The intra- and inter-observer reliability of a novel protocol for two-point discrimination in individuals with chronic low back pain.

Two-point discrimination is measured as an indicator of cortical reorganisation in musculoskeletal medicine. Nevertheless, data are lacking for the reliability of this measure in patients with non-specific chronic low back pain (NSCLBP). We aimed to quantify the intra- and inter-observer reliability of a novel protocol for measuring two-point discrimination in these patients. 35 participants (12 males, 23 females, mean age 52, SD 15 years) with NSCLBP were recruited. Three clinicians made 14 consecutive measurements of two-point discrimination with callipers. One of these clinicians repeated the assessment protocol within 7 d. During each measurement, the calliper width was widened in 5 mm increments until participants could consistently identify two points. Intra- and inter-observer agreement was quantified using mean difference, within-subject SD and limits of agreement (LOA). After using the first measurement for familiarisation, the mean of measurements 2-5 within an assessment resulted in the optimum compromise between clinic time constraints and acceptable intra-observer reliability; the within-subjects SD being 7.5 mm (LOA: 20.8 mm). Inter-observer reliability was generally poorer; requiring the mean of measurements 2-9 within an assessment for a similar within-subjects SD of 8.6 mm (LOA: 23.7 mm). It was estimated that these within-subjects SDs were small enough for a clinically-important change to be detected with a feasible sample size in future studies. The intra-observer reliability of our assessment protocol is acceptable for detecting a clinically relevant difference in two-point discrimination for future research purposes. Nevertheless, individual patient measurement variability is relatively high, especially between different clinicians.

Conversion rate in 300 laparoscopic rectal resections and its influence on morbidity and oncological outcome.

INTRODUCTION: The negative influence of conversion from laparoscopic to open colorectal resection on early postoperative morbidity and outcome has been demonstrated several times. In this study, we analyzed the conversion rate and its influence on early postoperative morbidity and short-term oncological outcome following laparoscopic rectal resections. METHODS: From January 1998 to December 2006, 300 patients underwent laparoscopic resection due to rectal carcinoma at our institution. We compared the converted patient group with the non-converted patient group regarding demographical, clinical, surgical, and histological data, compounded with the early and late postoperative results. RESULTS: Two hundred seventy-four (91.3%) patients underwent laparoscopic rectal resection (LR), while conversion resection (CR) was necessary in 26 cases (8.6%). Conversion rate was 13% during the first 100 resections and decreased to 3% during the last 100 procedures (p = 0.035). Male gender, higher body mass index, and presence of T4-tumor were risk factors for conversion. Early postoperative complications were more frequent in the CR group than in the LR group. Concerning local tumor recurrence and overall survival, there was no significant difference between both groups (local recurrence, CR at 3.8% vs. LR at 4.5% and overall survival rate, CR at 76.9% vs. LR at 89.1%) after a median follow-up period of 22.5 months. CONCLUSION: Conversion to an open procedure during laparoscopic rectal resection correlates with an increased postoperative morbidity, however, without impairment of the short-term oncological outcome. The conversion rate is minimized by the growing experience of the operating surgeon and, therefore, is a marker of the learning curve.

["Fast-Track" for laparoscopic-assisted rectum resection--what can be achieved? First results of a feasibility study]. / "Fast-Track" bei laparoskopisch assistierter Rektumresektion--was kann erreicht werden? Erste Ergebnisse einer Machbarkeitsstudie.

AIM: "Fast-track" multimodal rehabilitation is increasingly entering the perioperative management strategies in colon surgery aiming at minimized perioperative morbidity and accelerated recovery. So far little is known about the complementary effects of minimally invasive surgery along with "fast-track" rehabilitation in the treatment of rectal cancer. The aim of this pilot study was to investigate the influence of "fast-track" perioperative management on morbidity, recovery and length of hospital stay in laparoscopically-assisted rectum resections and to compare those data to earlier results. METHODS: An interdiciplinary "fast-track" multimodal rehabilitation strategy with avoidance of mechanical bowel cleansing, with a restrictive intravenous intra- and postoperative fluid regimen, forced mobilisation, and early enteral nutrition was introduced into clinical practice and applied in 16 laparoscopically-assisted rectum resections. Data were collected in the course af a prospective analysis. The mean patient age was 62 (42-79) years. RESULTS: Mean time of surgery was 245 (SD 46) min, and the mean intraoperative infusion rate was 11.2 (SD 2.6) ml/kg/BW. On day 2, 14 of the 16 patients tolerated solid food and 12 patients had had bowel movements. All patients returned to their initial body weight by day 4. The median postoperative hospital stay was 7.5 days (6-20), 12 patients were discharged between day 6 and 8. Two patients were readmitted for intestinal atony, one patient developed an anastomotic leakage. CONCLUSIONS: "Fast-track" rehabilitation is feasible in rectum surgery and seems to complement the beneficial effects of minimally invasive surgery without increasing the complication rate.

[Angiosarcoma as a rare differential diagnosis in spontaneous rupture of the spleen]. / Ein Angiosarkom als seltene Differenzialdiagnose der spontanen Milzruptur.

A splenectomy was performed in a 37-year-old woman because of spontaneous rupture of the spleen. Primary angiosarcoma of the spleen was diagnosed postoperatively based on histology. Primary angiosarcoma of the spleen is a very rare neoplasm with disastrous prognosis. Immunohistochemical and ultrastructural examinations are necessary to verify the diagnosis because the histopathological picture of the tumor is variable. Due to the small number of reported cases, there are no guidelines for adjuvant or palliative therapy, and up to today all adjuvant means of radiotherapy and chemotherapy have not improved the prognosis of the patients.

["Simplified Acute Physiology Score" (SAPS II) ina the assessment of severity of illness in surgical intensive care patients]. / "Simplified Acute Physiology Score" (SAPS II) zur Einschätzung der Erkrankungsschwere bei chirurgischen Intensivpatienten.

INTRODUCTION: In 1993, Le Gall proposed a new Simplified Acute Physiology Score (SAPS II) to assess the severity of illness in intensive care patients and to predict the risk of hospital mortality using a large data base of more than 13,000 patients of different intensive care units. Up to the present time, no satisfactory form of validation for surgical intensive care patients has been available. We investigated the prognostic quality of this score system for the assessment of the severity of the illness in surgical intensive care patients. METHODS: Between October 1997 and December 1998, 310 consecutive patients were included in our study. We calculated the SAPS II score according to the published guidelines. Additionally, we calculated the risk of mortality by referring to the score. We used a receiver operating characteristics (ROC) analysis for statistical evaluation. RESULTS: The median duration of stay on our intensive care unit was 8.4 days. In all patients, the mean SAPS II was 29.9 +/- 12.7. In the survivors, calculation of mean SAPS II was 27.7 +/- 11.4. In the non-survivors, mean SAPS II was 45.7 +/- 11.2. The predicted risk of mortality was 15.7%, the actual risk of mortality was 15.8%. CONCLUSION: The SAPS II score has proved to be a good prognostic instrument in surgical intensive care patients. SAPS II is particularly effective in providing an exact estimation of the risk of death, classifying patient groups in clinical studies, epidemiological investigations, and quality assessment.

[Ventilation in prone position in a 5-year-old child after multiple trauma. Effective treatment of persistent atelectasis]. / Beatmung in Bauchlage bei einem 5-jährigen Kind nach Polytrauma. Effektive Therapie persistierender Atelektasen.

We report on the ventilation in prone position in a 5-year-old traumatized child with severe thoracic and abdominal injuries (lung contusion, rib fractures, rupture of liver and spleen). Under continuous analgesic sedation, the young patient was ventilated in prone position for 6 h, since acute lung injury and atelectasis persisted despite various therapeutic measures (artificial ventilation in the pressure controlled mode, fiberoptic bronchoscopy, reexpansion maneuver). After initiation of the prone position, we observed a rapid increase in arterial oxygenation, which persisted in the following period. The hemodynamic situation remained stable. The complete disappearance of atelectasis was demonstrated radiologically after supine repositioning. After cessation of analgesic sedation, the extubation was performed 2 days later. Furthermore, we found no side effects of the prone position on the injured abdomen, and the liver function improved rapidly. Although there is a lack of experience with ventilation in prone position in pediatric intensive care, our report might be a recommendation for the indication of this technique in children.

Molecular strategies to improve the nutritional quality of legume proteins.

Legume proteins are relatively deficient in the sulfur amino acids. Among the different strategies to increase the sulfur amino acid contents of legumes, we have chosen to increase the biosynthesis of endogenous, non-abundant sulfur-rich proteins we have identified in soybean seed. We identified and isolated an 8 kDa sulfur-rich protein from the albumin fraction of soybean seed. Subsequently, a cDNA designated Gm2S-1, has been isolated and characterized. The Gm2S-1 cDNA encodes a pre-proprotein that contains a signal peptide and a precursor protein that undergoes post-translational processing to yield the mature 8 kDa protein containing 7.8% methionine and 7.8% cysteine. The Gm2S-1 gene is an ideal candidate for overexpression to improve the nutritional quality of soybean and other legumes.

[Abdominal surgery in the elderly--a retrospective analysis over 11 years]. / Abdominalchirurgie im Alter--eine retrospektive Analyse über 11 Jahre.

Particular problems of abdominal surgery in geriatric patients were analyzed in a retrospective study of 1569 surgical procedures of the abdomen carried out in 1420 patients aged 70 years or more. Emergency procedures were necessary in 357 (22.8%) cases with a lethality of 25.5% compared to 8.8% in the elective group. Morbidity was also visibly different in both groups (59.3% vs. 40.2%). While the average time of hospitalisation was 22.4 days, almost 80% of our patients could be released and 12.6% died in hospital.