[Hepatorenal syndrome in decompensated cirrhosis : A special form of acute renal failure]. / Hepatorenales Syndrom bei dekompensierter Leberzirrhose : Eine besondere Form der akuten Niereninsuffizienz.

Renal failure is a serious complication in patients with advanced cirrhosis. It occurs in about 20 % of patients hospitalized with cirrhosis. In about 70 % it is caused by prerenal failure, and in 30 % it is due to intrarenal causes. In about 70 % of patients with rperenal failure, renal function can be restored with fluid replacement, but the remaining 30 % are unresponsive to volume expansion. Minor increase in serum creatinine have been shown to be clinically relevant and can adversely affect survival. Therefore early efforts should be made to avoid precipitation of renal failure.Hepatorenal syndrome (HRS) is a  fully reversible impairment of renal function in patients with cirrhosis unresponsive to volume expansion characterized by an acute progressive decrease in kidney function (serumcreatinin > 1,5 mg/dl) - type 1 HRS, whereas type 2 HRS features a decrease in kidney function over a long time, mostly in patients with refractory ascites. Therapy with vasoconstrictors like terlipressin to reverse splanchnic vasodilation, together with albumin is effective in 30-50 % of patients with HRS 1 and improves survival. The only effective longterm therapy is livertransplantation. An improvement of kidney fuction before transplantation is associated with a better outcome and posttransplant kidney function.

Inhibition of in vitro adhesion and virulence of Porphyromonas gingivalis by aqueous extract and polysaccharides from Rhododendron ferrugineum L. A new way for prophylaxis of periodontitis?

The effect of an aqueous extract from the leaves of Rhododendron ferrugineum (RF) was investigated for its capacity of inhibiting the adhesion of Porphyromonas gingivalis cells to epithelial buccal KB cells. RF was characterized by HPLC (12.1% taxifolin-3-O-ß-l-arabinopyranoside, 1.6% hyperoside, 0.9% isoquercitrin, 1.6% chlorogenic acid and a tannin content of 8.7%). Additionally raw polysaccharides (RPS) were obtained from the leaves of R. ferrugineum by aqueous extraction. RF and RPS interacted in a dose-dependent manner (max. 25% reduction at 1mg/ml each) with the adhesion of P. gingivalis by influencing bacterial outer membrane proteins. On protein level a time- and concentration-dependent inhibition of Arg-gingipain activity by RF was observed, while the Lys-gingipain activity remained unaltered. In addition, RF and RPS inhibited the bacterial hemagglutinin. RF affected the P. gingivalis adhesion also by interacting with KB cells in pre-incubation assays of the eukaryotic host cells, leading to reduced bacterial adhesion of about 75%. Gene expression analysis by RT-PCR indicated significant downregulation for arginine-specific gingipain rgpA by RF, while lysin-specific gingipain kgp and fimbrillinA fimA were strongly upregulated. Moreover, pre-incubation with RF abolished the P. gingivalis induced expression of IL-1ß, IL-6, IL-8 and TNFα in KB cells. Results of this study indicate that an aqueous extract from R. ferrugineum combines cytoprotective and antimicrobial effects by both downregulating the expression of pro-inflammatory genes and inhibiting the adhesion of P. gingivalis. Thus RF may be potential candidate for the development of an adjunctive antimicrobial approach in the prevention of periodontal diseases.

[Pilot study of levosimendan : Effect on liver blood flow and liver function in acute decompensated heart failure]. / Pilotstudie zu Levosimendan : Effekt auf Leberdurchblutung und -funktion bei akut dekompensierter Herzinsuffizienz.

BACKGROUND: In a pilot study, 9 patients (39-48 years) with acute decompensated heart failure and a cardiac index (CI) of 1.9 ± 0.3 l/min/m(2) were included after exclusion of an underlying hepatic disease. MATERIALS AND METHODS: The effect of levosimendan on liver blood flow and liver function was measured with the LiMON(®) system using the indocyane green plasma disappearance rate (ICG PDR). RESULTS: Levosimendan (Simdax(®)) infusion resulted in a significant increase of the CI, thus, achieving normal ranges of 2.9 ± 0.9 l/min/m(2) after 4 h and 3.3 ± 1 l/min/m(2) (p = 0.003) after 24 h. ICG PDR increased from 8.2 ± 0.8 % to 10.2 + 1.8 % after 4 h and to 11.9 ± 2.9 % after 24 h (p = 0.04). DISCUSSION: The reason for the early increase in systemic blood flow with no concomitant change in ICG PDR is not clear. A primary increase in liver blood flow with sustained low liver function might be one explanation; a low flow-mediated increased release of cytokines from liver cells with consequent deterioration of liver function is another possible explanation.

[Vascular surgery in a vascular centre--the different way--2 years of the Karlsbad model]. / Gefässchirurgie im Gefässzentrum - der andere Weg - 2 Jahre Karlsbader Modell.

BACKGROUND: The G-DRG system will lead from specialty-bound to process-bound pathways to guarantee efficient patient treatment in specialised units. Innovative concepts will have a trend-setting character. Certified vascular centres are currently cooperating in an interdisciplinary manner but on a specialty- and department-based background. PROJECT: In the "Karlsbad Model", the vascular surgery was integrated into existing medical departments like internal medicine/angiology, neurology and radiology in 2004. Treatment takes place in a department-overlapping, guide-line equitable and process-orientated manner with shared treatment competence. Clinical pathways, interdisciplinary case discussion and consultation hours guarantee a target-oriented pathway. The Karlsbad Model was certified by the German Society of Angiology. The internal (patients, staff) and external (cooperating doctors) contentment was augmented. The (preoperative) and overall length of stay was reduced from (6.47) 11.73 days in 2004 to (3.49) 9.32 days in 2005 for all vascular surgery G-DRGs. CONCLUSION: The Karlsbad Model with its process- and case-orientated cooperation has a trend-setting character with a positive influence on internal and external contentment.

[Fast-track rehabilitation after open aorto-iliac vascular procedures]. / Strukturiertes perioperatives Management (Fast-track Rehabilitation) bei konventionellen aorto-iliakalen Eingriffen.

BACKGROUND: Fast-track rehabilitation programs have resulted in a decrease in mortality and morbidity after major surgical procedures, e. g., in colorectal surgery. It is not known whether fast-track rehabilitation can safely be applied in major vascular surgery. METHOD: 35 patients (mainly ASA III) who underwent open aorto-iliac reconstruction (21 for abdominal aneurysm, 14 for aorto iliac occlusive disease) between May 2005 and June 2006 were treated with a fast-track protocol including PDA, early postoperative oral fluid and food supply, early postoperative mobilisation, all starting on the day of operation. The average daily oral fluid amount, duration of mobilisation, step of oral nutrition, day of first defecation, PONV, pain levels while resting, under effort and mobilisation, and fatigue were monitored. RESULTS: The 30-day mortality was 0%, overall morbidity was 14.8% with 9% pulmonary, 2.9% cardiac and 2.9% renal complications. Mobility was safely achieved. The oral fluid consumption was 329 mL on the day of operation and 1160 mL on the second day after operation. 33 patients (94%) achieved total oral nutrition on day four after operation. The average pain level in all categories and the fatigue were below 4 on the VAS. CONCLUSION: Fast-track rehabilitation can safely be applied to patients undergoing conventional aorto-iliac reconstruction. Early onset of oral nutrition and mobilisation influence the fatigue in a positive way. Thoracal PDA leads to acceptable pain levels.

[Symptomatic aneurysm of the right gastroepiploic artery. Case report and review of the literature]. / Symptomatisches Aneurysma der Arteria gastroepiploica dextra. Fallbericht und Literaturübersicht.

Aneurysms of the splanchnic arteries have rarely been reported. Aneurysms of the splenic artery are the most common aneurysms of the splanchnic vessels, followed by the hepatic and the mesenteric artery. Aneurysms of the gastroepiploic vessels show an incidence of only 0.4%. Due to a rupture rate of nearly 90% they are of great clinical importance. Therefore treatment is indicated for every diagnosed aneurysm of the gastroepiploic artery. While for ruptured aneurysms a conventional operation is inevitable, for asymptomatic aneurysms laparoscopic or interventional therapy is an alternative.

[Results and complications of endovascular therapy of aortic aneurysms]. / Ergebnisse und Komplikationen nach endovaskulärer Therapie des Aortenaneurysmas.

INTRODUCTION: Endovascular repair (ER) has been established as an alternative treatment option for aortic aneurysm (AA) in case of a suitable morphology. However, there are specific problems related to diagnostic and therapeutic management including potential complications of the new procedure. PATIENTS AND METHODS: Between 8/1996 and 11/1999, 41 patients (6 female, mean age 67.9 (range 55-84) years) underwent an operation with the intention of ER. Modular, self-expanding stent-grafts were used for aorto-biiliacal (36), aorto-monoiliacal (1), and aorto-aortal (infrarenal-1, thoracic-1) aortic aneurysm (AA) exclusion. Postoperatively and during the follow-up period, diagnostic measures included clinical investigation, native X-ray, and color-coded Doppler sonography, and spiral computed tomography, and digital subtraction angiography. Results were analysed with special reference to complications and resulting therapeutic consequences. RESULTS: Technical success was achieved in 36/41 patients (87.8%). There were 2 primary distal endoleaks and 3 conversions because of lacking vascular access. Of 4 primary endoleaks, a proximal one was treated successfully by overstenting, a distal one was sealed off by iliac extension, and 2 distal ones were treated conservatively. Three secondary endoleaks, a proximal and 2 distal ones, required conversion each by retro- and transperitoneal approach. Presently, there are 4 endoleaks, with the maximal aortic diameter remaining constant except one case. Five secondary occlusions of an iliac limb (4) or artery (1) were treated by thrombectomy (1), PTA (1), PTA with overstenting (1), and cross-over (1) or ilicofemoral bypass (1). Three patients died of unrelated disease during the follow-up period. DISCUSSION: On condition of a critical indication, improved diagnostic management and further refinement of stent-graft systems ER constitutes an alternative, minimally invasive treatment option for AA. Long-term results must be obtained by means of continued prospective and comparative studies to definitely evaluate ER.

[Automated mammary sonography and mammography: the differentiation of benign and malignant breast lesions]. / Automatisierte Mammasonographie und Mammographie: Differenzierung benigner und maligner Mammaläsionen.

PURPOSE: A prospective study on the differentiation of breast lesions was carried out using experimental combination schemes of mammography and automatic sonography. MATERIALS AND METHODS: X-ray mammograms and a B image from automatic sonography of 39 malignant and 41 benign lesions as well as 40 cases without lesions were separately examined by four experienced diagnosticians. The observers differentiated the findings mammographically and by measurement in the B images. RESULTS: For two examiners the combination of mammography and automatic sonography gave with regard to the differentiation of breast lesions an improvement in sensitivity of 3 or 5% and in specificity of 31 and 18%, respectively, as compared to mammography alone while for the other two examiners an improved specificity of 21 and 36%, respectively, was accompanied by an 8 and 10% decrease in sensitivity as compared to mammography alone. CONCLUSIONS: The differentiating criteria from automatic sonography and mammography can, in principle, be used to evaluate the dignity of breast lesions. However, an optimization is necessary since the improvement in specificity does not compensate the loss in sensitivity.

Detection of malignant and benign breast lesions with an automated US system: results in 120 cases.

PURPOSE: To evaluate clinically an automated ultrasound (US) system for detecting benign and malignant breast lesions. MATERIALS AND METHODS: A prototype automated US system was used to examine 119 patients: 38 patients with 39 proved malignant breast lesions (7-50 mm), 41 patients with 41 proved benign breast lesions (8-40 mm), and 40 patients without breast lesions. The device yields a three-dimensional set of B-mode scans and reconstructed US images comparable to mammograms. All patients had undergone mammography. Four radiologists who had not performed the examinations independently assessed the mammograms and US images to detect benign and malignant breast lesions. RESULTS: Each of the four readers did not recognize one to three detectable malignant lesions on mammograms, one to two detectable malignant lesions on US images, two to four detectable benign lesions on mammograms, and five to seven detectable benign lesions on US images. All readers identified the 39 cancers with at least one of the modalities. The 40 cases without lesions were diagnosed correctly more frequently on the US images by three readers and on the mammograms by one reader. CONCLUSION: Depiction of breast lesions at automated US is reproducible. Automated US is complementary to mammography.

[Women in surgery--the status at universities in North-Rhine-Westphalia]. / Frauen in der Chirurgie--Die Situation an den Hochschulen in Nordrhein-Westfalen.

As a part of the survey of "women in surgery" of the German Association of Surgeons data were collected of Nordrhein-Westfalen to characterize the participation of women in academic surgery: 1996 only 6 women held a faculty appointment, 4 were head physicians, 49 were residents and 14 interns.

[Can the reliability of sensory evoked potential monitoring during carotid artery surgery be improved?]. / Lässt sich die Sicherheit des SEP-Monitorings während der Carotis-Chirurgie verbessern?

Neurological monitoring during endarteriectomy of the internal carotid artery is essential, especially while operating without shunt. In our own department, SEP monitoring was improved by the introduction of so-called Farfield Analysis of evoked potentials. Since the introduction of Farfield Potential Measurement, no recognizable neurological deficit has been evident.

Magnetic bead protamine-linked microtiter assay for detection of heparin using iodinated low-molecular-mass heparin-tyramine.

We have developed a competitive heparin binding assay employing protamine-coated magnetic beads for detection and measurement of heparin. The assay utilizes 125-iodine specifically bound to newly synthesized low-molecular-mass (LMM) heparin-tyramine. The tracer was stable over a period of 3 weeks, as demonstrated by gel filtration chromatography. The protamine-coated beads were found to be stable over at least two months. The heparin-tyramine bead assay had in buffer a lower detection limit of 0.04 microgram/ml and in plasma of 0.23 microgram heparin/ml. 50% binding was obtained at 0.7 microgram/ml and 20% binding at 4 micrograms/ml in plasma. The within assay coefficient of variation ranged from 9 to 28% for unfractionated, high molecular mass (HMM) heparin and from 12 to 15% for LMM-heparins in buffer system and in plasma. Various heparin fractions displaced the tracer from the protamine-coated magnetic beads to different extents. The validity of the assay was proven after intravenous administration of unfractionated and LMM-heparin in man. The elimination rate was similar using the heparin-tyramine bead assay compared with the anti-factor Xa coagulation assay. After intravenous dosing of LMM-heparin the maximal concentration was lower using the heparin-tyramine bead assay compared with the anti-factor Xa coagulation assay. The bead assay was found to be reproducible, valid, and rapid for measurement of the concentration of heparin preparations in purified systems and for HMM-heparin in plasma. Measurement of the concentration of LMM-heparin in plasma has a high coefficient of variation using the binding assay.

Synthesis of a N'-alkylamine anticoagulant active low-molecular-mass heparin for radioactive and fluorescent labeling.

Heparin plays an important role in anticoagulation and several other biological processes. Cleavage of heparin by nitrous acid results in a reactive 2,5-anhydromannose (Am) which can be used to selectively insert primary and secondary amines by reductive amination. Low-molecular-mass heparin (LMMH) was bound to 4-(2-aminoethylphenol) as shown by nuclear magnetic resonance spectroscopy (NMR), high-performance size-exclusion chromatography (HPSEC), polyacrylamide gel electrophoresis (PAGE), and ultraviolet/visible (uv/vis) spectroscopy. 1H NMR spectra revealed an average sequence of (IdoA2SO3-GlcNSO36SO3)9-IdoA2SO3-Am-tyramine and a 50% binding rate of tyramine to LMMH. LMMH-Tyr had an anticoagulant activity of 108 antifactor Xa activity (aXa) U/mg and 42 antifactor IIa activity (aIIa) U/mg. The compound was neutralized by protamine. The N-alkylamine derivative was adopted to label LMMH with iodine-125 by oxidation with chloramine T. Fluorescein-5-isothiocyanate (Fitc) was used to label LMMH-Tyr with fluorescence. NMR, HPSEC, PAGE, and uv/vis spectroscopy demonstrated the binding of Fitc to LMMH-Tyr. 1H NMR spectra indicated that about 80% of the LMMH-Tyr was labeled at the secondary amino group. The fluorescent compound exhibited 70 aXa and 5 aIIa U/mg and was neutralized by protamine. The selectively bound labeled heparin derivatives are "endpoint attached" and have intact anticoagulant activity.

[High-frequency dental surgery near metal reconstructions]. / Zahnärztliche Hochfrequenzchirurgie in der Nähe metallischer Rekonstruktionen.

Dental electrosurgery carries the risk of incidental contact between the active electrode and metallic restorations. So far, on-line measurements of basic physical parameters during dental electrosurgery have not been performed under realistic conditions. The aim of our experimental study in pig jaws was to describe the physical phenomena more closely. 86 teeth in the jaws of freshly slaughtered pigs received occlusal amalgam fillings. Using 3 different units electrosurgical procedures were performed adjacent to the fillings. Voltage, current, impedance and power output were registered using a computer-controlled measuring system with high temporal resolution and broad dynamic range. The impedances of the amalgam fillings ranged from 0.5 to 9 k omega, with half of them being in the lower range of 0.5 to 1.5 k omega. During contact to amalgam fillings the dental electrosurgical unit had a high power output. Contact to fillings with low impedance yielded a power output up to 50 W. The other two electrosurgical units were equipped with different power output control systems thus preventing high power output during contact to metallic restorations. In conclusion, dental electrosurgery should be improved by units with dynamic power output control.

Near fatal pulmonary hypertension after surgical repair of congenital diaphragmatic hernia. Successful use of inhaled nitric oxide.

The addition of 10-20 parts per million nitric oxide to the inspired gas was successful in controlling near fatal pulmonary hypertension after surgical repair of a congenital diaphragmatic hernia in a neonate. A preceding prostacyclin infusion was unable to prevent the failure of pulmonary perfusion. No side effect of nitric oxide therapy was observed, and ventilatory support could be substantially reduced as a result of the treatment. On the basis of the striking and lifesaving effects of nitric oxide therapy demonstrated in this child, we believe that nitric oxide treatment will prove to be a major contribution to the management of postoperative pulmonary hypertensive crises.

Infection pattern in children with vesicoureteral reflux randomly allocated to operation or long-term antibacterial prophylaxis. The International Reflux Study in Children.

A total of 306 children with grade III to IV vesicoureteral reflux (international classification) and a history of documented urinary tract infection was randomized into medical (155 patients) or surgical (151 patients) treatment arms in the European portion of the International Reflux Study in Children. Children treated medically were maintained on prophylactic antibacterials as long as the reflux persisted, while those treated surgically were covered prophylactically until followup studies at 6 months postoperatively demonstrated the reflux to be corrected. Standard definitions for bacteriuria were used, and the distinction was made clinically among acute pyelonephritis, cystitis and asymptomatic bacteriuria, supported in many instances by additional laboratory testing. Urine was cultured after 3 months and whenever suspicious symptoms occurred. Urinary tract infections developed during the first 5-year followup period in 59 patients (38%) in the medical group and in 59 (39%) in the surgical group but the incidence of pyelonephritis was higher in the medical group (21%) than in the surgical group (10%) (p < 0.01). Pyelonephritis often followed catheterization or cystoscopy but asymptomatic bacteriuria was uncommon after these procedures in either group. Recurrent infections were related to age, sex and treatment center. They were common in boys and girls entering under 1 year of age but were less common in girls and rare in boys entering after 1 year of age. Recurrences were lowest among the Finnish children and highest in the German and Belgian children.

Surgical results in the International Reflux Study in Children (Europe).

In the European part of the International Reflux Study in Children (7 participating centers) 151 infants and children were randomly allocated to surgical treatment of primary grades III and IV vesicoureteral reflux. Reimplantation was performed unilaterally in 65 patients and bilaterally in 86, for a total of 237 ureters reimplanted. The patients were followed at regular intervals for 5 years. Reflux was absent in 231 of the reimplanted ureters (97.5%) at the end of 5 years. No patient underwent reoperation for reflux. In 10 ureters (4.2%, 10 patients) obstruction developed postoperatively and 7 needed reoperation. All reoperations were performed on the left side. Of the obstructed kidneys new scars developed in 6 during the 5-year followup. Including these cases, the number of new renal scars was equal in the surgical and medical groups (20 each). The number of pyelonephritic episodes during followup was significantly less in the surgical group (without chemoprophylaxis) than in the medical group (on chemoprophylaxis). No kidneys were lost and no child became hypertensive. If voiding cystourethrography and excretory urography were normal 6 months postoperatively, the reflux had been permanently eradicated and postoperative obstruction could be ruled out. In this study the patients who underwent reimplantation had a 74% (112 of 151) chance of an uncomplicated postoperative course (no persisting reflux, obstruction, pyelonephritis or severe renal damage).