[Ultrasound visualization of the guidewire and positioning of the central venous catheter : A prospective observational study]. / Sonographische Visualisierung des Führungsdrahtes und Positionierung des zentralen Venenkatheters : Eine prospektive Beobachtungsstudie.

BACKGROUND: After insertion of a central venous catheter (CVC) the catheter position must be controlled and a pneumothorax ruled out. OBJECTIVE: The aim was to examine whether the use of two standard acoustic windows known from emergency sonography examination techniques is feasible to 1) verify the correct intravenous localization and direction of the guidewire before final CVC insertion and 2) correctly predict the required CVC length for positioning of the catheter tip in the lower third of the superior vena cava. MATERIAL AND METHODS: This single center prospective observational study included adult patients (age ≥18 years) with an indication for CVC insertion after institutional ethics approval was obtained. Puncture sites were restricted to bilateral internal jugular and subclavian veins and except for duplicate examinations no further exclusion criteria were defined. After vessel puncture and insertion of the guidewire, the vena cava was displayed by an additional ultrasound examiner (sector scanner 1.5-3.6 MHz) using the transhepatic or subcostal acoustic window to localize the guidewire. For positioning of the CVC tip, the required catheter length in relation to the cavoatrial junction was measured using the guidewire marks during slow retraction and consecutive disappearance of the J­shaped guidewire tip from each acoustic window. From the resulting insertion length of the guidewire 4 cm was subtracted for the transhepatic and 2 cm for the subcostal window under the assumption that this length correlates to the distance from the cavoatrial junction. The CVC was finally inserted and a chest radiograph was performed for radiological verification of the CVC position. RESULTS: Of 100 included patients, 94 could finally be analyzed. The guidewire could be identified in the vena cava in 91 patients (97%) within a time period of 2.2 ± 1.9 min. In three patients, the wire could not be visualized, although two catheters had the correct position, while one catheter was incorrectly positioned in the opposite axillary vein. In the second study part, positioning of the CVC was evaluated in 44 of the 94 patients. In 5 of these 44 patients, the correct direction and disappearance of the guidewire from the acoustic window could also be reliably visualized; however, with the left subclavian vein as the puncture site, the respective catheters were up to 6 cm too short for correct positioning. Thus, these 5 patients were excluded from this analysis. In the remaining 39 patients, the position of the CVC tip was optimally located in the lower third of the superior vena cava according to the chest radiograph in 20 patients (51%), while it was relatively too high in 5 patients (13%) and too low (entrance of the right atrium) in 9 patients. In the other 5 patients, disappearance of the guidewire from the acoustic window was not definitely detectable. CONCLUSION: The presented intraprocedural ultrasound-based method using two standard acoustic windows is reliable for verification of the correct intravenous location and direction of the guidewire even before dilatation of the vessel puncture site for insertion of the catheter. Furthermore, the method allows the clinically acceptable measurement of the required length for catheter positioning. A chest radiograph can be waived provided the ultrasound examination (identification of the guidewire and exclusion of puncture-related complications such as pneumothorax) is unambiguous.

Sufentanil administration guided by surgical pleth index vs standard practice during sevoflurane anaesthesia: a randomized controlled pilot study.

BACKGROUND: Evaluation of analgesia and antinociception during anaesthesia is still a challenging issue and routinely based on indirect and non-specific signs such as movement, tachycardia, or lacrimation. Recently, the surgical pleth index (SPI) derived by finger plethysmography was introduced to detect nociceptive stimulation during anaesthesia. While SPI guidance reduced the number of unwanted events during total i.v. anaesthesia (TIVA), the impact of SPI during volatile-based anaesthesia with intermittent opioid administration has not yet been elucidated. METHODS: Ninety-four patients were randomized into either SPI-guided analgesia or standard practice (Control). In both groups, anaesthesia was maintained with sevoflurane to keep bispectral index values between 40 and 60. In the SPI group, patients received a sufentanil bolus (10 µg) whenever SPI value increased above 50, whereas in the control group, sufentanil was administered according to standard clinical practice. The number of unwanted somatic events, haemodynamics, sufentanil consumption, and recovery times were recorded. RESULTS: The incidence of intraoperative unwanted somatic events was comparable between the groups (P=0.89). No significant differences with respect to hypotensive or hypertensive events were found. The mean (95% confidence interval) sufentanil consumption was non-significantly (P=0.07) reduced in the SPI group, 0.64 (0.57-0.71) vs 0.78 (0.64-0.91) µg min(-1). Recovery times were comparable between the groups. CONCLUSIONS: Sufentanil administration guided by SPI during sevoflurane anaesthesia is clinically feasible. In contrast to TIVA, it did not improve anaesthesia conduct with respect to unwanted somatic events, haemodynamic stability, sufentanil consumption, emergence time, or post-anaesthesia care unit care. Therefore, we conclude that anaesthesia regimen has an impact on beneficial effects by SPI guidance. Clinical trial registration NCT01525537. (Registered at Clinicaltrials.gov.).

Smooth-muscle contraction without smooth-muscle myosin.

Here we have used gene-targeting to eliminate expression of smooth-muscle myosin heavy chain. Elimination of this gene does not affect expression of non-muscle myosin heavy chain, and knockout individuals typically survive for three days. Prolonged activation, by KCl depolarisation, of intact bladder preparations from wild-type neonatal mice produces an initial transient state (phase 1) of high force generation and maximal shortening velocity, which is followed by a sustained state (phase 2) characterized by low force generation and maximal shortening velocity. Similar preparations from knockout neonatal mice do not undergo phase 1, but exhibit a normal phase 2. We propose that, in neonatal smooth muscle phase 1 is generated by recruitment of smooth-muscle myosin heavy chain, whereas phase 2 can be generated by activation of non-muscle myosin heavy chain. We conclude that phase 1 becomes indispensable for survival and normal growth soon after birth, particularly for functions such as homeostasis and circulation.

[Study protocol to improve the quality of delirium management in intensive care]. / Protokoll einer Studie zur Qualitätsverbesserung des Delirmanagements auf der Intensivstation.

BACKGROUND: Delirium in cardiac surgery patients is common and is associated with prolonged mechanical ventilation and hospital stay as well as higher mortality. Protocols may improve outcome. In our cardiac surgery intensive care unit (ICU), patients with delirium have not received standardized treatment so far. HYPOTHESIS: In cardiac surgery ICU patients, standardized delirium management will lead after a 4­week introduction, compared to nonstandardized treatment, to a reduction of delirium duration. METHODS: Prospective before/after study to evaluate a quality improvement project for delirium management over 12 weeks including 140 patients. INCLUSION CRITERIA: (a) ≥18 years, (b) consent for research with their data. EXCLUSION CRITERIA: (a) palliative status, (b) present during both the before/after phase, (c) pregnancy, (d) included in a competitive study, or (e) delirium not assessable. The implementation includes the introduction of a protocol with interprofessional training, bedside-teaching, pocket cards, posters, and reminders. The primary outcome is the duration of delirium, assessed four times a day with validated instruments. Secondary outcome measures include delirium incidence, duration of mechanical ventilation, length of stay in ICU and hospital, mortality, nursing/therapeutic interventions, cumulative doses of delirium-related drugs, and complications of delirium for a follow-up of 28 days. Empirical data will be analyzed with descriptive and inferential statistics. OBJECTIVES: The purpose of the study is a reduction of the duration and frequency of delirium in cardiac ICU patients and will provide evidence of the effect size of the introduction of a delirium management.

Global and regional assessment of sustained inflation pressure-volume curves in patients with acute respiratory distress syndrome.

OBJECTIVE: Static or quasi-static pressure-volume (P-V ) curves can be used to determine the lung mechanical properties of patients suffering from acute respiratory distress syndrome (ARDS). According to the traditional interpretation, lung recruitment occurs mainly below the lower point of maximum curvature (LPMC) of the inflation P-V curve. Although some studies have questioned this assumption, setting of positive end-expiratory pressure 2 cmH2O above the LPMC was part of a 'lung-protective' ventilation strategy successfully applied in several clinical trials. The aim of our study was to quantify the amount of unrecruited lung at different clinically relevant points of the P-V curve. APPROACH: P-V curves and electrical impedance tomography (EIT) data from 30 ARDS patients were analysed. We determined the regional opening pressures for every EIT image pixel and fitted the global P-V curves to five sigmoid model equations to determine the LPMC, inflection point (IP) and upper point of maximal curvature (UPMC). Points of maximal curvature and IP were compared between the models by one-way analysis of variance (ANOVA). The percentages of lung pixels remaining closed ('unrecruited lung') at LPMC, IP and UPMC were calculated from the number of lung pixels exhibiting regional opening pressures higher than LPMC, IP and UPMC and were also compared by one-way ANOVA. MAIN RESULTS: As results, we found a high variability of LPMC values among the models, a smaller variability of IP and UPMC values. We found a high percentage of unrecruited lung at LPMC, a small percentage of unrecruited lung at IP and no unrecruited lung at UPMC. SIGNIFICANCE: Our results confirm the notion of ongoing lung recruitment at pressure levels above LPMC for all investigated model equations and highlight the importance of a regional assessment of lung recruitment in patients with ARDS.

Influence of tidal volume on ventilation inhomogeneity assessed by electrical impedance tomography during controlled mechanical ventilation.

The global inhomogeneity (GI) index is a parameter of ventilation inhomogeneity that can be calculated from images of tidal ventilation distribution obtained by electrical impedance tomography (EIT). It has been suggested that the GI index may be useful for individual adjustment of positive end-expiratory pressure (PEEP) and for guidance of ventilator therapy. The aim of the present work was to assess the influence of tidal volume (VT) on the GI index values. EIT data from 9 patients with acute respiratory distress syndrome ventilated with a low and a high VT of 5 ± 1 (mean ± SD) and 9 ± 1 ml kg(-1) predicted body weight at a high and a low level of PEEP (PEEPhigh, PEEPlow) were analyzed. PEEPhigh and PEEPlow were set 2 cmH2O above and 5 cmH2O below the lower inflection point of a quasi-static pressure volume loop, respectively. The lower inflection point was identified at 8.1 ± 1.4 (mean ± SD) cmH2O, resulting in a PEEPhigh of 10.1 ± 1.4 and a PEEPlow of 3.1 ± 1.4 cmH2O. At PEEPhigh, we found no significant trend in GI index with low VT when compared to high VT (0.49 ± 0.15 versus 0.44 ± 0.09, p = 0.13). At PEEPlow, we found a significantly higher GI index with low VT compared to high VT (0.66 ± 0.19 versus 0.59 ± 0.17, p = 0.01). When comparing the PEEP levels, we found a significantly lower GI index at PEEPhigh both for high and low VT. We conclude that high VT may lead to a lower GI index, especially at low PEEP settings. This should be taken into account when using the GI index for individual adjustment of ventilator settings.

Massive postpartum corpus luteum cyst: a case report.

A young woman presented with an asymptomatic unilateral adnexal mass at six weeks postpartum. Her abdomen and pelvis had been considered unremarkable upon examination at parturition, at which time no adnexal masses were palpated. At laparotomy a 20 cm. right ovarian cyst was found, which was shown microscopically to be of corpus luteum origin. Each of the features--size, rapid development, and presentation in the postpartum state--is most unusual.

Reactive lymph node hyperplasia with giant follicles.

Twenty-two cases are presented of patients whose solitary painless, enlarged lymph nodes demonstrated an extreme degree of reactive hyperplasia with giant follicles which were misdiagnosed as lymphoma in 11 (50%) instances. Parotid or submandibular nodes were involved most frequently, and the mass was thought clinically to be a salivary gland tumor in at least one-third of the cases. Occurrence in men predominated (6.3:1) with a median age of 24.5 years (mean, 26.8 years). There were no recurrences during follow-up periods which ranged from 6 months to 15 years. No specific etiologic factors were identified. Microscopically, the enlarged giant follicles involved the entire surface area of the lymph node, frequently assuming a serpentine configuration resulting from coalescence. The description of findings in these exemplary cases is followed by discussion of the histologic differential diagnosis.

Calcofluor white detection of fungi in cytopathology.

Calcofluor/Cellufluor (CFW) binds to fungal cell walls and causes them to fluoresce blue-green when illuminated with UV light. Retrospective and prospective studies were made to determine if CFW could be added to the Papanicolaou (PAP) stain procedure without altering diagnostic cytopathologic features while still allowing fungi to be identified. The retrospective study included 136 cytology specimens that were designated positive for fungus by PAP stain; these were stained with a 0.1% aqueous solution of CFW and examined by fluorescent microscopy. The overall agreement between the two methods in the detection of fungi was 90.4%. The incorporation of CFW into the PAP stain was tested at various points in the PAP stain sequence; optimum results were obtained when CFW was introduced after acid eosin. A total of 197 random, sequentially accessioned cytology specimens were stained with the PAP/CFW combination in the prospective study. The results indicate that detection of fungi by a combination of regular light and fluorescent microscopy was far more effective than was examination for the organisms by light microscopy alone.

Developmental changes in the complexity of the electrocortical activity in foetal sheep.

The foetal sheep brain develops organised sleep states from 115-120 d gestational age (dGA, term 150 dGA) alternating between REM and NREM sleep. We aimed to investigate whether maturation of REM or NREM sleep generating structures leads to the development of distinct sleep states. The electrocorticogram (ECoG) was recorded from five unanaesthetised chronically instrumented foetal sheep in utero and was analysed every 5th day between 115-130 dGA by two different non-linear methods. We calculated a non-linear prediction error which quantifies the causality of the ECoG and applied bispectral analysis which quantifies non-linear interrelations of single frequency components within the ECoG signal. The prediction error during REM sleep was significantly higher than during NREM sleep at each investigated age (P<0.0001) coincidental with poor organisation of the rhythmic pattern in the ECoG during REM sleep. At 115 dGA, organised sleep states defined behaviourally were not developed yet. The prediction error, however, showed already different states of electrocortical activity that were not detectable using power spectral analysis. The prediction error of the premature NREM sleep ECoG decreased significantly during emergence of organised sleep states between 115 and 120 dGA and continued to decrease after the emergence of distinct sleep states (P<0.05). The prediction error of the premature REM sleep ECoG did not change until 120 dGA and began to increase at 125 dGA (P<0.05). Using bispectral analysis, we showed couplings between delta waves (1.5-4 Hz) and frequencies in the range of spindle waves (4-8 and 8-12 Hz) during NREM sleep that became closer during development. The results show that maturation of ECoG synchronisation mediating structures is important for the development of organised sleep states. The further divergence of the prediction error of NREM and REM sleep after development of organised sleep states reveals continuous functional development. Thus, complementary application of non-linear ECoG analysis to power spectral analysis provide new insights in the collective behaviour of the neuronal network during the emergence of sleep states.

[Surgical treatment of mediastinal tumors from personal material]. / Chirurgiczne leczenie guzów sródpiersia w materiale wlasnym.

90 patients with mediastinal tumors treated surgically was analysed. It was find, that tumor mostly was localized in anterior superior mediastinum, had benign character and in over half of cases was derived from thymus. 75% of mediastinal tumors were primary. In over 50% patients longitudinal sternotomy was performed. Radical excision of the tumor was possible nearly in 90% cases.

Histopathologic findings in ectopic tubal pregnancy.

In 141 consecutive cases of tubal ectopic pregnancy at Hermann Hospital in Houston, Texas, the histologic appearance of 129 surgically removed fallopian tubes containing ectopic pregnancies was reviewed and compared with an age- and race-matched control population. There was a higher incidence of chronic salpingitis (88 versus 2%) and salpingitis isthmica nodosa (SIN) (43 versus 5%). The ectopic pregnancy patients had a higher incidence of pelvic inflammatory disease, gonorrhea, previous abortions, bitubal ligation, intrauterine device use, and previous abdominal surgery. In our population, chronic salpingitis was the most commonly associated finding. The increase in SIN was associated with postinflammatory changes (89%). We also found that ectopic tubal pregnancies may grow either intratubally or extratubally by villous invasion into the wall and blood vessels; therefore, surgical salvage of the fallopian tube by extracting the products of conception will not always be curative.

Differential influences of carnitine palmitoyltransferase-1 inhibition and hyperthyroidism on cardiac growth and sarcoplasmic reticulum phosphorylation.

To characterize interventions resulting in 'physiological' growth of the heart, Wistar-Kyoto (WKY) rats and spontaneously hypertensive rats (SHR) had hyperthyroidism induced (0.05 mg.kg-1.day-1 triiodothyronine for 6 days) or were treated with a high dose of the carnitine palmitoyltransferase-1 inhibitor, etomoxir (15 mg.kg-1.day-1 for 5 weeks). Etomoxir increased cardiac growth evenly, but hyperthyroidism resulted in an over-proportional higher right ventricular weight. Both interventions increased the proportion of the myosin isozyme V1. The rate of sarcoplasmic reticulum (SR) Ca2+ uptake was increased to a greater extent in hyperthyroid rats than in etomoxir-treated rats (P < 0.05). Left ventricular levels of immunoreactive phospholamban (semiquantitative ELISA) were moderately decreased (P < 0.05) in hyperthyroid rats but not in etomoxir-treated rats. The protein kinase A-catalyzed in vitro 32P-incorporation into the SR Ca2+ pump modulator phospholamban was greatly reduced (P < 0.05) in hyperthyroid rats, indicating an increased in vivo phosphorylation. Etomoxir did not affect phospholamban phosphorylation in WKY rats. Thus, both a higher in vivo phospholamban phosphorylation state and a greater number of active Ca2+ pumps contributed to an increased rate of SR Ca2+ uptake in hyperthyroidism. The etomoxir treatment primarily increased the number of active Ca2+ pumps. A scheme is proposed focusing on long-term vs short-term regulation of the SR Ca2+ pump/phospholamban system in diseased states.

[Revision operations after tenotomy of the medial rectus muscle]. / Revisionsoperationen nach Tenotomie des Musculus rectus medialis.

BACKGROUND: Although tenotomy of the medial rectus (MR) is generally regarded to be obsolete, consecutive exotropia after this procedure, requiring a reoperation, still occurs. PATIENTS AND METHODS: In 143 patients a reoperation after tenotomy of the MR had to be performed because of consecutive exotropia. Either only the MR was sutured at the original insertion (advancement; this constitutes group 1, n = 101) or the lateral rectus (LR) was recessed in addition (group 2, n = 12). The recession of the LR was only added if the adduction was not distinctly limited and if the distance of the MR from the limbus was less than 16 mm. We wanted to find out whether the procedure in group 1 or 2 gave the better results. RESULTS: In group 1 the muscle sheath of the MR was found at a distance of 7 mm (median), the muscle itself at a distance of 18 mm from the limbus (confidence interval 13.5-25 mm). In group 2 the distance of the muscle sheath from the limbus was similar to group 1, the muscle itself was found already at a distance of 12 mm from the limbus (confidence interval 6-18 mm). After reinsertion of the muscle at the original insertion without recession of the LR, a distinct limitation of abduction combined with a globe retraction was seen immediately after surgery. A spontaneous release of the old contracture reduced these troublesome side effects. Three months postoperatively the initial surgical effect had diminished to 83%. The average postoperative squint angle was -3 degrees at 5 m and -4 degrees at 0.33 m with a high scatter. In group 1 [group 2 in brackets], the range of the horizontal motility was improved by 15 degrees [10 degrees] (median) and the incomitance, i.e. the difference between the angle of squint at 25 degrees gaze to the right and to the left, by 4 degrees [0 degrees, i.e. no improvement]. Thus, this postoperative improvement was smaller in cases of simultaneous recession of the LR (group 2). DISCUSSION: The most important aim in a reoperation after tenotomy of the MR is to find the muscle itself and to suture it to the original insertion. It can be expected that the contracture of the MR will loosen when the muscle is put under increased tension. This effect will be less if the LR is recessed in addition to the advancement of the MR. Consistent with this assumption, our not randomized, retrospective study revealed a better horizontal motility after advancement of the MR alone. Because of the difficulties in revising a tenotomy, we strongly advise a graded recession rather than any form of tenotomy.

Utmost cytoplasmic location of catalytic center in Na,K-motive ATPase disfavors Mitchell's phosphate-cation symport mechanism of Na/K transport across plasma membrane.

A combined electron microscopic and graded tryptic dissection analysis of the catalytic protein of pure Na,K-motive ATPase reveals that the aspartyl phosphate residue-carrying catalytic center is located at the utmost radius of the hydrophilic cytoplasmic domain. This makes the cation-phosphate symport mechanism of Na/K transport across plasma membrane as proposed by Mitchell topologically unrealistic, and indirectly favors the mechanism of conformational coupling between the catalytic and ionophoric function of the transport system.

Endocrine carcinoma intermediate cell type of the uterine cervix.

Nine cases of endocrine carcinoma, intermediate-cell type of the uterine cervix, were found in a study of 404 cases listed in the files of the University of Texas M. D. Anderson Hospital and Tumor Institute at Houston as adenocarcinoma of the cervix. Based on light microscopic patterns, these cases were divided into pure endocrine carcinoma (six cases), and endocrine carcinoma mixed with adenocarcinoma (three cases). All tumors were 3 cm or larger in at least one dimension. On light microscopic examination, the predominant pattern was trabecular; however, insular, glandular, and spindle patterns were also identified. Argyrophilic granules were demonstrated in all cases by Grimelius stain, and Fontana-Masson (argentaffin) stain was negative. Electron microscopic examination of three cases showed membrane-bound, dense-core granules of the neurosecretory type. Although no endocrine symptoms were found, immunoperoxidase studies demonstrated 5-hydroxytryptamine in seven cases, substance P in three, vasointestinal polypeptide in two, pancreatic polypeptide in one, and somatostatin in one. Clinical behavior of these tumors was extremely aggressive. Although five cases were Stage IB at presentation, two Stage IIB, one Stage IIIB, and one Stage IV, 87.5% of these patients died of their neoplasms within 3 years. This study emphasizes the importance of correctly diagnosing endocrine carcinoma, intermediate-cell type in the uterine cervix, because of the poor prognosis of this tumor when compared with adenocarcinoma of the cervix.

Influence of different culture conditions on sarcoplasmic reticular calcium transport in isolated neonatal rat cardiomyocytes.

This study investigates sarcoplasmic reticulum (SR) calcium-(Ca2+) transport ATPase (SERCA2a) and phospholamban (PLB) in cultured spontaneously contracting neonatal rat cardiomyocytes (CM) to ascertain the function of both SR proteins under various culture conditions. The two major SR proteins were readily detectable in cultured CM by immunofluorescent microscopy using specific anti-SERCA2 and anti-PLB antibodies. Double labeling technique revealed that PLB-positive CM also labeled with anti-SERCA2. Coexpression of SERCA2 and PLB in CM was supported by measurement of cell homogenate oxalate-supported Ca2+ uptake which was completely inhibited by thapsigargin and stimulated by protein kinase A-catalyzed phosphorylation. Under serum-free conditions, incubation of CM with the SERCA2a expression modulator 3,3', 5-triiodo-L-thyronine (100 nM, 72 h) resulted in elevated Ca2+ uptake of +33%. Specific Ca2+ uptake activity was not altered if insulin was omitted from the serum-free culture medium but total SR Ca2+ transport activity was reduced under this culture condition. The results indicate that primary culture of spontaneously contracting neonatal rat CM can be employed as a useful model system for investigating both short- and long-term mechanisms determining the Ca2+ re-uptake function of the SR under defined culture conditions.

CT-findings in ARDS.

The CT features of 28 patients with ARDS are described. Diffuse lung consolidation, multifocal patchy involvement and lobar or segmental disease were observed. Large lung cysts as well as small cysts producing a "swiss-cheese" appearance of the parenchyma, were detected. These findings were not regularly appreciated on chest radiographs. The overall mortality of our 28 patients was 72.7% (22 out of 28). Patients with lung cysts showed a trend toward higher mortality (87.5% or 13 out of 16). Other unexpected findings were basilar lung abscesses and an empyema. In 15 out of 28 patients, CT scans provided additional information, not obvious on bedside chest radiographs and led to a change in management in five patients.