[Service robots in elderly care. Possible application areas and current state of developments]. / Servicerobotik für den demografischen Wandel. Mögliche Einsatzfelder und aktueller Entwicklungsstand.

The term "Service robotics" describes semi- or fully autonomous technical systems able to perform services useful to the well-being of humans. Service robots have the potential to support and disburden both persons in need of care as well as nursing care staff. In addition, they can be used in prevention and rehabilitation in order to reduce or avoid the need for help. Products currently available to support people in domestic environments are mainly cleaning or remote-controlled communication robots. Examples of current research activities are the (further) development of mobile robots as advanced communication assistants or the development of (semi) autonomous manipulation aids and multifunctional household assistants. Transport robots are commonly used in many hospitals. In nursing care facilities, the first evaluations have already been made. So-called emotional robots are now sold as products and can be used for therapeutic, occupational, or entertainment activities.

A Rare Case of Propofol-Induced Acute Liver Failure and Literature Review.

The incidence of drug-induced acute liver failure is increasing. A number of drugs can inhibit mitochondrial functions, alter ß-oxidation and cause accumulation of free fatty acids within the hepatocytes. This may result in hepatic steatosis, cell death and liver injury. In our case, propofol, an anesthetic drug commonly used in adults and children, is suspected to have induced disturbance of the mitochondrial respiratory chain, which in consequence led to insufficient energy supply and finally liver failure. We report the case of a 35-year-old Caucasian woman with acute liver failure after anesthesia for stripping of varicose veins. Liver histology, imaging and laboratory data indicate drug-induced acute liver failure, presumably due to propofol. Hepatocyte death and microvesicular fatty degeneration of 90% of the liver parenchyma were observed before treatment with steroids. Six months later, a second biopsy was performed, which revealed only minimal steatosis and minimal periportal hepatitis. We suggest that propofol led to impaired fatty acid oxidation possibly due to a genetic susceptibility. This caused free fatty acid accumulation within hepatocytes, which presented as hepatocellular fatty degeneration and cell death. Large scale hepatocyte death was followed by impaired liver function and, consecutively, progressed to acute liver failure.

Autonomic dysfunction in patients with achalasia of the oesophagus.

It has been suggested that achalasia is associated with extraoesophageal sympathetic and parasympathetic dysfunction. In a prospective study we applied conventional ultrasonography and duplex sonography to investigate basal and postprandial peak systolic velocity (PSV), pulsatility index (PI) and resistance index (RI) of superior mesenteric artery and PSV of portal vein in nine patients with achalasia and 10 healthy controls (study I). In addition, in eight of these patients autonomic nervous function was investigated by pupillary function tests as well as cardiovascular reflex tests and compared with eight age- and sex-matched controls (study II). The results indicated that postprandial increase of PSV in the superior mesenteric artery was significantly lower, and postprandial decrease of PI and RI significantly higher in achalasia compared to healthy controls. In contrast, postprandial increase of PSV in the portal vein was not significantly different between both groups. Autonomic function tests revealed significant lower maximal pupillary contraction and redilatation velocities, significantly lower heart rate variation during orthostasis, deep respiration test and Valsalva manoeuvre in achalasia compared to controls. It is concluded that achalasia is associated with extraoesophageal autonomic nervous dysfunction that involves cardiovascular and pupillary function as well as regulation of mesenteric arterial blood flow.

[How accurate is preoperative staging as a basis for treatment decisions in gastric carcinoma?]. / Wie sicher ist das präoperative Staging als Grundlage der Therapieentscheidung beim Magenkarzinom?

The treatment of advanced gastric carcinoma by various neoadjuvant and adjuvant multimodal therapy regimes is under current investigation to improve the poor outcome of these patients. Therefore, pretherapeutic tumor staging according to the TNM classification is essential for the optimal application of various therapeutic modalities. According to recent studies, endoscopic ultrasonography (EUS) is the most sensitive technique in measuring tumor infiltration (T-staging). In addition, although less reliable compared to the T-staging, the sensitivity of EUS in assessing lymph node status (N-staging) is superior to computed tomography and conventional ultrasound. Pretherapeutic laparoscopic investigation may give additional important information about tumor stage. This overview describes the significance of various diagnostic techniques that can be applied in tumor staging investigations.

Transjugular intrahepatic portosystemic shunts: improved evaluation with echo-enhanced color Doppler sonography, power Doppler sonography, and spectral duplex sonography.

OBJECTIVE: We assessed the feasibility of contrast-enhanced color Doppler, power Doppler, and spectral duplex sonography for visualization and quantification of flow through transjugular intrahepatic portosystemic shunts (TIPS) in patients in whom the baseline sonographic evaluation was unsatisfactory. SUBJECTS AND METHODS: Thirty-three patients underwent color Doppler, power Doppler, and spectral duplex sonography after TIPS insertion or before TIPS revision (mean time interval +/- SD, 1 +/- 1 day). All sonograms were obtained before and after patients received echo-enhancing contrast material. Sonography was evaluated with regard to presence or absence of flow in the mid portion, portal segment, and hepatic segment of the shunt. The maximal peak velocity was measured in the mid portion of the shunt. For identifying and quantifying stenoses, the percentage of luminal diameter reduction was calculated at the tightest part of the shunt. Shunt angiography and measurements of portosystemic pressure gradients were independently evaluated and compared with the sonographic findings. RESULTS: Flow visualization on unenhanced color Doppler sonography was significantly improved through the use of power Doppler sonography and contrast-enhanced color Doppler and power Doppler sonography (p < .01). Between contrast-enhanced power Doppler and contrast-enhanced color Doppler sonography, a significant difference was found in the portal and hepatic segments (p < .05). All shunt stenoses (n = 8) and occlusions (n = 3) were revealed by power Doppler sonography, whereas color Doppler sonography failed to reveal six of eight stenoses. Compared with unenhanced sonography, the quality of spectral duplex sonography was improved in eight patients after contrast enhancement (p < .05). Maximal peak velocity ranged from 54 to 252 cm/sec (mean +/- SD, 132.7 +/- 52.1 cm/sec) in normal shunts and from 24.5 to 70.0 cm/sec (mean +/- SD, 45.0 +/- 18.9 cm/sec) in stenosed shunts. No correlation was found between maximal peak velocity and portosystemic pressure gradients (r = .28). CONCLUSION: Unenhanced power Doppler and contrast-enhanced color and power Doppler sonography can be helpful in the assessment of TIPS status in patients who previously underwent unsatisfactory sonography. These techniques may allow anatomic evaluation and quantification of shunt stenosis in most patients. Contrast enhancement may also considerably improve the quality of spectral duplex sonography.

[Biomechanics of combined Kirschner wire osteosynthesis in the human model of unstable dorsal, distal radius fractures (Colles type)]. / Biomechanik der kombinierten Kirschnerdraht-Osteosynthese am humanen Modell der dorsal instabilen, distalen Radiusfraktur (Colles-Typ).

In an experimental study, the biomechanical qualities of the combined Kirschner wire osteosynthesis (KWO) in the unstable Colles' fracture were analyzed. This type of pin fixation is our preferred osteosynthesis in the treatment of unstable Colles' fracture because it allows immediate functional therapy. It represents a modification of Kapandji's dynamic KWO, compensating for the insufficient volar stability by means of the conventional static KWO. Clinical experience according to the anatomical and functional results, was very encouraging suggesting that a clinical concept based on the biomechanical principles of combined KWO and its single components should be constituted. Simulation of the unstable Colles' fracture was realized by dorsal wedge osteotomy of the distal end of the radius using cadaveric material. This fracture model was subsequently pinned using the different KWO types and tested by a standardized vector energy testing device regarding its stability in the four main loading directions. The combined KWO unifies the advantage of volar stability of the conventional KWO with the high dorsal stability of dynamic KWO. The main functional principle of dynamic KWO with regard to its axial stability consists in the repositioning of the dorsal bone fragmentation zone and hence the reconstitution of cortical load transmission. Besides its good stabilization, dynamic KWO also leads to optimal alignment of the distal metaphyseal fragment. Furthermore, the experiments yielded important information about technical aspects of the surgical procedure, which helps us to avoid anatomical and functional deficiencies. Based on these experimental findings, the surgical technique of combined KWO was standardized.

Anal endosonography and manometry: comparison in patients with defecation problems.

PURPOSE: Correlations between anal sphincter function as assessed by anorectal manometry and anal sphincter anatomy measured by endoluminal ultrasound have been reported in the literature both for patients and for healthy individuals but have not been confirmed by other authors. METHODS: For a larger series of patients (152 consecutive patients, mean age 54.1 +/- 15.5 years; female:male ratio, 111:41) with anorectal dysfunctions such as incontinence (n = 92), constipation (n = 37), and other symptoms (n = 23), diagnostic work-up included conventional multilumen anorectal manometry to evaluate internal sphincter pressure at rest, maximum external sphincter squeeze pressure during contraction, and endoanal sonography to determine anal sphincter integrity and to measure dorsal, left lateral, and right lateral diameter of the internal anal sphincter (IAS) and external anal sphincter (EAS) muscles. RESULTS: Maximum squeeze pressure was significantly correlated to muscle thickness of the EAS (P = 0.001). No association was found between resting pressure and IAS diameter. Women had significantly lower resting and squeeze pressures than men (P = 0.008 and P = 0.003, respectively), but age-related changes of function were only found for resting pressure. Endosonographic values of IAS and EAS did not differ between genders but were significantly correlated with age (P = 0.008 and P = 0.02, respectively). Because all correlations were rather weak, they only can explain a small portion of data variance. CONCLUSION: Anal manometry and anal ultrasound, therefore, are of complementary value and are both indicated in adequate clinical problems.

How reproducible are measures of the anal sphincter muscle diameter by endoanal ultrasound?

UNLABELLED: Anal endosonography is an imaging technique for the anal sphincter system and offers analysis of its muscular integrity. It is generally assumed that measurement of the thickness of muscle layers is provided by sonography; however, reproducibility of such measurements have not yet been investigated. METHODS: Study 1: In 10 healthy volunteers, endoanal ultrasound was performed independently by two experienced investigators with two different ultrasound machines, and thickness of the muscle layers of the internal and external anal sphincter was assessed in the position of the intermediate dorsal anal canal in a randomized cross-over fashion. Study 2: In a study of similar design, sonography was performed in nine healthy volunteers by two investigators independently using a single ultrasound machine in three standardized positions (proximal/intermediate/distal anal canal) and the sphincter layers assessed in the left, right, and dorsal segment. RESULTS: Study 1: Both the same investigator with different ultrasound scanners and different investigators with the same machine failed to obtain reproducible results with respect to internal and external anal sphincter muscle layer diameter (four bivariate correlations, all with p > 0.05). Study 2: Standardization of the probe position did not improve the agreement (2 x 9 bivariate correlations, all but two p > 0.05). CONCLUSION: At present, therefore, endoanal ultrasound does not provide reliable morphometric data on anal sphincter muscle diameter. This could explain previously conflicting observations of associations between anal sphincter morphometry and function.

Comparison of anal sonography with conventional needle electromyography in the evaluation of anal sphincter defects.

OBJECTIVE: A comparison of anal sonography with conventional electromyographic mapping in the evaluation of anal sphincter defects was the aim of this study. METHODS: In 23 patients with defecatory problems referred for conventional needle electromyography (EMG), anal endosonography, with a 7.5-MHz, 355 degrees scanner, was performed before EMG to determine the structural integrity of the external anal sphincter. If lesions were found, they were described in terms of location and extent. Subsequently, concentric needle EMG of the external sphincter was performed circumferentially to locate muscle parts exhibiting normal and diminished or missing muscle activity. Lesions found by EMG were also described like those found by sonography. RESULTS: Of 23 patients, eight exhibited no abnormalities on EMG, and no muscle defects were identified endosonographically in any of these patients. In the remaining 15 patients, EMG showed either an incomplete pattern of interference or a complete absence of voluntary activity; in all of these patients endosonography also identified structural deficit. In 14 of these 15 patients, abnormalities were found at the same location with both endosonography and EMG. In the remaining patient, the two techniques identified structural and functional abnormalities at different locations. CONCLUSION: Although EMG is the gold standard for assessment of the functional relevance of muscle defects, anal endosonography yields a sensitivity and specificity of almost 100%.

Endosonography of the anal sphincters: incontinent and continent patients and healthy controls.

It has previously been shown that in healthy subjects anal sphincter functions as assessed by anorectal manometry and anal sphincter anatomy as measured by endoluminal ultrasound are poorly correlated. It remains to be shown, however, whether this is true for a larger series of patients with anorectal dysfunctions such as incontinence, and what is the clinical relevance of anal sonography. Anal sonography was performed in 42 consecutive patients with fecal incontinence, in 19 patients with constipation and/or anal pain, and in 15 healthy volunteers to determine anal sphincter integrity and the dorsal diameter of the internal and external anal sphincter muscles. Conventional multilumen anorectal manometry was performed in all subjects and patients to determine, among others, external and internal sphincter (EAS, IAS) performance at rest and during squeezing. It was shown that healthy subjects exhibit significantly higher muscle diameters of the IAS than both patient groups, but the EAS was similar in all groups. In 11/42 cases of incontinent patients, in 3/19 constipated patients, but in none of the controls a muscle defect of the EAS was found with sonography. Thirteen of these 14 patients were women with previous birth traumas. EAS but not IAS muscle thickness and muscle performance (squeezing and resting, respectively) were significantly correlated. Across all groups, women had smaller EAS muscle diameters than men. It is concluded, that in incontinent patients anal sonography may reveal additional information of clinical relevance in a substantial fraction of patients, and, thus, both anal manometry and anal ultrasound are of clinical value.