplied with NH4+ or NO2-. ATU concentrations of 0.1-0.5 mM interfered with the indophenol blue method for NH4+ quantification leading to underestimation of the measured NH4+ concentration. Interference was stronger at higher ATU levels and resulted in no NH4+ detection at 0.5 mM ATU. ClO3- at typical concentrations for inhibition assays (1-10 mM) inhibited nitratation by less than 6%, while nitritation was instead inhibited by 91% when NH4+ was supplied. On the other hand, nitratation was inhibited by 67-71% at 10-20 mM ClO3- when NO2- was supplied, suggesting significant nitratation inhibition at higher NO2- concentrations. No chlorite (ClO2-) was detected in the effluent, and thus we could not confirm that nitritation inhibition was caused by ClO3- reduction to ClO2-. In conclusion, ATU and ClO3- should be used with caution in inhibition assays, because analytical interference and poor selectivity for the targeted process may affect the experimental outcome and compromise result interpretation.

The effect of sedation during transoesophageal echocardiography on heart rate variability: a comparison of hypnotic sedation with medical sedation.

BACKGROUND: There is no ideal sedation technique that can be used during transoesophageal echocardiography (TEE), and the data concerning the effects of available sedation techniques on heart rate variability (HRV) are limited. AIM: To compare the effects of sedation through hypnotherapy with medical sedation achieved by midazolam on HRV. METHODS: We recruited 76 patients with an indication of TEE; the age range was 18-83 years. In Group T there were 26 patients who had the procedure under topical pharyngeal anaesthesia, in Group D there were 23 patients who received midazolam, and in Group H there were 27 patients receiving hypnosis. All patients had an IV access; throughout the procedure heart rate, rhythm electrocardiography, and peripheric O2 saturation were monitored with a non-invasive monitor, and blood pressure measurements were taken every 3 min. Rhythm Holter recordings were obtained from all patients and TEE was performed. RESULTS: When time domain parameters for HRV were compared in all three groups, the hypnosis group had significant increases in pNN50 and RMSSD compared to Groups D and T (p < 0.05). As concerns frequency domain parameters, there were no significant differences between groups where low frequency (LF) was decreased in hypnosis group and high frequency (HF) was increased (p > 0.05). However, LF/HF was decreased statistically significantly (p < 0.05) when compared with the midazolam group. CONCLUSIONS: Contrary to standard sedation in TEE patients, when hypnosis is used autonomic cardiac tone is modified to a significant extent. Hypnotic sedation achieves this by increasing the parasympathetic activity, decreasing the sympathetic activity, and changing the sympathovagal interaction balance.

Evaluation of QT and P wave dispersion and mean platelet volume among inflammatory bowel disease patients.

BACKGROUND: In inflammatory bowel disease (IBD) number of thromboembolic events are increased due to hypercoagulupathy and platelet activation. Increases in mean platelet volume (MPV) can lead to platelet activation, this leads to thromboembolic events and can cause acute coronary syndromes. In IBD patients, QT-dispersion and P-wave dispersion are predictors of ventricular arrhythmias and atrial fibrilation; MPV is accepted as a risk factor for acute coronary syndromes, we aimed at evaluating the correlations of these with the duration of disease, its localization and activity. METHODS: The study group consisted of 69 IBD (Ulcerative colitis n: 54, Crohn's Disease n: 15) patients and the control group included 38 healthy individuals. Disease activity was evaluated both endoscopically and clinically. Patients with existing cardiac conditions, those using QT prolonging medications and having systemic diseases, anemia and electrolyte imbalances were excluded from the study. QT-dispersion, P-wave dispersion and MPV values of both groups were compared with disease activity, its localization, duration of disease and the antibiotics used. RESULTS: The P-wave dispersion values of the study group were significantly higher than those of the control group. Duration of the disease was not associated with QT-dispersion, and MPV levels. QT-dispersion, P-wave dispersion, MPV and platelet count levels were similar between the active and in mild ulcerative colitis patients. QT-dispersion levels were similar between IBD patients and the control group. No difference was observed between P-wave dispersion, QT-dispersion and MPV values; with regards to disease duration, disease activity, and localization in the study group (p>0.05). CONCLUSIONS: P-wave dispersion which is accepted as a risk factor for the development of atrial fibirilation was found to be high in our IBD patients. This demonstrates us that the risk of developing atrial fibrillation may be high in patients with IBD. No significant difference was found in the QT-dispersion, and in the MPV values when compared to the control group.

Stone formation from intravesical Hem-o-lok clip migration after laparoscopic radical prostatectomy.

Intravesical Hem-o-lok clip (HOLC) migration is a rare complication of prostatic surgery. We report two cases of migration of a HOLC into the bladder leading to stone formation. As such, these devices should be used with caution in the region of the vesicourethral anastomosis.

Percutaneous versus transurethral cystolithotripsy.

PURPOSE: To compare transurethral cystolithotripsy (TUCL) and percutaneous cystolithotripsy (PCCL) modalities performed during simultaneous transurethral resection of the prostate (TURP) in patients with prostate hyperplasia and large bladder stones. PATIENTS AND METHODS: Sixty-three patients with prostate volume >40 cc and aggregate stone size >2.5 cm were enrolled in the study between August 2003 and February 2007. TUCL (n = 38) or PCCL (n = 25) procedures were performed during simultaneous TURP. In the TUCL group, the stones were removed after fragmentation through a 23F cystolithotripter with pneumatic lithotripsy. This was followed by TURP, performed with a 26F continuous-flow resectoscope. In the PCCL group, the stones were removed through a suprapubic 30F Amplatz sheath after fragmentation. TURP was then performed with the suprapubic sheath providing continuous drainage. RESULTS: Mean age and prostate volumes of the groups were similar. Mean aggregate stone sizes were significantly larger in the PCCL group. The operative time for stone removal was significantly less in the PCCL group while time needed for TURP was statistically similar in the two groups. In the TUCL group, three patients had residual stones necessitating repeated TUCL and urethral stricture developed in three patients. CONCLUSION: The smaller caliber of the working channel during TUCL, compared with PCCL, necessitates disintegration of the stones into smaller fragments. This elongates the duration of the intervention and results in increased urethral and bladder trauma. Combined TURP and PCCL is a safer, more effective, and much faster alternative to combined TURP and TUCL in patients with large bladder stones and prostate hyperplasia.

An unusual complication of familial Mediterranean fever: intestinal volvulus and necrosis.

Familial Mediterranean fever is an autosomal recessive disease characterized by recurring inflammatory attacks of synovial membranes. More than 95% of patients show peritoneal involvement which mimics acute abdomen and can sometimes cause unnecessary surgical intervention. The authors present two patients with the diagnosis of familial Mediterranean fever who underwent surgery because of rare abdominal complication of the disease. Two patients with the diagnosis of familial Mediterranean fever underwent laparotomy, and segmental small bowel resection was done because of the necrosis. Adhesive intestinal obstruction with associated bowel strangulation and volvulus is a rare complication of familial Mediterranean fever, and this life-threatening emergency must be kept in mind.

Urinary tract involvement in a child with epidermolysis bullosa simplex.

Epidermolysis bullosa is a rare disorder which may present various systemic involvement. We present a 15-month-old boy with epidermolysis bullosa simplex who was admitted with symptoms of hematuria and dysuria and discuss the pathology from a urological standpoint.

Embryonal rhabdomyosarcoma of the common bile duct mimicking choledochal cyst.

Embryonal rhabdomyosarcoma of the common bile duct is a very rare malignancy of childhood. The radiological appearance of the lesion is similar to that of congenital choledochal cyst if there is no local invasion to the adjacent tissues. The authors present a case of embryonal rhabdomyosarcoma of the common bile duct which was considered to be a congenital choledochal cyst preoperatively, and they discuss this very rare childhood tumor, with a brief survey of the literature. In conclusion, it is important to know that this rare tumor can simulate congenital choledochal cyst; it should be considered in the differential diagnosis of obstructive jaundice in children.

Bronchogenic cysts: a rare congenital cystic malformation of the lung.

PURPOSE: Bronchogenic cysts are rare congenital cystic malformations of the lung. We retrospectively analyzed ten cases of bronchogenic cyst (BC) to reinforce the importance of recognizing this malformation. METHODS: Between 1985 and 2000, ten pediatric patients with BC were treated surgically in our department. Their clinical presentation, radiological, operative, and pathological findings were analyzed retrospectively. RESULTS: There were five boys and five girls, ranging in age from 16 days to 6 years (mean 6.5 months). The clinical signs and symptoms included respiratory distress in seven patients (70%), cyanosis in four (40%), chronic cough and fever in five (50%), and dysphasia in two (20%). Routine chest X-ray revealed a pulmonary air-filled cyst in six patients (60%) and a pulmonary nodular opacity in four (40%). The diagnosis was supported by computed tomography in four patients and by ultrasonography in two. Eight of the patients were treated by cyst excision and two by lobectomy. The pathological diagnosis made from all specimens was bronchogenic cyst, with squamous metaplasia in two. CONCLUSION: In newborns, infants, and even children, the development of dyspnea, cyanosis, chronic cough, and fever should alert us to the suspicion of a cystic malformation in the lung, such as a bronchogenic cyst, especially if an air-filled cyst is seen on a plain chest X-ray.

The effect of pentoxifylline on intestinal anastomotic healing after ischemia.

The negative effects of ischemia-reperfusion injury (IRI) on intestinal anastomotic healing have been described in previous studies. To determine the effect of pentoxifylline (PTF) on small-bowel anastomoses performed after IRI, 20 male Wistar albino rats were studied. Under ketamine anesthesia, the superior mesenteric artery was occluded for 30 min and ileal resection-anastomosis was performed after 10 min of reperfusion. In group I, no medication was given. In group II, PTF 50 mg/kg was administered intraperitoneally before reperfusion and i.m. on the 1st, 2nd, 3rd and 4th postoperative days (POD). All rats were killed and anastomotic segments were removed on the 7th POD. Anastomotic bursting pressure (ABP) and hydroxyproline (HP) content were measured in the anastomotic segments; parameters were compared statistically with Student's t-test. In group I, the mean ABP was 225.5 +/- 38.18 mmHg the and mean HP level was 16.03 +/- 1.91 micro mol/g tissue. In group II, these levels were 277 +/- 41.1 mmHg and 19.85 +/- 1.81 micro mol/g tissue, respectively. The differences between the groups were significant (P < 0.005). Thus, PTF can improve anastomotic healing in an experimental model after IRI by promotion of collagen synthesis.