Tracheal airway pressure in tracheostomy tube capping trials: an experimental study.

BACKGROUND: Tracheostomy tube capping is a commonly used test to determine if the tracheostomy tube can be removed. The success of the capping trial depends on the patient's ability to maintain sufficient spontaneous breathing with an occluded tracheostomy tube. The impact of an occluded tracheotomy tube on airway resistance is currently unknown. The aim of this study was to investigate tracheal pressure during capping or stoma button insertion and potential determinants concerning cuff. METHODS: Eight cuffed and uncuffed tracheostomy tubes and three stoma buttons of various manufacturers and sizes were inserted into the trachea model. Cuffs were completely deflated or contained atmospheric pressure. The trachea was ventilated bidirectional with a respirator in volume-controlled mode and volume flows 15-60 L/min. Tracheal pressure drop during inspiration as a parameter of pressure required to move gas through the airway was measured. RESULTS: Tracheal pressure drops occurred linearly or irregularly during capping trials to a maximum of 4.2 kPa at flow rates of 60 L/min for atmospheric pressure cuffs. In tracheostomy tubes with completely deflated cuffs, pressure drop in the trachea reaches a maximum of 3.4 kPa at a flow rate of 60 L/min. For tracheostomy tubes with cuff smaller inner or outer diameters do not regularly result in lower tracheal pressure drop. The pressure drop varies between different tracheostomy tubes depending on the manufacturer. In cuffed tracheostomy tubes, we observed three phenomena: sail-like positioning, folding over, and tightening of the cuff during flow. The maximum tracheal pressure drop during stoma button insertion reaches 0.014 kPa. CONCLUSIONS: The cuff is a central element for the pressure drop in the airway and thus airway resistance during spontaneous translaryngeal breathing with a capped TT. Complete deflation reduces the pressure drop in the trachea. Due to deformation of the cuff, measured pressures are irregular as the volume flow is increased. Incomplete deflated cuffs and material characteristics of tracheostomy tubes and cuffs in addition to anatomical and clinical variables may cause unsuccessful capping trials due to increased airway resistance. All stoma buttons showed that pressure drop and thus airway resistance due to stoma buttons has no clinical relevance.

Safety of percutaneous dilatational tracheotomy (PDT) with the rigid tracheotomy endoscope (TED): a 6-month follow-up multicenter investigation.

BACKGROUND: The rigid tracheotomy endoscope (TED) was recently introduced to improve the fiberoptic technique during percutaneous dilatational tracheotomy (PDT) in critically ill patients. The aim was to evaluate the long-term complications of PDT using TED equipment in a prospective multicenter investigation. METHODS: One hundred eighty adult patients underwent PDT using TED in four German hospitals. Patients who were alive or their guardians were contacted via telephone and interviewed using a structured questionnaire 6 months following the tracheostomy procedure. Patients with airway complaints were invited for outpatient clinical ENT examination. The incidence of adverse events related to PDT was registered. RESULTS: Of 180 patients who received tracheostomy, 137 (76.1%) were alive at the time of follow-up. None of the 43 lethal events was related to the PDT. Fifty-three (38.7%) patients were available for follow-up examination, whereas 14 (10.2%) were able to visit ENT physicians. Two (3.8%) out of 53 patients developed tracheocutaneous fistula with required surgical closure of tracheostoma. Dyspnea (7.5%), hoarseness (5.7%), stridor and swallowing difficulties (both with 3.8%) were the most common complaints. Tracheal stenosis was confirmed in 1 patient (1.88% [95% CI: 0.33; 9.93]). CONCLUSION: The use of TED for PDT in the clinical setting is safe regarding adverse events at 6-month follow-up. The incidence of tracheal stenosis after PDT with TED is comparable with that of flexible bronchoscopy; however, its role for PDT at the intensive care unit should be clarified in further investigations.

Computerized 4-choice reaction time test for the measurement of psychomotor recovery after general anesthesia.

The recovery of patients after general anesthesia is usually estimated by using clinical scores. Since there is a lack of objective methods for assessing psychomotor recovery, the aim of this study was to evaluate three psychological tests for this purpose. Patients, scheduled for ambulatory gynecological surgery, underwent 3 standard psychological tests before (T1), 15 min after the surgery (T2) and on discharge from the recovery room (T3). The tests used were Wechsler memory scale (test 1, working memory capacity), d2-test (test 2, concentration endurance) and computer-based 4-choice-reaction time (4CRT, test 3, reaction time) as well as Postanesthesia Discharge Scoring System (PADSS). The same test battery was used in healthy female volunteers, all test results were compared at the different time points. In 109 patients, working memory capacity and concentration (tests 1 and 2) decreased, the reaction time (test 3) was prolonged at T2 in comparison with T1 and T3 (P < 0.01). PADSS increased from 8 (T2) to 10 (T3) (medians, P < 0.001). Fifty-seven healthy volunteers demonstrated a practice effect in all 3 tests through the course of the study (P <0.01). 4CRT test had shortest duration and enabled computerized data processing. All three tests objectively assess the recovery of psychomotor function in patients after general anesthesia, the computer-based 4CRT seems to be the most convenient for the clinical routine.

Discussing euthanasia in two German states: scientific terminology and public discourse in the German Democratic Republic and the Federal Republic of Germany.

Discussions on euthanasia ("Sterbehilfe") that took place in the German Democratic Republic (GDR) have remained widely unnoticed by the historical sciences. By referring to various publications dating from the 1950s until today, this paper presents the basic ideas of the debate on euthanasia in the GDR and compares them-partly synchronically, partly diachronically-with the situation in the Federal Republic of Germany (FRG). A special focus is placed on positions and terminology related to medical ethics at the end of life in the former two German states. The methodical approach of the paper allows a transparent analysis of the question of whether the GDR debates on euthanasia are significant and independent, and whether they are relevant to current ethical debates on end-of-life practices in Germany.

Feasibility and safety of dilatational tracheotomy using the rigid endoscope: a multicenter study.

BACKGROUND: Fiberoptic tracheo-bronchoscopy is the most commonly used procedure for percutaneous dilational tracheotomy (PDT). However, PDT can be associated with major complications, including death. Furthermore it is unclear, whether the tracheal ring fractures may contribute to the development of tracheal stenosis after PDT nor whether tracheal ring fractures can be prevented by using a rigid endoscope for this procedure. The purpose of this study was to evaluate the feasibility of and the incidence of complications for PDT using the rigid tracheotomy endoscope (TED). METHODS: In a prospective multicenter observational study from 2006 to 2010, 180 adult patients in intensive care and those scheduled for ear, nose and throat surgery underwent PDT using TED. Data collection was performed using a structured protocol. The patients were observed according to PDT phase (phase 1: puncture, phase 2: dilatation and phase 3: cannula insertion). The descriptive data are given as the number (percent) of cases and the mean ± standard deviation (SD) where appropriate. The relationships between dichotomous and categorical parameters were analyzed using the chi-square test. P values ≤ 0.05 were considered significant. RESULTS: PDT was performed in 179 patients. The procedure time was 14.8 ± 6.2 (mean ± SD) minutes. Pneumothorax or procedure-related lethal complications did not occur. Other adverse events included tracheal ring fractures (17.1%), desaturations (6.8%), special incidents (6.2%), bleeding (5.5%), anesthesia complications (4.5%) and posterior tracheal wall injuries (1.1%). CONCLUSION: The use of TED in PDT is feasible, and the incidence of complications and adverse events was comparable with that of PDT using the flexible endoscope. Tracheal ring fractures in PDT cannot be avoided by the use of a rigid endoscope. With TED, the airway always remains open thus the use of jet ventilation via the TED during PDT is possible.

Rare association of cystic squamous cell carcinoma and small lymphocytic B cell lymphoma: successful surgical approach.

Non-melanoma skin cancer is the most common type of cutaneous neoplasm worldwide. While basal cell carcinoma is the most common tumor, squamous cell carcinoma (SCC) causes higher morbidity and has a risk of metastatic spread, depending on immune status, tumor size, and desmoplastic growth. We reported the case of a 77 year old male patient with retroauricular tumor, which started growing 3 years ago and was excised, buth relapsed three times. The initial diagnosis was infundibular cyst. Delayed Mohs surgery was performed, as was an additional open lymph node biopsy of the patient's right groin, on the occasion of an indolent swelling of the same which developed within 3 months. The first histopathological report confirmed the diagnosis of a cystic squamous cell carcinoma. The histopathologic evaluation of the groin tumor revealed a small lymphocytic B cell lymphoma (BCL). The patient fulfilled the following criteria for high-risk SCC: tumor size ≥2 cm (or 1 cm on the head and 6 mm on the genitals, hands, and feet), tumor thickness ≥4 mm, recurrent tumor, rapid growth. Therefore, lymph node metastasis had to be considered. High-risk SCC has a propensity to metastasize. In cases of primary tumor, Mohs surgery is the most effective treatment, particularly in relapsing tumors. The combination of cystic SCC with a small-sized BCL is very rare. The differential diagnosis and treatment may be challenging. In high-risk SCC, lymph node enlargement warrants histologic evaluation. However, not all suspicious lymph node lesions corroborate as metastatic.

Sentinel lymph node biopsy in early melanoma-comparison of two techniques for sentinel removal.

BACKGROUND: Sentinel lymph node biopsy is an established technique for melanoma staging. OBJECTIVE: There are no studies available comparing different techniques for the removal of sentinel lymph nodes related to safety and postsurgical complication rate. METHODS: This is a retrospective single-center trial. We analyzed the postsurgical complications in 201 consecutive melanoma patients with ligature of lymphatic vessels by sutures (group A) and in 91 consecutive patients with occlusion of lymphatic vessels by bipolar tweezers (group B). We paid particular attention to complications related to disturbed lymphatic function, such as lymph edema, lymphatic fistula, and seroma. RESULTS: The complication rate was 5.5 % (group A) and 9.6 % (group B) which is in the range of other published trials (p = 0.89). There was no increase of complications related to lymphatic vessels in group B, although the rate of patients with more than two sentinel lymph nodes removed was 5­times higher than in group A. CONCLUSIONS: Removal of sentinel lymph nodes with the use of bipolar tweezers does not increase the risk of postsurgical complications, and in particular it is not associated with a higher rate of complications related to lymphatic vessel dysfunction.

Mineral dust photochemistry induces nucleation events in the presence of SO2.

Large quantities of mineral dust particles are frequently ejected into the atmosphere through the action of wind. The surface of dust particles acts as a sink for many gases, such as sulfur dioxide. It is well known that under most conditions, sulfur dioxide reacts on dust particle surfaces, leading to the production of sulfate ions. In this report, for specific atmospheric conditions, we provide evidence for an alternate pathway in which a series of reactions under solar UV light produces first gaseous sulfuric acid as an intermediate product before surface-bound sulfate. Metal oxides present in mineral dust act as atmospheric photocatalysts promoting the formation of gaseous OH radicals, which initiate the conversion of SO(2) to H(2)SO(4) in the vicinity of dust particles. Under low dust conditions, this process may lead to nucleation events in the atmosphere. The laboratory findings are supported by recent field observations near Beijing, China, and Lyon, France.

Juxta-articular adiposis dolorosa (Dercum's disease type IV): report of four cases and treatment by dermolipectomy.

Juxta-articular adiposis dolorosa is a rare subtype of Dercum's disease. It manifests mainly on the medial parts of the knees. Pain and impaired mobility are common symptoms. We report on four females (aged between 52 and 83 years) who suffered from juxta-articular adiposis dolorosa for more than 10 years. These patients were successfully treated by dermolipectomy resulting in dramatically improved pain and mobility. Adverse effects and complications were minor with a lymph fistula in a single patient which was treated by surgery.

Relapsing advanced metatypical basal cell carcinomas (MTBCC) of the face: surgical modalities.

Metatypical basal cell carcinoma (MTBCC) represents a high-risk type of cutaneous tumour. We report about three different patients with relapsing advanced large MTBCC: one of the scalp and two of the cheek region. Such patients required in most of the cases a complex surgical approach to achieve a stable and complete remission. In the first presented patient a combination of flaps and grafts has been performed. We describe tailored surgical approaches. By this contrivance it is possible to treat even elderly patients with exposed bone after complete excision effectively and safe. Interdisciplinary team work is for the benefit of these patients.

Methods of administering superimposed high-frequency jet ventilation and the associated risk for aspiration in a model of tracheal bleeding.

BACKGROUND: To determine the suitability of different superimposed high-frequency jet ventilation (SHFJV) application methods during tracheal bleeding. OBJECTIVE: To determine the effect of SHFJV on the aspiration of blood during tracheal bleeding. METHODS: A test lung was ventilated using SHFJV via a rigid endoscope, a jet laryngoscope and a 4-lumen jet catheter. Packed red blood cells (PRBCs) were injected into the artificial trachea caudally to the rigid endoscope and jet laryngoscope ventilation, and both caudally and cranially during ventilation via the 4-lumen jet catheter, and the migration of PRBCs during ventilation was studied using continuous video recording. RESULTS: Migration of blood into the lower respiratory tract did not occur during SHFJV via the rigid endoscope and jet laryngoscope and via the 4-lumen jet catheter with the bleeding caudal to ventilation source. If the bleeding was cranial to the 4-lumen jet catheter ventilation, migration of blood into the lower respiratory tract was seen when reflux of blood reached the entrainment area. From this area, blood is transported within the jet stream into the lower respiratory tract. CONCLUSIONS: SHFJV protects the lower respiratory tract from blood aspiration in case of tracheal bleeding. During SHFJV via the 4-lumen jet catheter, aspiration of blood only occurs if bleeding is localized cranial to the 4-lumen jet catheter ventilation. In case of heavy tracheal bleeding, the jet sources should be positioned cranial to the site of bleeding.

Management of severe anogenital acne inversa (hidradenitis suppurativa).

BACKGROUND: Severe anogenital acne inversa (AI) is a debilitating chronic inflammatory disease with a major negative effect on quality of life. OBJECTIVES: To evaluate the role of surgery in the treatment of severe anogenital AI. METHODS: We analyzed the records of patients with anogenital AI from 2000 to 2010. Assessment was done using the Hidradenitis Suppurativa Lesion, Area, and Severity Index (HS-LASI), pain visual analogue scale, physician global assessment (PhGA), and patient global assessment (PaGA). Comorbidities and adverse events were analyzed. RESULTS: Sixty-seven patients with a Hurley score of 3 were identified. Mean follow-up was 56.9 ± 41.3 months. A number of comorbidities were observed. After surgery, mean pain scores decreased from 6.3 ± 1.5 to 0.8 ± 0.7, PhGA improved from 6.8 ± 1.2 to 0.9 ± 0.6, PaGA improved from 7.3 ± 1.2 to 1.1 ± 0.5, and HS-LASI decreased from 41.8 ± 21.3 to 2.4 ± 2.8. Adverse reactions were seen in 10.4%. The total relapse rate was 6% (5 patients) with only one case with healing by secondary intention (2% of 49 patients). CONCLUSIONS: Surgery is the cornerstone of treatment for advanced AI. Healing by secondary intention results in significant reduction of complaints and achieves satisfying body contouring.

Auricular stimulation for preoperative anxiety - A systematic review and meta-analysis of randomized controlled clinical trials.

STUDY OBJECTIVE: Previous randomized controlled trials (RCTs) suggest that auricular stimulation (AS) is safe and effective in treatment of preoperative anxiety; however, a systematic evaluation is lacking. The aim was to summarize the evidence on efficacy and safety of AS for preoperative anxiety, as well as for other outcomes. DESIGN: We conducted a systematic review of RCTs including patients from all available populations. The search was done through MEDLINE (PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science and Scopus Database from inception to June 2020. Study selection and data extraction were performed in by 2 independent reviewers with ability to resolve disagreements by a third author. Meta-analyses as well as the risk of bias and evidence quality assessments were performed according to the Cochrane 6.2, 2021 handbook recommendations. INTERVENTIONS: We compared AS with pharmacological and non-pharmacological interventions for different outcomes. MEASUREMENTS: We assessed the repercussion of the evaluated interventions over anxiety scores and their safety, physiological parameters, perioperative medications requirement and intensity of postoperative pain. MAIN RESULTS: We have included 15 studies with 1603 patients. AS has presented reduced anxiety scores as compared to the sham control (Standardized Mean Difference (SMD) -0.72, 95% confidence interval (CI) -1.09 to -0.36, p < 0.0001; 8 trials; 701 patients; heterogeneity: I2 80%; GRADE: moderate certainty) and to no intervention (SMD -1.01, 95% CI -1.58 to -0.45, p = 0.0004; 4 trials; 420 patients; heterogeneity: I2 84%; GRADE: very low certainty). There was no difference between AS and benzodiazepines (SMD -0.03; 95% CI: -0.34 to 0.28; p = 0.84; 3 trials; 158 patients; heterogeneity: I2 0%; GRADE: very low certainty). No trials reported serious adverse effects of AS. CONCLUSIONS: AS may be useful in treatment of preoperative anxiety. Due to heterogenous certainty in effect estimates, further research is needed to clarify the actual efficacy of AS for preoperative anxiety.

Cardiac arrest during elective orthopedic surgery due to moderate hypokalemia.

We report the case of a perioperative cardiac arrest (ventricular fibrillation) of a patient undergoing elective orthopedic surgery due to moderate hypokalemia (serum potassium 2.8 mmol/l), whereas preoperative levels were normal. He was successfully resuscitated without neurological deficits and underwent postoperative intensive care monitoring. In times of increasing populations of elderly people presenting with considerable co-morbidity, clinicians should be aware of possible rapid changes of electrolyte levels resulting in perioperative cardiac arrhythmia.

Nonmelanoma Skin Cancer with Skull Infiltration and Cranial Involvement.

BACKGROUND: Skin cancer is an uncommon cause of skull invasion, dural infiltration and brain parenchyma involvement. CASE REPORT: We report on a series of three elderly patients who presented with squamous cell carcinoma of the scalp with skull bone and cerebral invasion and discuss the diagnostic and therapeutic challenges. CONCLUSION: A major factor of delayed diagnosis of this potentially life-threatening skin cancer feature is patients' neglecting.

Dermatoporosis - The Chronic Cutaneous Fragility Syndrome.

Dermatoporosis is an important clinical condition leading to chronic skin fragility. It can be separated into primary and secondary subtypes, with the latter induced by medical drugs and environmental factors. Dermatoporosis can be classified into 4 major stages with increasing morbidity and mortality with the advanced stages. Its aetiology has been related to the epidermal hyalusome. Dermatoporosis is a cause of mortality in the intensive care unit and should be known not only by a dermatologist but another medical speciality as well. Prevention is of major importance. Therapeutic options are limited but available.