Delirien erh�hen die Morbidit�t und die Liegezeit nach gef��chirurgischen Operationen

OBJECTIVE

We intended to analyze the influence of postoperative delirium on postoperative morbidity and length of hospital stay.

PATIENTS AND METHOD

153 patients undergoing elective arterial surgery were studied prospectively. Patients were examined postoperatively by a psychiatrist daily from days 1 to 7. Delirium was diagnosed according to standardised criteria (Diagnostic and Statistical Manual of Mental Disorders). The severity of delirium was quantified using the Delirium Rating Scale. We compared patients without delirium to those who developed postoperative delirium using univariate statistical analysis (t-test, chi (2) test, and Fisher's test).

RESULTS

Sixty patients (39.2%) developed postoperative delirium. They removed catheters significantly more frequently than patients without delirium and had more catheter-related infections. Their length of stay in intensive care units was higher, as was their total postoperative length of stay in hospital.

CONCLUSIONS

Patients who developed postoperative delirium have significantly more complications and increased postoperative length of stay in hospital and intensive care units.

Pattern and wave number selection in magnetic fluids

The formation of patterns of peaks on the free surface of a magnetic fluid subject to a magnetic field normal to the undisturbed interface is investigated theoretically. The relative stability of ridge, square, and hexagon planforms is studied using a perturbative energy minimization procedure. Extending previous studies the finite depth of the fluid layer is taken into account. Moreover, adding the wave number modulus k to the set of variational parameters also the wave number selection problem is addressed. The results are compared with previous investigations and recent experimental findings.

[Delirium after vascular surgery interventions. Intermediate-term results of a prospective study]

INTRODUCTION

Postoperative delirium is a common psychic disturbance occurring acutely after various surgical procedures and typically presenting with a fluctuating course. These patients' recovery takes longer. In this study we analyze the incidence of postoperative delirium in patients undergoing vascular surgery and try to identify risk factors for its development.

METHODS

Patients undergoing elective arterial operations were included. Their medical history, the specific vascular diagnosis and operation performed, the medication and laboratory data were monitored. Additionally the patients were preoperatively interviewed by a psychiatrist. Intraoperatively the drugs, infusions, possible transfusions, blood gases and pressures were monitored, as were the times of surgery and anesthesia. Postoperatively patients were seen daily by the psychiatrist and the surgeon for at least 7 days. Postoperative delirium was diagnosed according to DSM IV criteria, and mild, moderate and severe delirium were distinguished.

RESULTS

Fifty-four patients entered the study. Twenty-one (38.9%) developed postoperative delirium (11 mild, 2 moderate, 8 severe). Patients with aortic operations developed delirium more frequently than those with non-aortic procedures(55.5 vs 22.2%, n = 27 each). Some preexisting diseases (hearing disturbance) increased the probability of postoperative delirium, while age was not identified as a risk factor. General psychopathological and depressive disturbances increased the likelihood of postoperative delirium. Patients who had a severe intraoperative course developed postoperative delirium more frequently. This was not seen in the absolute time of surgery or anesthesia nor in the intraoperative development of blood pressure or intraarterial gases, which did not differ between patients with and without postoperative delirium. More reliable parameters were an increased intraoperative need for crystalloid volume, intra- or postoperatively decreased hemoglobin values (Hb < 10 g/dl) and the development of acidosis that had to be treated. Patients with delirium had serious complications more often (8/21 = 38.1% vs 6/33 = 18.2%) and needed Intensive Care treatment longer (2.7 vs 2.1 days, only aortic surgery 3.2 vs 2.4 days).

CONCLUSIONS

Postoperative delirium after vascular surgery is frequent. Patients undergoing aortic surgery, with specific concomitant medical disease, psychopathological disturbances and a severe intraoperative course, are at risk of developing postoperative delirium.

[Imaging tumor extension of renal cell carcinomas with magnetic resonance tomography. Improved tumor-tissue contrast with Gd-DTPA-assisted spin-echo sequences and simultaneous fat suppression]

PURPOSE

To evaluate the use of contrast-enhanced T1-weighted images with fat suppression (T1FS) to improve the contrast-to-noise ratio of renal cancer and renal parenchyma as well as perirenal fat.

METHODS

25 patients with histologically proven unilateral renal cancer after nephrectomy were examined before surgery. In addition to plane and contrast-enhanced T1-weighted as well as T2-weighted spin-echo images, all patients had T1 FS immediately after administration of Gd-DTPA in two planes. The contrast-to-noise ratio was calculated using circular regions-of-interest which outlined the tumor, the renal parenchyma, pyelon, and the perirenal fat.

RESULTS

T1 FS significantly improved the contrast-to-noise ratio of renal cancer and renal parenchyma compared to all conventional spinecho sequences (p < 0.001; Wilcoxon-Test). Compared to contrast-enhanced T1-weighted images without fat-suppression T1 FS yielded a higher CNR of the tumor, the perirenal fat and the pyelon. Another advantage was the absence of the chemical-shift artifact which is mostly pronounced in T2-weighted images and a reduced number of observed artifacts due to breathing.

CONCLUSION

T1 FS should replace conventional contrast-enhanced T1-weighted spin-echo images in the work-up of renal cancer using MRI.

[Determining the depth of infiltration in urinary bladder carcinoma with contrast medium enhanced dynamic magnetic resonance tomography. With reference to postoperative findings and inflammation]

OBJECTIVE

The purpose of this study was to evaluate dynamic contrast-enhanced magnetic resonance imaging for the staging of urothelial bladder carcinoma and to compare it with plain and contrast-enhanced spin-echo MRI.

METHODS

Pre-operative MRI was carried out in 62 patients. Post-operative histological examination confirmed bladder carcinoma in 50/62 patients. Carcinoma was excluded in 12 patients. Beside spinecho MRI a dynamic contrast-enhanced study was performed immediately after IV application of Gd-DTPA using 10 sequential FLASH-2Dsequences, each with a duration of 15 s. Images were evaluated visually by three radiologists in a blinded fashion.

RESULTS

In 41/62 patients pre-operative tumor staging with the dynamic contrast-enhanced study was confirmed by the histological examination after surgery. MRI with spinecho sequences yielded correct staging in 30/62 patients (P = 0.028). Staging of superficial bladder cancer was more accurate with dynamic contrast-enhanced MRI than with conventional MRI (P = 0.024). Overstaging was observed in some patients with stage pT1 tumors. Furthermore, postoperative changes of the bladder wall could be differentiated from cancer due to significantly earlier contrast enhancement of bladder cancer compared with postoperative and inflammatory alterations (P < 0.001).

CONCLUSION

Contrast-enhanced dynamic MRI is a helpful addition in the presurgical T-staging of bladder cancer.

Quality of semen after extracorporeal shock wave lithotripsy for lower urethral stones

PURPOSE

We investigated whether extracorporeal shock lithotripsy (ESWL) of stones in the distal ureter can cause decreased in male fertility.

MATERIALS AND METHODS

In vivo and in vitro examinations were performed to clarify possible changes in semen after ESWL of lower urethral stones. For the in vivo examination semen from 10 patients was examined on the day before and 3 days after ESWL. For the in vitro examination semen from 12 healty volunteers was divided into 2 portions after ejaculation, with half immediately examined according to World Health Organization criteria and half directly exposed to the ESWL focus.

RESULTS

The in vitro and in vivo examinations revealed a decrease in sperm density and sperm motility after ESWL. Macroscopic analysis revealed hemospermia in 30% of the patients after ESWL compared to 0% before ESWL. In addition, after ESWL all patients had microscopic hemospermia compared to 10% before ESWL.

CONCLUSIONS

The in vivo and in vitro examinations demonstrated deterioration in semen quality. Sperm density and sperm motility returned to normal 3 months after ESWL, indicating at least a transitory decrease in male fertility may occur.

Use of endorectal surface coil magnetic resonance imaging for diagnosis of a multicystic seminal vesicle with ipsilateral renal agenesis

We report a symptomatic multicystic seminal vesicle with ipsilateral renal agenesis in a 37-year-old man. Preoperatively the diagnosis could be suggested by different imaging modalities, including endorectal surface coil magnetic resonance imaging. To our knowledge, we present the 1st case of seminal vesicle cyst to be evaluated by magnetic resonance imaging using a rectal coil. The value of different imaging modalities is discussed.

[MR urography with the T2-weighted turbo-spin-echo sequence]

Tumor-induced dilatation of the urinary tract is difficult to diagnose in the distal part of the ureter, including the stenosis, by ultrasound and X-ray. Often on account of renal insufficiency and allergy, i.v.-contrast media cannot be used. The present study should show the suitability of fast T2-weighted (turbo-) spin-echo sequences (T2-TSE) for MR-urography (MRU). Seven patients (62.3 +/- 6.1 years) were examined in the coronal plane with T2-TSE sequence (TR = 4500 ms, TE = 160 ms) and an MRU was calculated by using the MIP method (maximal intensity projection). This technique enabled urogram-like morphological representation of dilated urinary tract including stenosis in 6 of 7 patients. Assuming a high magnetic field homogeneity, MRU by using a T2-TSE-sequence, without i.v.-contrast media administration, can visualize the urinary tract dilatation and localize tumor-induced stenosis.

[Osteoplastic bone metastases in prostatic carcinoma: magnetic resonance tomography and bone marrow scintigraphy]

MRI of the vertebral column was performed in 28 patients with histologically confirmed prostate carcinoma. Besides routine spin-echo sequences all patients were examined with gradient-echo sequences using the chemical shift mode. In addition, in all patients bone marrow scintigraphy (BMS) was performed, and all results were compared with routine bone scan (BS). In our study BMS was not superior to bone scan. In contrast, MRI scan revealed solitary metastases in two patients with negative BS and BMS. Osteoplastic metastases showed a contrast enhancement in the MRI and could be distinguished from benign alterations.

Effect of different local and systemic therapy upon urinary bladder cytology

1,900 cytological analyses of urine and bladder washings were made in 127 patients with urothelial bladder carcinomas before, during and after therapy. Following transurethral resection, all patients were treated by intravesical instillation of mitomycin C or thiotepa. Because of a locally advanced bladder carcinoma, 26 patients who were not candidates for radical cystectomy were given an integrated treatment of radiotherapy and chemotherapy. Intravesical administration of mitomycin C and thiotepa as well as integrated radiotherapy and chemotherapy induce a variety of cytological effects (toxic and/or metabolical) which may lead to cytological misinterpretations in the follow-up. DNA measurements by means of single-cell spectrocytophotometry show that the cytological effects induced by the above-mentioned therapies are not accompanied by an increase in the nuclear DNA content. It is concluded that the knowledge of these induced effects is mandatory for a correct interpretation of urinary cytology in the follow-up. Considering these effects and the clinical history, bladder carcinoma recurrences during and after intravesical chemotherapy or integrated radiotherapy and chemotherapy may be detected early by urinary cytology in the hands of an experienced cytopathologist or urologist. Furthermore, alterations of the urinary cytology occur after systemic application of cyclophosphamide and under immunosuppressive therapy.

[Bladder tumors--Magnevist-assisted magnetic resonance tomography]

Magnetic resonance imaging (MRI, Magnetom 0.5 Tesla) using a high-resolution surface coil was performed on 10 healthy volunteers, 16 patients with bladder tumours, 2 patients with cystitis and 15 patients with bladder tumours and cystitis. Lesion delineation versus urine, bladder wall and surrounding organs was evaluated in plain and contrast-enhanced (IV Magnevist, 0.1 mmol/kg) T1-weighted, plain proton-density and T2-weighted spin-echo images. Surface-coil MRI proved very sensitive since all lesions were found in plain scans. Cystitis and 27 of 31 tumours exhibited contrast enhancement, however, differentiation of tumours and cystic lesions was not improved. Plain T2 and contrast-enhanced T1-weighted images demonstrated bladder wall disruption and perivesical tumour spread with equal sensitivity. Post-contrast images permitted unequivocal visualisation of perivesical tumour spread in surrounding peritoneal fat. The authors conclude that T2-weighted imaging may be restricted to non-enhancing bladder tumours thus significantly reducing imaging time.

[Primary hyperparathyroidism: studies of 4,000 urinary calculi patients treated with extracorporeal shockwave lithotripsy]

The incidence of primary hyperparathyroidism was determined in 4000 renal stone formers treated by ESWL at our institution from 1983 to 1990. Based on repeated measurements of serum calcium and serum parathyroid hormone an incidence of 2.8% was found. In 60% of patients with primary hyperparathyroidism stone disease occurred for the first time. The majority of patients (68%) were more than 50 years of age. 56% of patients were men, 44% were women.

[Early results following radical prostatectomy in patients with capsule invasion, seminal vesicle infiltration and micrometastases]

One hundred thirty-three patients with prostatic carcinoma underwent bilateral pelvic lymphadenectomy and radical retropubic prostatectomy between 1975 and 1988. Patients who had a localized prostatic carcinoma (less than or equal to T2b N0 M0 or less than or equal to B 2) and a small number (n = 10) with limited T3 carcinoma were considered for surgical therapy on the basis of a digital prostatic examination. Histological examination revealed locally advanced prostatic carcinoma in 89 patients with capsular infiltration or perforation and seminal vesicle involvement. Microscopic lymph node metastases were noted in 14 cases. Some patients with capsular perforation and seminal vesicle involvement received adjuvant therapy (orchiectomy or radiation). All patients with lymph node metastases were treated by orchiectomy. One local failure occurred among 24 patients with capsular infiltration within 42 months of follow-up. No failure occurred in stage pT3 disease (capsular perforation) with adjuvant therapy (n = 12) and in stage pT3 disease (seminal vesicle involvement) with (n = 9) and without (n = 12) adjuvant therapy after mean follow-up periods of 35, 42 and 52 months, respectively. Distant metastases occurred in 2 patients with stage pT3 disease (capsular perforation) without adjuvant therapy (n = 18) within a mean follow-up of 51 months, and 1 of these patients died of prostatic cancer. Distant metastases occurred in 3 patients with pT2-pT3N1 disease within a mean follow-up of 54 months: 1 of these patients died of prostatic cancer. Local failure was noted in 1 patient in this group.(ABSTRACT TRUNCATED AT 250 WORDS)

Unilateral adrenal hemorrhage in forty-five-year-old woman

We herein describe a case of adrenal hemorrhage on the right side in a forty-five-year-old woman. Her medical history did not show any evidence of an acute bleeding. The hematoma was removed and adrenalectomy performed. A veinectasis and a localized vasculitis are discussed as causes of bleeding.

X-ray microanalysis--a method for determination of elements in bladder biopsies

Chemical elements in biopsies of normal human urothelium and transitional cell carcinoma (TCC) are determined by X-ray microanalysis in combination with scanning electron microscopy. The methodology presented is intended to be used in subsequent studies to compare data of normal urothelium and TCC of different stage and grade.

Differential diagnosis and therapy of rare testicular tumors

The origin, differential diagnosis and therapy of rare testicular tumors are reviewed. 5% of all testicular tumors are rare tumors. Most of these rare tumors are of non-germ cell origin.

[Evaluation of spontaneous renal extravasation of contrast media in the excretory urogram]

Spontaneous renal extravasation is the term used to refer to the radiological demonstration of contrast medium outside the collecting system without previous trauma, ureter catheterization, operation on the kidney or its vicinity, and without external compression during urography. In a review of 1300 intravenous urograms, 13 cases of extravasation of contrast medium were found to satisfy the above criteria. Differences in the radiological appearance may cause problems with regard to evaluation and classification. From a therapeutic point of view it is important to distinguish between two forms: transient sinus extravasation due to minute tears in the calyceal fornix after an increase in intrapelvic pressure and persisting rupture of the previously impaired renal pelvis, which may require surgical intervention.

Quantitative analysis of glycosaminoglycans in urothelium and bladder wall of calf

Glycosaminoglycans (GAG) were described by histochemical staining procedures in the normal urothelium of the urinary bladder; they are supposed to be involved in the antibacterial defense mechanism. Our quantitative analysis, however, demonstrated only heparan sulfate in the normal calf urothelium (less than 600 nmol/Gm d.wt.); only trace amounts of other GAG were to be analyzed. High concentrations of GAG were found in the submucosa and muscle layers as to be expected in mesoderm originating tissues. According to these results there were no GAG with the exception of heparan sulfate at the surface of the normal urothelium; therefore, glycoproteins detected in mumol/Gm d.wt. ranges are more likely to be involved in the antibacterial defense mechanism.

Glycosaminoglycans in urothelial carcinomas

The glycosaminoglycan (GAG) content in human urothelial carcinomas was biochemically determined and compared to that of normal urothelium and bladder wall of the calf. The total GAG content was elevated in urothelial carcinomas, and the distribution pattern differed from that of normal urothelium and bladder wall. Whereas urothelial carcinomas contained heparan sulphate, dermatan sulphate, chondroitin 4-sulphate and chondroitin 6-sulphate, only heparan sulphate could be detected in the normal urothelium. The GAG determination was based on hexosamine analysis and thin layer chromatography after elution on Dowex 1 X 2 columns.

Intravesical single and combination therapy in superficial bladder cancer. An experimental study

In this animal experiment it was investigated if intravesical combination therapy is superior to single drug therapy to reduce the growth of N-butyl-N(4-hydroxybutyl)-nitrosamine (BBN)-induced bladder carcinomas in the rat. The evaluation of the histological data gave the following results: intravesical instillation of cytostatic drugs in concentrations similar to that used in man reduce the growth of BBN-induced tumors. The effectiveness of mitomycin C or adriamycin alone is similar to that of alternative administration of mitomycin C and adriamycin.

Effect on hearing thresholds of surgical modification of the external ear

Modifications of external ear anatomy following tympanomastoid surgery can have significant effects on the hearing threshold. Experiments are described that demonstrate the acoustical effect of changes in the dimensions of the concha and ear canal on external ear sound pressure gain. An attempt is made to correlate these findings with results in 30 post-tympanomastoidectomy ears and develop some basic principles of external ear surgery that might be clinically useful.