Patient’s anxiety and fear of anesthesia: effect of gender, age, education, and previous experience of anesthesia. A survey of 400 patients

Purpose

Patients express high anxiety preoperatively, because of fears related to anesthesia and its implications. The purpose of this survey was to gain insight into these fears and to study whether they are affected by patients’ sex, age, education, or previous experience of anesthesia.

Methods

Questionnaires with fixed questions were distributed to consenting, consecutive surgical patients before the pre-anesthetic visit. The questionnaires included patients’ demographics and questions related to their fears about anesthesia.

Results

Four-hundred questionnaires were collected and analyzed. Eighty-one percent of patients experience preoperative anxiety. The main sources of their anxiety were fear of postoperative pain (84 %), of not waking up after surgery (64.8 %), of being nauseous or vomiting (60.2 %), and of drains and needles (59.5 %). Patients are less concerned about being paralyzed because of anesthesia (33.5 %) or of revealing personal issues (18.8 %). Gender seems to affect patients fears, with women being more afraid (85.3 vs. 75.6 % of men, p = 0.014). The effects of patients’ age, level of education, and previous experience of anesthesia are minor, except for individual questions. Sixty-three percent of our patients (mostly women 67.4 vs. 57.4 % of men, p = 0.039) talk about these fears with their relatives, although a vast majority of 95.5 % would prefer to talk with the anesthesiologist and be reassured by him.

Conclusion

All patients, mostly women, express fears about anesthesia; this fear leads to preoperative anxiety. Slight differences are observed for some individual questions among patients of different sex, education level, and previous experience of anesthesia.     

Renal Production,Uptake, and Handling of Circulating αKlotho

αKlotho is a multifunctional protein highly expressed in the kidney. Soluble αKlotho is released through cleavage of the extracellular domain from membrane αKlotho by secretases to function as an endocrine/paracrine substance. The role of the kidney in circulating αKlotho production and handling is incompletely understood, however. Here, we found higher αKlotho concentration in suprarenal compared with infrarenal inferior vena cava in both rats and humans. In rats, serum αKlotho concentration dropped precipitously after bilateral nephrectomy or upon treatment with inhibitors of αKlotho extracellular domain shedding. Furthermore, the serum half-life of exogenous αKlotho in anephric rats was four- to five-fold longer than that in normal rats, and exogenously injected labeled recombinant αKlotho was detected in the kidney and in urine of rats. Both in vivo (micropuncture) and in vitro (proximal tubule cell line) studies showed that αKlotho traffics from the basal to the apical side of the proximal tubule via transcytosis. Thus, we conclude that the kidney has dual roles in αKlotho homeostasis, producing and releasing αKlotho into the circulation and clearing αKlotho from the blood into the urinary lumen.     

Pathophysiology,diagnosis, and treatment of methylmalonic aciduria—recent advances and new challenges

Classical methylmalonic aciduria is a relatively rare inborn error of branched-chain amino acid metabolism, occurring in 1:50,000 to 1:80,000 newborns. Three decades after its recognition, major progress has been made in survival and prevention of neurological sequelae in affected children, if the diagnosis is made early and treatment and follow-up care are meticulous. Therapy consists of a specially formulated protein diet, carnitine supplementation, and vigorous emergency treatment during intercurrent illnesses aimed at preventing the development of catabolism. Recently the clinician has been challenged by partially unexpected long-term complications. These include chronic neurological symptoms, specifically an extrapyramidal movement disorder caused by progressive destruction of the basal ganglia, which are similar to those observed in other organic acid disorders, such as propionic aciduria or glutaric aciduria type I. Unexpected and unique is the development of chronic renal failure in a major subset of patients. As the pathophysiological basis of renal failure is still obscure, no causative treatment is available and hemodialysis may become necessary. Experience with transplantation of liver, kidney, or kidney and liver is very limited and allows as yet no conclusions. Interdisciplinary research efforts in this field should reveal new pathophysiological links and hopefully provide additional therapeutic approaches.     

Morphodynamics and Surgical Correction of the Body’s Creases,Folds, and Wrinkles

The aesthetics of the human body are a balance of furrows and orifices, and artists of every period have studied the distance between ear and eye, eye and nostrils, nostrils and mouth, nipple and submammary crease, subgluteus folds and iliac crest and so on, to create a code for all body proportions. Currently, the ideal of female beauty prefers more elongated shapes than in the past, and surgical body modeling, performed in accordance with anthropometric rules, uses a combination of techniques to alter the orientation and depth of aesthetic reference points, such as body folds and curves. These must be integrated into the bodys biodynamics to both prevent and correct defects and irregularities of the body, which has an inherent disposition to change shape, both because of the physical forces acting on it and because of constant tissue replacement.     

Effects of chitosan on cell proliferation and collagen production of tendon sheath fibroblasts, epitenon tenocytes, and endotenon tenocytes

Flexor tendon repair in zone II is often complicatedby adhesions to the surrounding fibro-osseoustendon sheath. Adhesion between the tendon andtendon sheath will impair the gliding function oftendons and result in marked impairment of handfunction. Experimental strategies to decrease adhesionformation, with the long-term goal of improving clinicaloutcome after tendon injury and repair, have been thesubject of numerous studies over the past 20 years.Biochemical agents such as antihistamines, s…     

Analyis of Protamine mRNA in sperm of men,rats and mice

Aim: To investigate the existence of the protamine mRNA insperm of men, rats and mice. Methods: By means of RT-PCRtechniques, protamine cDNA fragments were obtained from totalRNA of the mature sperm of men, rats and mice. Results:mRNA of protamine gene was present in the mature sperm of men,rats and mice. The protamine cDNA obtained by RT-PCR in ratsperm with an abnormal head was much less in number than that inthe normal rat sperm. Conclusion: mRNA in the sperm mightrepresent the condition of corresponding gene expression duringspermatogenesis. (Reprod Contracep 2001; 21: 200 - 5)     

Survival and prognostic factors of germ cell tumors of the testis in the departments of Bas-Rhin, Isère, and Somme]

The authors report a study of the prognosis of germ cell tumours of the testis in populations of the Bas-Rhin, Isère and Some departments. This study was performed on French Eurocare data (European testicular cancer register study). 247 patients diagnosed between 1987 and 1993 were studied. Estèv's method and model were used to estimate the relative survival and for prognosis analysis with reference to the French age-matched male population. 84.6% of patients were between the ages of 20 and 49 years. The 5-years relative survival was 90.1%; 95 CI% [85.5-94.8]. The 5-year relative survival was lower (63.9%) in advanced forms (stage III). Univariate analysis in 223 patients demonstrated the following significant prognostic factors: stage, metastatic sites, treatment, retroperitoneal lymph node dissection and testicular vascular invasion. Multivariate analysis identified: stage, age, CNS metastases, retroperitoneal lymph node dissection and treatment. This study confirms the generally good prognosis of this cancer. As reported in the literature, factors negatively influencing relative survival are those related to advanced disease. Age, a controversial factor in the literature, was correlated with relative survival in this study.     

β-defensins and the epididymis: contrasting influences of prenatal,postnatal, and adult scenarios

β-defensins are components of host defense, with antimicrobial and pleiotropic immuno-modulatory properties. Research over the last 15 years has demonstrated abundant expression of a variety of β-defensins in the postnatal epididymis of different species. A gradient of region- and cell-specific expression of these proteins is observed in the epithelium of the postnatal epididymis. Their secretion into the luminal fluid and binding to spermatozoa as they travel along the epididymis has suggested their involvement in reproduction-specific tasks. Therefore, continuous attention has been given to various β-defensins for their role in sperm function and fertility. Although β-defensins are largely dependent on androgens, the underlying mechanisms regulating their expression and function in the epididymis are not well understood. Recent investigation has pointed out to a new and interesting scenario where β-defensins emerge with a different expression pattern in the Wolffian duct, the embryonic precursor of the epididymis, as opposed to the adult epididymis, thereby redefining the concept concerning the multifunctional roles of β-defensins in the developing epididymis. In this review, we summarize some current views of β-defensins in the epididymis highlighting our most recent data and speculations on their role in the developing epididymis during the prenatal-to-postnatal transition, bringing attention to the many unanswered questions in this research area that may contribute to a better understanding of epididymal biology and male fertility.     

Etiology, classification and clinical evaluation of partialthickness tears of rotator cuff

ince partial-thickness tears of the rotator cuffwere described well by Codmanl in 1934, theyhave been extensively discussed in all kinds ofliteratures. Partial-thickness tears of the rotator cuffare now considered to play a more significant role thanpreviously in inducing patients‘ disability. Partial     

Trends in Incidence and Prevalence of Specialized Intestinal Metaplasia,Barrett’s Esophagus,and Adenocarcinoma of the Gastroesophageal Junction

Most available information on the epidemiology of Barretts esophagus (BE) relates to patients with long segments (> 3 cm) of specialized intestinal metaplasia (SIM). Its prevalence is 3% in patients undergoing endoscopy for reflux symptoms and 1% in those undergoing endoscopy for any clinical indication. The latter prevalence is similar to the 1% found in autopsy series. A silent majority with BE remain unrecognized in the general population. BE is more common in men, and the prevalence rises with age. Recent endoscopic series document a rise in the diagnosis of endoscopically apparent short segments (< 3 cm) of BE (SSBE). The prevalence of SSBE in both unselected and reflux patients is 8% to 12%. Specialized intestinal metaplasia at the cardia, below a normal-appearing squamocolumnar junction, has been reported to vary from 6% to 25% in patients presenting for upper endoscopy. Unlike patients with long segment Barretts esophagus (LSBE), the role of gastroesophageal reflux disease in the pathogenesis of SSBE and SIM of the cardia is controversial. Recent data suggest that the etiology of SIM of the cardia might be secondary to Helicobacter pylori infection, although the role of other environmental factors cannot be ruled out. The incidence of adenocarcinoma of the esophagus and esophagogastric juction (EGJ) has been increasing over the past 15 years in Western countries. Surgical series and population-based studies show that by 1994 adenocarcinomas of the esophagus accounted for half of all esophageal cancer among white men. LSBE and SSBE predispose to the development of adenocarcinoma of the esophagus and EGJ. The role of SIM of the cardia as a precursor lesion for EGJ adenocarcinoma is still unclear. The prevalences of dysplasia in LSBE and SSBE are around 6% and 8%, respectively. The incidence of adenocarcinoma in patients with LSBE is about 1 in 100 patient-years. Cancer risk for SSBE and SIM at the cardia is unknown. Smoking and obesity increase the risk for esophageal and EGJ adenocarcinomas.     

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure

BACKGROUND: Calls abound for a culture change in health care to improve patient safety. However, effective change cannot proceed without a clear understanding of perceptions and beliefs about error. In this study, we describe and compare operative team members' and patients' perceptions of error, reporting of error, and disclosure of error. METHODS: Thirty-nine interviews of team members (9 surgeons, 9 nurses, 10 anesthesiologists) and patients (11) were conducted at 2 teaching hospitals using 4 scenarios as prompts. Transcribed responses to open questions were analyzed by 2 researchers for recurrent themes using the grounded-theory method. Yes/no answers were compared across groups using chi-square analyses. RESULTS: Team members and patients agreed on what constitutes an error. Deviation from standards and negative outcome were emphasized as definitive features. Patients and nurse professionals differed significantly in their perception of whether errors should be reported. Nurses were willing to report only events within their disciplinary scope of practice. Although most patients strongly advocated full disclosure of errors (what happened and how), team members preferred to disclose only what happened. When patients did support partial disclosure, their rationales varied from that of team members. CONCLUSIONS: Both operative teams and patients define error in terms of breaking the rules and the concept of "no harm no foul." These concepts pose challenges for treating errors as system failures. A strong culture of individualism pervades nurses' perception of error reporting, suggesting that interventions are needed to foster collective responsibility and a constructive approach to error identification.     

Obstruction of Magendie's and Luschka's Foramina. Cine-MRI, Ætiology and Pathogenesis

Summary  Background. Obstruction of the foramina of Magendie and Luschka represents one possible aetiology for a progressive tetra-ventricular hydrocephalus.  Method. Our case report is a 58-year-old woman initially presenting with a pseudo-vertebrobasilar insufficiency clinical syndrome. A ventriculo-cisternostomy of the third ventricle was performed by an endoscopic procedure with a clinical and radiological success (three year follow-up).  Findings. Comparative studies of cerebrospinal fluid (CSF) flow measurements by cine magnetic resonance imaging (cine-MRI) showed that Magendie's and Luschka's foramina permeabilities were restored after the ventriculo-cisternostomy.  Interpretation. This case shows that endoscopic ventriculo-cisternostomy of the third ventricle can provide an effective treatment for specific tetra-ventricular hydrocephalus. Cine-MRI findings open the discussion on possible aetiologies and pathophysiologies.     

Which questionnaire is best? The reliability, validity and ease of use of the Patient Evaluation Measure, the Disabilities of the Arm, Shoulder and Hand and the Michigan Hand Outcome Measure

The Patient Evaluation Measure (PEM), The Michigan Hand Outcome Questionnaire (MHQ) and the Disabilities of the Arm, Shoulder and Hand (DASH) score were assessed independent of their originators for reliability, construct and criterion validity and acceptability, using an ease of use questionnaire. These were administered in random order to 100 patients with different hand and wrist disorders and with different impairments of movement, pain, sensation and strength. The internal consistency of all three questionnaires was very high suggesting redundancy in the questions. All questionnaires were reproducible and valid for finger and wrist disorders, but less for nerve disorders. All had poor construct validity. The PEM was the easiest to understand and complete, taking the least time. Correlation between the scales is high and conversion equations were calculated. All three are reliable and reproducible patient completed questionnaires, but the PEM is the easiest to use. The validity of all is suspected for nerve disorders.     

Jan Mikulicz-Radecki (1850–1905): Pioneer of Endoscopy and Surgery of the Sinuses,Throat, and Digestive Tract

The authors described the medical achievements of Jan Antoni Mikulicz-Radecki—–a famous surgeon and laryngologist of Polish origin, belonging to the Viennese surgical school of Prof. Theodor Billroth at the turn of the 20th century. His scientific and clinical activity in Vienna, Cracow, Königsberg, and Wroclaw resulted in 232 publications and several new surgical methods. He changed the opinion on scleroma and described benign lymphoepithelial lesions. He was one of the authors of modern aseptics, antisepsis in surgery, and is regarded as a pioneer of endoscopic procedures. He was interested mainly in thoracic surgery, surgery of the abdomen, orthopedics, and laryngology. Mikulicz was the first to describe the method of surgical treatment of the maxillary sinus, osteoplastic surgery of the nose, esophagoscopy, and lateral pharyngotomy in tonsil carcinoma. Prof. Mikulicz was the first to perform thoracic surgery; he performed the first pyloroplasty, the first partial esophagectomy and gave rise to antiseptic procedures and general surgical management. He described many modifications of surgical operations and he constructed the esophagoscope, scoliozymeter, and many other useful surgical devices.     

The classification, management and molecular biologic study of disorders of sexual differentiation

Disordersofsexualdifferentiationisagroupofnotsorarediseasesthatoccupyabout1%ofaIIcasesinourgynecologicalen-docrineclinic.Thisisagroupofmostconfus-ingdisordersbecauseoftheirdifferentpatho-logicetiologyandtheirwidespectrumofclini-calmanifestationseveninthesamedisorder.ItwastraditionallyclassifiedastrueAlandpseudo-hermaphroditebasedonthepathologyofgonads,phenotypeandkaryotype.Withtheadvancernentinbasicresearch,especiallyinendocrinebiochernistry,geneticsandmolecularbiology,theunderstandingaboutdi…     

Association of TNFα, TNFR1, and TNFR2 polymorphisms with sperm concentration and motility

Tumor necrosis factor α (TNFα) is a multifunctional cytokine that regulates various cellular processes related to spermatogenesis. Two types of cell receptors, TNFR1 and TNFR2, mediate TNFα activity. In the present study, we sought to explore the association of TNFα -857C→T, TNFR1 36A→G, and TNFR2 676T→G polymorphisms with sperm concentration and motility. Two hundred ninety men were examined during infertility investigation; of those, 170 men were normozoospermic and 120 were oligospermic. Polymerase chain reaction analysis revealed significant differences in genotype distribution of the TNFR1 36A→G polymorphism between normozoospermic and oligospermic men. Men with oligozoospermia presented TNFR1 36A/A genotypes less frequently than normozoospermic men (P < .001). The presence of the TNFR1 36G allele was significantly increased in oligospermic men (P < .001). Furthermore, the presence of the TNFR1 36G allele was associated with lower sperm concentration in normozoospermic men (P < .03) and in the total study population (P < .001), and with lower sperm motility in normozoospermic men (P < .007) and in the total study population (P < .001). No significant associations were found between TNFα -857C→T and TNFR2 676T→G polymorphisms and semen quality. The TNFR1 36A allele is associated with increased sperm concentration and motility in our series, supporting the significance of TNFR1 gene in semen quality.     

Effects of rosiglitazone, glyburide, and metformin on β-cell function and insulin sensitivity in ADOPT

OBJECTIVE

ADOPT (A Diabetes Outcome Progression Trial) demonstrated that initial monotherapy with rosiglitazone provided superior durability of glycemic control compared with metformin and glyburide in patients with recently diagnosed type 2 diabetes. Herein, we examine measures of β-cell function and insulin sensitivity from an oral glucose tolerance test (OGTT) over a 4-year period among the three treatments.

RESEARCH DESIGN AND METHODS

Recently diagnosed, drug-naïve patients with type 2 diabetes (4,360 total) were treated for a median of 4.0 years with rosiglitazone, metformin, or glyburide and were examined with periodic metabolic testing using an OGTT.

RESULTS

Measures of β-cell function and insulin sensitivity from an OGTT showed more favorable changes over time with rosiglitazone versus metformin or glyburide. Persistent improvements were seen in those who completed 4 years of monotherapy and marked deterioration of β-cell function in those who failed to maintain adequate glucose control with initial monotherapy.

CONCLUSIONS

The favorable combined changes in β-cell function and insulin sensitivity over time with rosiglitazone appear to be responsible for its superior glycemic durability over metformin and glyburide as initial monotherapy in type 2 diabetes.In the UK Prospective Diabetes Study (UKPDS), a progressive decline in β-cell function was the major determinant of loss of glycemic control over time in type 2 diabetes (1). However, differential effects of diet, sulfonylurea, and metformin on insulin sensitivity and β-cell function did not yield substantive differences in the rates of increase in glycated hemoglobin (1).Subsequently, thiazolidinediones were introduced that primarily improve insulin sensitivity in the peripheral tissues (2), while also affecting β-cell function by reducing the demand to synthesize and release insulin. In contrast, the biguanide metformin acts primarily to reduce hepatic glucose production, whereas the sulfonylureas stimulate insulin release by binding to their receptor on the β-cell (2).Given these different mechanisms of action, A Diabetes Outcome Progression Trial (ADOPT) was designed to assess whether initial monotherapy with the thiazolidinedione rosiglitazone could slow the rate of decline of β-cell function in type 2 diabetes and associated loss-of-glucose control, relative to metformin or sulfonylurea (glyburide) (3). In ADOPT, rosiglitazone provided lower rates of monotherapy failure and lower levels of fasting plasma glucose and glycated hemoglobin, yielding superior durability of glycemic control than metformin or glyburide (4).Measures of insulin sensitivity and β-cell function determined from fasting and 30-min samples during an oral glucose tolerance test (OGTT) allowed examination of mechanisms by which each agent affected glycemic outcomes. Herein, changes over time for these measures are compared among the three treatment groups in the full cohort and separately among those who either successfully completed or failed initially assigned monotherapy over a period of 4 years. Joint vector plots are used to display concomitant changes in secretory response and insulin sensitivity over time with each therapy.     

Quantification,Localization, and Expression of IGF-I and TGF-β1 During Growth Factor-Stimulated Fracture Healing

Because of the increasing interest on stimulating fracture healing, knowledge about the role and chronology of growth factors during the healing process is important. The purpose of this study was to quantify the protein concentration of IGF-I and TGF-1 during rat tibial fracture healing 5, 10, and 15 days after fracture using ELISA methods and to analyze the distribution of the proteins and the related mRNA expression in the fracture callus by immunohistochemistry and in situ hybridization. The following three groups were analyzed: Fractured tibiae intramedullary stabilized with K-wires coated with IGF-I and TGF-1 compared with fractures stabilized with uncoated K-wires and unfractured tibiae. The weight of the callus increased during the healing process in both experimental groups. The protein concentration of IGF-I and TGF-1 in the fracture callus showed significant changes between the investigated time points and treatment groups compared with the unfractured tibia. IGF-I increased with healing time whereas TGF-1 revealed a constantly elevated level at the investigated time points. Mesenchymal cells, osteoblasts, osteocytes, proliferating and immature chondrocytes, and osteoclasts expressed both growth factors. No differences in the expression and localization pattern of the growth factors were detectable among the groups. Using the different methods for quantification and visualization of the growth factors, no differences (except the increased IGF-I concentration at day 15 in the growth factor group) were seen between the normal and the growth factor-stimulated fracture healing as an indication for physiological healing after exogenous growth factor treatment. Parts of this study have been presented at the annual meeting of the ORS 2002 (Orthopaedic Research Society, Dallas, Feb. 2002) (Trans Orthop Res Soc 48^th, poster).