Quantification of Internal Carotid Artery Stenosis with 3D Ultrasound Angiography.

PURPOSE: The aim of this study was to evaluate a new method of three-dimensional ultrasound (3D-US) angiography of carotid vessels including 3D-US quantification of internal carotid artery (ICA) stenosis (ICAS). MATERIALS AND METHODS: Two neurologists performed native ultrasound scans of the brain-supplying carotid arteries in 73 probands (including 22 patients with 25 cases of ICAS) using a Toshiba Aplio 500 ultrasound machine equipped with the 3 D application of Curefab CS. Additionally, 25 probands underwent contrast-enhanced magnetic resonance angiography (CE-MRA) of the neck vessels. RESULTS: The mean length of the proximal ICA was 32.1 mm ±â€Š9.8 mm & 31.3 mm ±â€Š9.0 mm (each n = 97). The interrater reliability (intraclass correlation, ICC) was 0.75 ±â€Š0.23 for the common carotid artery (CCA, n = 90) and 0.78 ±â€Š0.21 (n = 92) for the ICA. The intermethod agreement between 3D-US angiography and CE-MRA was 0.67 ±â€Š0.19 (n = 45) & 0.66 ±â€Š0.19 (n = 44) for the CCA and 0.79 ±â€Š0.17 (n = 47) & 0.75 ±â€Š0.19 (n = 46) for the ICA. Quantification of ICAS applying 3D-US in comparison to 2D color-coded duplexsonography (2D-CDS) showed a moderate to good intermethod agreement both by the Bland and Altman analysis and by ICC (0.8 & 0.72; with each p < 0.001). The interrater reliability for quantification of ICAS was 0.79; p < 0.001. CONCLUSION: Native 3D-US angiography of carotid vessels shows good interrater and intermethod agreement in comparison to CE-MRA. Together with a moderate to good intermethod and interrater agreement in the quantification of ICAS, when compared to 2D-CDS, 3D-US angiography is thus a promising complementary imaging technique for carotid artery disease.

Cases of community-acquired meticillin-resistant Staphylococcus aureus in an asylum seekers centre in Germany, November 2010.

In an asylum seeker centre in Schleswig-Holstein, a resident was diagnosed with furuncle caused by a Panton-Valentine leukocidine (PVL)-positive community-acquired meticillin-resistant Staphylococcus aureus (CA-MRSA). As a result of active case finding, 232 of 427 persons (54% of all residents) were screened for MRSA and two further PVL-positive CA-MRSA cases were identified

[The bite-jumping-appliance]. / Die Vorschubdopplerplatte.

By the development of the bite-jumping-appliance (BJA) the wearing comfort for the patient was significantly improved and also the handling through the doctor was multiple facilitated. 1. While treating with the BJA the forward advancement of the mandible can be done simultaneously with the harmonizing of the maxillary and mandibular dental arches. 2. The wearing comfort during the day time, as well as the speech with the BJA in the patients mouth is possible without any problems due to the fact, that the BJA consist of two separate appliances. 3. The functioning of the BJA can be improved while using extraoral forces. Also the wearing of the BJA without extraoral forces leads to a headgear effect onto the maxilla. 4. Also uncontrolled muscle activities during the night leads, if the muscle activity is great enough, to a total biting together. 5. To avoid the contact between protrusive sticks and inclined plane in the lower appliance, the patient will bring unconsciously the mandible, while speaking during day time, in a more anterior position. This training effect leads to an accelerated forward advancement of the mandible as well as to an accelerated harmonizing of the muscular chewing pattern in the anterior position. 6. A harmonized muscular chewing pattern in the sagittal plane as well as in the frontal plane can be achieved in nearly all patients after finishing the BJA-therapy. These results couldn't be achieved with other bimaxillary appliances [28].

[Criterias for the selection of neckstraps in therapy with extraoral forces]. / Kriterien für die Auswahl von Nackenzügen für die Headgearbehandlung.

1. Considerable differences could be measured in the force-deflexion-diagram whilst using different neckstraps. These differences could be explained by the different material qualities. 2. Force-deflexion-diagramm achieved in vitro could not be transfered directly to the therapy of patients. 3. Extreme asymmetrical force distributions at the outer bows will arise during the therapy with extraoral forces, because of the friction between skin, textile neckstrap and adjustable traction bands. These asymmetrical force distributions will arise particularly during functional movements of the head. Turnings and noddings lead to extreme values, by reaching the maximum asymptotically. 4. The use of a force snap-away neckpad also often leads to asymmetrical force distributions at the outer bows. 5. Asymmetries occur less often whilst using the low-cervical-pull according to Sander, due to the reduced friction between the two plastic parts of this headgear system. Head movements nearly always lead to an equalization of the forces at the outer bow. Extreme forces last less than one second. The mean value of the force at the outer bow, ascertained over a longer period, is only a little bit less than the force of 500 g adjusted at the beginning. 6. The mean value of the forces measured over a longer period while wearing an adjustable traction band is nearly 50% less than the force adjusted at the beginning. 7. The adjustment of the force at the outer bows is done while the patient is sitting in an upright position. However the patient is normally very seldom in such a position so that, as a rule, the forces at the outer bows are less than the adjusted force. 8. The problem of lesser forces at the outer bows can be compensated by a longer wearing period and by a higher initial force adjustment. 9. The adjustment of the force at the outer bow with the help of a spring-balance leads to inaccuracy and, as rule, the real force application to the molar is significantly less. 10. Only the wearing of the low-cervical-pull according to Sander leads to reproducible force values during head turning and noddings. Also the mean force value corresponds to the initial applied force. 11. While using an adjustable traction band it is advisable to change this often during the treatment. Otherwise the function of the treatment with the extraoral force will be reduced because of the loss of elasticity of the traction band.

Continuous ketamine infusion for one-lung anaesthesia.

The mechanism which normally affects distribution of blood flow through unventilated areas of the lung is hypoxic pulmonary vasoconstriction; this acts to divert the blood to well ventilated alveoli, resulting in a better ratio of ventilation to perfusion. Several reports have focused attention on the reduction or abolition of this reflex in the unventilated lung by most of the volatile anaesthetic agents used in clinical practice. This response was not abolished by the intravenous anaesthetic agents. One hundred and ten patients undergoing elective pulmonary resection were studied to evaluate the effect of a continuous infusion of ketamine during one-lung anaesthesia, by observing the changes in PaO2 as a reflection of shunt. Ketamine was chosen as the intravenous agent for its positive inotropic and chronotropic action. Additionally, by providing both analgesia and hypnosis, we were able to administer inspired oxygen concentrations of 50-100 per cent without concern that the patient might have recall for events during operation. We have demonstrated that in all cases a PaO2 in excess of 9.31 kPa (70 torr) was achieved with ketamine and FIO2 1.0 as well as an increase in shunt fraction from 25.9 per cent (FIO2 0.5) to 36.0 per cent (FIO2 1.0). We feel that ketamine provides a satisfactory alternative to the volatile agents for one-lung anaesthesia in patients where relative hypoxaemia might be unacceptable during operation.

A comparison of the effects of continuous ketamine infusion and halothane on oxygenation during one-lung anaesthesia in dogs.

It has been shown that a continuous infusion of ketamine during one-lung anaesthesia combined with a 50 per cent oxygen-curare anaesthetic technique will provide consistently lower shunt fraction and higher Pao2 compared with halothane under the same experimental conditions. Because no additional factor was observed which could account for these changes and because the responses of the animals to the two anaesthetic agents were similar--the only difference being a different initial set point--the experimental model may be considered adequate. In the authors' view the difference in shunt fractions may be attributed to a more stable hypoxic reflex during ketamine anaesthesia. Further experimentation will be necessary to fully exclude the possibility of sequence-related changes affecting some of these results and to determine whether or not certain groups of dogs respond in a qualitatively different fashion.

The cerebral function monitor during open-heart surgery.

Open-heart surgery has entered the third decade of its existence. The period has demonstrated increased patient safety during and after open-heart surgery due to the employment of simple and reliable monitoring techniques. The monitoring of the function of the brain has not kept pace with these advances. Electroencephalographic (EEG) method is impractical for routine use in the operating room and in the intensive care unit. The cerebral function monitor (CFM) offers simplified continuous monitoring and interpretation of cerebral electrical activity (integrated EEG) in the clinical situation. The unit displays a two channel tracing, one representing cerebral activity and a second indicating electrode impedance artefacts. The early changes seen in addition to other conventional monitoring of the electrocardiogram, blood pressures, pulse rate, etc. offers information especially pertinent to open-heart surgery. It would appear that there is a place in anesthetic practice during and after cardiopulmonary bypass for the routine use of the CFM to supplement existing monitoring for the safer conduct of open-heart surgery. This study analyzes the value of a cerebral function monitor in 112 patients undergoing open-heart surgery.

Perioperative awareness and recall.

This study was designed to introduce a relevant stimulus at successive time intervals during the entire anesthetic period, including the pre- and postanesthetic periods. Using galvanic skin responses, the authors were able to recognize a plane of light anesthesia and arousal, at which time it is considered that sensory input might be perceived. Presenting to the patient a stimulus of some relevance, but one not likely to be psychically traumatic, they investigated the correlation between the ability to maintain an attention span and to recall in the postoperative period. No recall was obtained during the intraoperative period, the first occurrence of recall being in the immediate postanesthetic period and the incidence of recall increasing with increasing time intervals after the end of anesthesia. The authors conclude, however, that since intraoperative awareness without recall is a possibility, care should be taken to avoid emotionally disturbing auditory stimuli throughout the anesthetic procedure.

Anesthesia for transcervical thymectomy in myasthenia gravis.

This review of anesthetic experience in 100 cases of transcervical thymectomy for myasthenia gravis (MG) at The Mount Sinai Hospital (1970-1974) underlines current trends in the surgical management at Mount Sinai, where transcervical thymectomy is the procedure of choice for all patients with nonthymomatous MG and for selected patients with thymomatous MG. The transthoracic approach is now limited to malignant thymomas and tumors not accessible through the transcervical approach. Formerly, patients coming for thymectomy either already had a preexisting tracheostomy, or an elective tracheostomy was performed at the time of thymectomy. Since 1972, none of these patients has had elective tracheostomy at the time of operation, and only four were performed in the postoperative period, patients being intubated orotracheally at the time of operation. The tube is usually removed within 1 hour after completion of thymectomy. All patients are followed in the intensive care unit for 24 hours or longer, under close supervision of experienced personnel aware of the inherent problems and able to assist ventilation at any stage. This approach has greatly changed the postoperative course of this disease.