Effect of induced hypotensive anaesthesia vs isovolaemic haemodilution on blood loss and transfusion requirements in orthognathic surgery: a prospective, single-blinded, randomized, controlled clinical study

Induced hypotensive anaesthesia and isovolaemic haemodilution are well-established blood-sparing techniques in major surgery. This prospective study compared them for blood loss, transfusion requirements, and surgical field quality during standardized orthognathic operations. In a surgeon-blinded trial, 60 healthy patients requiring either Le Fort I osteotomy or bimaxillary surgery were randomly allocated to receive normotensive anaesthesia, induced hypotensive anaesthesia, or induced hypotensive anaesthesia combined with isovolaemic haemodilution. Blood loss and haemoglobin level were measured intraoperatively and calculated on postoperative day 3. The surgeons rated surgical field quality. Mean blood loss was 1021.63, 392.38 (p<0.05) and 1191.65ml in the normotensive, hypotensive and haemodilution groups, respectively. Mean haemoglobin level immediately after surgery was 9.3, 10.3, and 7.4g/dl (p<0.05), respectively. No hypotensive group patients received transfusions; four normotensive group patients required allogenic transfusions; seven haemodilution group patients needed autogenous retransfusions (p<0.05). Surgical field quality was significantly better in the hypotensive than in the normotensive (p<0.05) or haemodilution (p<0.05) groups. In orthognathic surgery, hypotensive anaesthesia significantly reduces blood loss and transfusion requirements and minimizes allogenic transfusions risks. Induced hypotensive anaesthesia combined with isovolaemic haemodilution has no additional blood-sparing effects but impairs surgical field quality.

Polarization synthesis by computer-generated holography using orthogonally polarized and correlated speckle patterns

An interlaced polarization computer-generated hologram (PCGH) is designed to produce specific irradiance and polarization states in the image plane. The PCGH produces a tangentially polarized annular pattern with correlated speckle, which is achieved by a novel application of the diffuser optimization method. Alternating columns of orthogonal linear polarizations illuminate an interlaced PCGH, producing a ratio of polarization of 88% measured on a fabricated sample. The demonstrated technique can be applied to designs for arbitrary irradiance and polarization states in the image plane.

Continuous low- to moderate-intensity exercise training is as effective as moderate- to high-intensity exercise training at lowering blood HbA(1c) in obese type 2 diabetes patients

AIMS/HYPOTHESIS

Exercise represents an effective interventional strategy to improve glycaemic control in type 2 diabetes patients. However, the impact of exercise intensity on the benefits of exercise training remains to be established. In the present study, we compared the clinical benefits of 6 months of continuous low- to moderate-intensity exercise training with those of continuous moderate- to high-intensity exercise training, matched for energy expenditure, in obese type 2 diabetes patients.

METHODS

Fifty male obese type 2 diabetes patients (age 59 +/- 8 years, BMI 32 +/- 4 kg/m(2)) participated in a 6 month continuous endurance-type exercise training programme. All participants performed three supervised exercise sessions per week, either 55 min at 50% of whole body peak oxygen uptake (VO(2)peak (low to moderate intensity) or 40 min at 75% of VO(2)peak (moderate to high intensity). Oral glucose tolerance, blood glycated haemoglobin, lipid profile, body composition, maximal workload capacity, whole body and skeletal muscle oxidative capacity and skeletal muscle fibre type composition were assessed before and after 2 and 6 months of intervention.

RESULTS

The entire 6 month intervention programme was completed by 37 participants. Continuous endurance-type exercise training reduced blood glycated haemoglobin levels, LDL-cholesterol concentrations, body weight and leg fat mass, and increased VO(2)peak, lean muscle mass and skeletal muscle cytochrome c oxidase and citrate synthase activity (p < 0.05). No differences were observed between the groups training at low to moderate or moderate to high intensity.

CONCLUSIONS/INTERPRETATION

When matched for energy cost, prolonged continuous low- to moderate-intensity endurance-type exercise training is equally effective as continuous moderate- to high-intensity training in lowering blood glycated haemoglobin and increasing whole body and skeletal muscle oxidative capacity in obese type 2 diabetes patients.

TRIAL REGISTRATION

ISRCTN32206301

FUNDING

None.

[Waste management in hospitals. Current situation in the state of North Rhine-Westphalia]

In 20 hospitals in North Rhine-Westphalia in-plant handling wastes and the delivery of the waste to the disposer were examined. Deficits were seen regarding risk assessment and operating instructions, support by company doctors, personal protection equipment, and break areas for the waste collecting personnel. Also the qualification of the waste management officer and his/her time contingent, correct declaration of the wastes, the training of the waste collecting personnel, the cleaning of multi-use containers and transportation vehicles, storage of the wastes at the collecting points, and the use of sharp collecting boxes were to be partly criticized. Consequences and recommendations are given, concerning the company's obligations (e.g., provide risk assessment, operating instructions), waste management officer (e.g., qualification, enough time contingent, regular inspections), waste collecting personnel (e.g., training courses), industrial safety (e.g., protection equipment, break area wash places), company doctors, transportation vehicles in the house (e.g., regular cleaning), one-way collectors (e.g., labelling at the site of the collection), multi-use collectors (e.g., cleaning), and compressing containers (e.g., larger maintenance openings).

Absence of high‐affinity calreticulin autoantibodies in patients with systemic rheumatic diseases and coeliac disease

Calreticulin has been reported to be an autoantigen in various autoimmune connective tissue diseases and in coeliac disease. Previous studies have used incubation buffers with low salt and low detergent concentrations (low stringency conditions) with serum albumin or other proteins as a blocking agent. Using these conditions we found a relatively high level of non-specific binding in many sera. Antibodies to proteins that are used as blocking reagents in ELISA (bovine serum albumin (BSA), ovalbumin, skimmed milk powder) are frequently present in sera, and these may cause false-positive results. Moreover, the low isoelectric point of calreticulin and its chaperone properties may give rise to false-positive results under low stringency conditions. We report that the use of a simple buffer without protein (50 mM Tris, pH 7.5, 1% Tween 20, 0.3 M NaCl) removes most of the problems with unwanted binding (high stringency conditions). Using the high stringency conditions, we screened sera from 107 patients with systemic lupus erythematosus, sera from patients with other systemic autoimmune diseases and from children with coeliac disease for the presence of high-affinity calreticulin autoantibodies by immunoblotting and ELISA. None of the sera contained high-affinity calreticulin antibodies. It is concluded that calreticulin is not a common autoantigen in patients with autoimmune connective tissue diseases or coeliac disease.

Environmental sampling of particulate matter and fungal spores during demolition of a building on a hospital area

Demolition or renovation works adjacent to hospitals pose risks of fungal airborne infections. During November 2005 and March 2006 an old building with three floors was demolished on the area of University Hospital of Essen. To prevent dust exposure the building was sealed up by impermeable plastic foil and mechanical disruption of structures was accomplished using excavators. Dust emission was minimised by water jet. To determine if there were any infectious risks for patients from emissions from the demolition work we monitored particle and fungal concentration of the air before and during demolition. Air sampling was performed at seven positions around the building and weather conditions were monitored at the same time. Concentrations of ultrafine particles, particles > or =0.3, > or =0.5 and > or =1 microm were significantly higher during demolition than before, but only by small factors (ultrafine particles 1.6-fold, particles > or =0.3 microm 1.6-fold, particles > or =0.5 microm 2.9-fold and particles > or =1 microm 3.3-fold). Concentrations of moulds which could be cultured at 37 degrees C did not differ between the two periods (median before demolition: 66 cfu/ m3; median during demolition: 80 cfu/m3). Concentrations of moulds which grew at 22 degrees C correlated significantly with temperature and humidity and were significantly higher before (median: 510 cfu/m3) than during the demolition period (median: 210 cfu/m3). We conclude that the fungal infection risks for patients during demolition work in hospital areas is not increased by demolition if protective measures are in place.

The use of retrievable inferior vena cava filters in orthopaedic patients

This study was undertaken to evaluate the safety and efficacy of retrievable inferior vena cava filters in high-risk orthopaedic patients. A total of 58 patients had a retrievable inferior vena cava filter placed as an adjunct to chemical and mechanical prophylaxis, most commonly for a history of previous deep-vein thrombosis or pulmonary embolism, polytrauma, or expected prolonged immobilisation. In total 56 patients (96.6%) had an uncomplicated post-operative course. Two patients (3.4%) died in the peri-operative period for unrelated reasons.

Of the 56 surviving patients, 50 (89%) were available for follow-up. A total of 32 filters (64%) were removed without complication at a mean of 37.8 days (4 to 238) after placement. There were four filters (8%) which were retained because of thrombosis at the filter site, and four (8%) were retained because of incorporation of the filter into the wall of the inferior vena cava. In ten cases (20%) the retrievable filter was left in place to continue as primary prophylaxis. No patient had post-removal thromboembolic complications.

A retrievable inferior vena cava filter, as an adjunct to chemical and mechanical prophylaxis, was a safe and effective means of reducing the acute risk of pulmonary embolism in this high-risk group of patients. Although most filters were removed without complications, thereby avoiding the long-term complications that have plagued permanent indwelling filters, a relatively high percentage of filters had to be left in situ.

[Necessity of increasing autopsy frequency following the introduction of DRGs]

With the introduction of DRGs (diagnosis related groups) in 2004, a new charging system was initiated in Germany. Changes primarily involve lump sum based charging of inpatient cases regardless of the duration or complexity of diagnostic procedures and therapy, and the equalization of costs for similar services. Calculation of DRGs also includes the costs of autopsy. This has three major consequences for autopsy practice: Quality assurance: continuous monitoring of professional quality under lump sum payment can only be permanently guaranteed and independently and reliably attained by autopsy. This is the only way to overcome the danger of abolishing essential diagnostic procedures because of economic pressure and thus risking incorrect diagnoses. Economy: additional diagnoses revealed by autopsy will, in many cases, raise calculated charges. This could have a significant financial impact. Legal certainty: autopsies increase the accuracy and objectivity of diagnoses. Thus, they protect the attending physician from incorrect charging which may be unintended but could be legally relevant, especially when the cause of death is unclear. For these reasons, autopsy should become more important in clinical routine.

Sex-specific association of the human PTPN22 1858T-allele with type 1 diabetes

Type 1 diabetes (T1D) is a common organ-specific autoimmune disease of complex aetiology, involving the interaction of a large number of disease-associated genes. By comparison of a Danish population sample of 253 Caucasian children and adolescents with T1D and a control group consisted of 354 unrelated healthy blood donors, the present study provides evidence of an isolated association of the disease-associated PTPN22 1858T-allele with T1D to the female sex. Furthermore, the present data suggest that PTPN22 genotypes affect the age of onset in a sex-specific manner. The increased frequency of the risk allele and its association with age at onset in female T1D children and adolescents indicates that the genetic contribution to disease pathogenesis is more prominent in females in this population of Danish patients.

Peripheral insulin and brain structure in early Alzheimer disease

OBJECTIVE

Accumulating evidence suggests insulin and insulin signaling may be involved in the pathophysiology of Alzheimer disease (AD). The relationship between insulin-mediated glucoregulation and brain structure has not been assessed in individuals with AD.

METHODS

Nondemented (Clinical Dementia Rating [CDR] 0, n = 31) and early stage AD (CDR 0.5 and 1, n = 31) participants aged 65 years and older had brain MRI to determine whole brain and hippocampal volume and 3-hour IV glucose tolerance tests to determine glucose and insulin area under the curve (AUC). Linear regression models were used to assess the relationship of insulin and glucose with brain volume, cognition, and dementia severity.

RESULTS

In early AD, insulin and glucose AUCs were related to whole brain (insulin beta = 0.66, p < 0.001; glucose beta = 0.45, p < 0.01) and hippocampal volume (insulin beta = 0.42, p < 0.05; glucose beta = 0.46, p < 0.05). These relationships were independent of age, sex, body mass index, body fat, cardiorespiratory fitness, physical activity, cholesterol, and triglycerides. Insulin AUC, but not glucose, was associated with cognitive performance in early AD (beta = 0.40, p = 0.04). Insulin AUC was associated with dementia severity (Pearson r = -0.40, p = 0.03). Glucose and insulin were not related to brain volume or cognitive performance in nondemented individuals.

CONCLUSIONS

Increased peripheral insulin is associated with reduced Alzheimer disease (AD)-related brain atrophy, cognitive dysfunction, and dementia severity, suggesting that insulin signaling may play a role in the pathophysiology of AD.

Success of MRSA eradication in hospital routine: depends on compliance

BACKGROUND

To prevent transmission of MRSA, eradication by antiseptic washings and nasal ointment is recommended. There are few studies, which investigated the success of eradication of MRSA carriage during everyday clinical working conditions and results are controversial. We wanted to assess the effectiveness of MRSA eradication procedures--especially octenidine whole body washings and mupirocin nasal ointment--under conditions of everyday life.

PATIENTS AND METHODS

We retrospectively analyzed the files of all patients who were admitted to the medical department of a tertiary care hospital between 1999 and 2004 and who were infected or colonized by MRSA. According to hospital's standards of care patients should have been washed with octenidine and should have got mupirocin nasal ointment only in case of nasal carriage. Patients were regarded as MRSA-eradicated when swabs taken on three consecutive days, earliest, three days after discontinuation of antiseptic and antiinfective procedures were without proof of MRSA.

RESULTS

Only 6% of patients were eradicated. MRSA could be cultured from swabs taken on dismissal of 60% of patients. Fifteen percent of patients had only one or two negative series of swabs. In 19% of patients success of eradication remained unknown. Besides we found that under every day clinical working conditions compliance with several tasks of the eradication protocol was insufficient.

CONCLUSION

Under every day clinical working conditions MRSA eradication is successful only in few patients. Whole body washings should be tested in detailed studies before they should become a recommendation for eradication of MRSA.

[Hygiene in home care. A study with home care providers]

We studied the implementation of infection control guidelines of 9 providers of home care in the German Ruhr area. The study included 22 nurses, and 214 home care patients were seen. The following main problems were identified: Qualified infection control staff is lacking, infection control protocols are lacking or are not adapted, the cooperation with family doctors often is problematic, there are deficits in hand hygiene and great deficits with clothing hygiene and waste disposal. We suggest improvements for some care tasks, e.g., handling of urinary catheters, infusions and prescription of tracheostomy tubes.

Klinischer Behandlungspfad „laparoskopische Prostatektomie“

METHODS

In this study we investigated the anesthesiological module of a clinical pathway. We chose the pathway of "laparoscopic prostatectomy" as an example for time-consuming minimally invasive surgery and 40 patients were randomly assigned to 2 groups receiving either total intravenous anesthesia (TIVA) using propofol/ remifentanil or balanced minimal flow anesthesia using desflurane/ remifentanil. During this module the indicators of quality such as vigilance, pain, postoperative nausea and vomiting (PONV) and mobilization were measured. Costs were evaluated and analyzed by a bottom-up procedure.

RESULTS

There were no anesthesia-related deviations from clinical pathways and both forms of anesthesia management were equally well tolerated by the patients. No significant difference was observed regarding hemodynamic measurements or PONV. The patients in the desflurane/ remifentanil group recovered more rapidly (p=0.037) and had more pain. The amount of analgesic agents given immediately following anesthesia was significantly higher than in the TIVA group (p=0.017). The median anesthesia costs per minute for laparoscopic prostatectomy in the propofol group were 2.79 EUR (minimum cost 2.41 EUR, maximum cost 3.21 EUR) and in the desflurane group 2.68 EUR (minimum cost 2.45 EUR, maximum cost 3.39 EUR). The total anesthesia costs for both groups were within the proceeds matrix range for diagnosis-related groups (DRG). However, the cost analysis for medication was slightly higher than the proceeds matrix range for DRGs.

CONCLUSION

Both forms of anesthesia can be implemented for time-consuming surgical procedures and allow a cost-effective anesthesia management. Anesthesiological procedures must go hand-in-hand with the type of anesthesia selected. The prophylactic use of analgetics for desflurane/ remifentanil anesthesia should be given earlier and in higher doses than in propofol/ remifentanil anesthesia. The prophylactic use of antiemetics following laparoscopic procedures of long duration is indicated. Optimizing anesthesiological procedures could lead to a continuous improvement in the quality of therapeutic pathways.

Association of a putative regulatory polymorphism in the PD-1 gene with susceptibility to type 1 diabetes

The immunoreceptor programmed cell death-1 (PD-1) is reported to play an important role in the regulation of peripheral tolerance in rodents, and it was recently shown that a polymorphism in a regulatory site of the PD-1 gene is associated with susceptibility to the autoimmune disease systemic lupus erythematosus (SLE) in humans. We investigated the existence of single-nucleotide polymorphisms (SNPs) in the PD-1 gene in patients with type 1 diabetes in comparison with healthy control subjects, by analyzing 94 children and adolescents with type 1 diabetes diagnosed before their eighteenth birthday (male : female = 52 : 42) and 155 control subjects. Polymorphisms in the complete PD-1 gene (minus the large intron 1) were detected by sequencing. In total, we identified 14 SNPs, of which six have been previously described, including an intronic 7146G/A SNP. We found this polymorphism to be associated with the development of type 1 diabetes [found in 12.2% of diabetic individuals vs 6.8% in controls; odds ratio (OR) = 1.92]. The associated allele is previously shown to alter a transcription factor-binding site (RUNX1/AML1), and the results of this study suggest that this allele could act as an additional susceptibility allele to type 1 diabetes.

[Experiences with anthrax emergency measures during 2001 and 2002 in the city of Essen]

After the terrorist attacks of 11 September 2001 suspected cases of anthrax also occurred in Germany. No case could be confirmed. From October 2001 to November 2002 the fire brigade of the city of Essen was called in 110 cases of suspected anthrax contamination. In 78 cases specimens were transported to diagnostic laboratories, in 22 cases persons were transported. Only in the first few days patients with suspected contamination had to stay in hospital and underwent chemoprophylaxis. Cooperation between the fire brigade, the local health authorities and the hygienists of the involved hospitals was very intense. It seems necessary to evaluate all the German experiences with suspected anthrax cases to develop risk estimations for different exposure situations and to develop specific recommendations for decontamination, disinfection and initial therapy.

A prospective study of thyroid function, morphology and autoimmunity in young patients with type 1 diabetes

OBJECTIVE

Thyroid autoantibodies (TA) and thyroid ultrasonography are widely used in the diagnosis of autoimmune thyroid disease (AITD). However, we know little of the significance of having ultrasonographic abnormalities (USabn) without having any other signs of AITD. In a previous population-based study of 105 young patients with type 1 diabetes (T1DM) we found a high prevalence (42%) of USabn. In the present study we evaluate the development of both USabn and TA in a 3-Year follow-up of this cohort.

DESIGN

Of the 105 previously investigated children and adolescents with T1DM (aged 5-21 Years), 101 were re-examined. Serum concentrations of tri-iodothyronine (T(3)), thyroxine (T(4)), TSH, thyroid peroxidase antibodies (TPOab) and thyroglobulin antibodies (Tgab), as well as thyroid size and morphology were determined in all patients.

RESULTS

During the 3 Years follow-up period, the prevalence of thyroid dysfunction increased from 5 to 8%, the prevalence of TPOab was unchanged at 13%, while the prevalence of Tgab decreased from 14 to 7%. The prevalence of USabn increased from 42 to 49%. Most patients presented USabn at both examinations. Patients with USabn had a higher prevalence of TA than those without USabn (P=0.038) and higher serum levels of TSH (P=0.027). All patients with thyroid dysfunction presented with USabn. However, many patients with USabn had no other signs of AITD.

CONCLUSIONS

A high prevalence of thyroid dysfunction, TA and thyroid USabn were found in young patients with T1DM. Thyroid USabn was a sensitive but non-specific marker of AITD and is therefore unsuitable for screening purposes. Instead, we recommend regular screening using serum TSH in the follow-up of young diabetic patients.

High prevalence of coeliac disease in Danish children with type I diabetes mellitus

The purpose of this population-based study was to determine the prevalence of coeliac disease (CD) in 106 Danish children (age 2-18 y) with type I diabetes mellitus compared with 106 age- and sex-matched healthy controls. Serum samples were analysed for immunoglobulin A (IgA) and IgG gliadin antibodies by enzyme-linked immunosorbent assay (ELISA), for IgA endomysium antibodies (EMA) by immunofluorescence and for IgA tissue transglutaminase antibodies (tTGA) by ELISA. None of the controls had EMA or tTGA. Two diabetics previously diagnosed with CD were antibody negative on a gluten-free diet. Ten diabetics had both EMA and tTGA. Intestinal biopsy was performed in nine of them. All biopsies showed a histological picture of partial or total villous atrophy confirming the diagnosis of CD. Diabetics with CD were significantly younger (p = 0.026). had an earlier onset of diabetes (p = 0.005), had a lower height standard deviation score (p = 0.019) and more often had thyroid antibodies (p = 0.040) compared with diabetics without CD.

CONCLUSION

A high prevalence of CD of 10.4% (95% confidence interval 4.6-16.2%) was found in young Danish diabetics. Early onset of diabetes may predispose to CD. Routine serological screening for CD may be valuable in patients with type I diabetes mellitus.

MCF-7/VD(R): a new vitamin D resistant cell line

Several in vitro and in vivo experiments have demonstrated potent cell regulatory effects of vitamin D compounds in cancer cells. Moreover, a promising phase I study with the vitamin D analogue Seocalcitol (EB 1089) in patients with advanced breast and colon cancer has already been carried out and more clinical trials evaluating the clinical effectiveness of EB 1089 in other cancer types are in progress (Mørk Hansen et al. [2000a]). However, only little is known about the mechanisms underlying the actions of vitamin D or about the possible development of drug resistance in the patients. Therefore, in an attempt to gain more insight into these aspects, we have developed the MCF-7/VD(R) cell line, a stable subclone of the human MCF-7 breast cancer cell line, which is resistant to the growth inhibitory and apoptosis inducing effects of 1alpha,25(OH)(2)D(3). Despite this characteristic, receptor studies on the VDR have clearly demonstrated that the MCF-7/VD(R) cells contain fully functional VDRs, although in a lower number than seen with the parental MCF-7 cells. The regulation of the 24-hydroxylase enzyme appeared to be intact in the MCF-7/VD(R) cells and no differences with regard to growth rate and morphological appearance between the MCF-7/VD(R) cells and the parental MCF-7 cells were observed. Interestingly, however, the sensitivity of the MCF-7/VD(R) cells to the pure anti-estrogen ICI 182,780 was found to be increased. The MCF-7/VD(R) cell line shows characteristics different from those of previously described vitamin D resistant breast cancer cell lines but also some similarities. Together such vitamin D resistant cell lines therefore serve as a useful tool for studying the exact mechanism of action of vitamin D and the development of vitamin D resistance.