Alcohol consumption and the body's biological clock

This review summarizes new findings on the bidirectional interactions between alcohol and the clock genes, underlying the generation of circadian rhythmicity. At the behavioral level, both adult and perinatal ethanol treatments after the free-running period and light response of the circadian clock in rodents; genetic ethanol preference in alcohol-preferring rat lines is also associated with alterations in circadian pacemaker function. At the neuronal level, it has been shown that ethanol consumption alters the circadian expression patterns of period (per) genes in various brain regions, including the suprachiasmatic nucleus. Notably, circadian functions of beta-endorphin-containing neurons that participate in the control of alcohol reinforcement become disturbed after chronic alcohol intake. In turn, per2 gene activity regulates alcohol intake through its effects on the glutamatergic system through glutamate reuptake mechanisms and thereby may affect a variety of physiological processes that are governed by our internal clock. In summary, a new pathologic chain has been identified that contributes to the negative health consequences of chronic alcohol intake. Thus, chronic alcohol intake alters the expression of per genes, and as a consequence, a variety of neurochemical and neuroendocrine functions become disturbed. Further steps in this pathologic chain are alterations in physiological and immune functions that are under circadian control, and, as a final consequence, addictive behavior might be triggered or sustained by this cascade.     

The VIP-secreting tumor as a differential diagnosis of protracted diarrhea in pediatrics

BACKGROUND: Vasoactive intestinal peptide (VIP) can be produced by mature neurogenic tumors. Pathologically elevated VIP plasma levels cause secretory diarrhea with excessive loss of water and electrolytes. Despite the clinical severity diagnosis of a VIP-secreting tumor is often delayed and subsequently its extirpation as the mainstay of therapy. PATIENTS: We report on two patients with ganglioneuroblastoma and secretory diarrhea. We contrast the case of a 13-month-old boy with advanced symptoms of secretory diarrhea, high VIP plasma levels, and late diagnosis to the case of a 14-month-old boy with mild secretory diarrhea and normal VIP plasma levels but positive proof of VIP in tumor tissue. Reviewing the literature we found 57 cases of pediatric VIP-secreting tumors. RESULTS: The clinical situation is characterized by the typical symptoms of secretory diarrhea with hypokalemia and metabolic acidosis. Histopathology predominantly reveals ganglioneuroblastoma or ganglioneuroma. The symptoms mostly stop after complete resection of the tumor whereas lack of resection is associated with elevated mortality rates. CONCLUSIONS: In case of prolonged therapy-resistant secretory diarrhea the existence of a VIP-secreting tumor should be considered. Diagnostic work-up should include the assessment of VIP plasma levels, catecholamines in urine, and appropriate imaging techniques in order to rule out or confirm the possibility of a VIP producing tumor.     

The incidence and prediction of automatically detected intraoperative cardiovascular events in noncardiac surgery

The objective of this study was to evaluate prognostic models for quality assurance purposes in predicting automatically detected intraoperative cardiovascular events (CVE) in 58458 patients undergoing noncardiac surgery. To this end, we assessed the performance of two established models for risk assessment in anesthesia, the Revised Cardiac Risk Index (RCRI) and the ASA physical status classification. We then developed two new models. CVEs were detected from the database of an electronic anesthesia record-keeping system. Logistic regression was used to build a complex and a simple predictive model. Performance of the prognostic models was assessed using analysis of discrimination and calibration. In 5249 patients (17.8%) of the evaluation (n = 29437) and 5031 patients (17.3%) of the validation cohorts (n = 29021), a minimum of one CVE was detected. CVEs were associated with significantly more frequent hospital mortality (2.1% versus 1.0%; P < 0.01). The new models demonstrated good discriminative power, with an area under the receiver operating characteristic curve (AUC) of 0.709 and 0.707 respectively. Discrimination of the ASA classification (AUC 0.647) and the RCRI (AUC 0.620) were less. Neither the two new models nor ASA classification nor the RCRI showed acceptable calibration. ASA classification and the RCRI alone both proved unsuitable for the prediction of intraoperative CVEs. IMPLICATIONS: The objective of this study was to evaluate prognostic models for quality assurance purposes to predict the occurrence of automatically detected intraoperative cardiovascular events in 58,458 patients undergoing noncardiac surgery. Two newly developed models showed good discrimination but, because of reduced calibration, their clinical use is limited. The ASA physical status classification and the Revised Cardiac Risk Index are unsuitable for the prediction of intraoperative cardiovascular events.     

Neonatal hemoperitoneum caused by a congenital liver angioma

Severe intraabdominal bleeding in neonates within 24 hours after birth are an extremely seldom event. In our neonate, the intraabdominal bleeding was diagnosed by the clinical picture and by abdominal ultrasound examination. The etiology for this bleeding was primarily a blunt abdominal trauma as described in most cases of the liver; however, histology showed a congenital cavernous angioma of the liver resulting in a different tensile strength of this part of the liver in comparison with the rest of the liver tissue. Therefore, a relatively blunt abdominal trauma caused a rupture of the liver in a histologically altered part, which histologically was found to be a relatively soft and fragile tumor of the liver.     

Complications in high tibial (medial opening wedge) osteotomy

Introduction The high tibial (medial opening wedge) osteotomy (HTO) is a standard procedure in the treatment of varus gonarthrosis. This is potentially associated with various complications. The aim of this study was an analysis of complications and potential technical mistakes.Materials and methods A total of 85 patients (49 male and 36 female) suffering from varus gonarthrosis underwent a medial opening wedge HTO. The osteotomy was fixed in 55 patients by a spacer plate (Puddu plate; group A). In group B (n=30), the osteotomies were fixed by C-plate.Results The rate of complications was 43.6% in group A and 16.7% in group B (p<0.05). Infraction of the lateral tibial head is a possible intraoperative complication. This was seen in 11.7%. An additional osteosynthesis was required in group A. In contrast, the C-plate can solve this problem without additional measures. General complications of the HTO were seen: infection (4.7%), hematoma (4.7%), and thrombosis (2.3%). In every case of a severe deep infection, the osteotomy space was filled with synthetic bone graft. These grafts were used only in group A. Failure of the implants is a potential cause of loss of correction. This complication was seen nine times in group A but never in group B.Conclusion A diligent surgical technique and a convenient implant are obligatory in (medial opening wedge) HTO.     

Laryngeal mask airway versus endotracheal tube for outpatient surgery: analysis of anesthesia-controlled time

STUDY OBJECTIVE: To show that efficiency of operating room times can be improved significantly using rapid changes between operative procedures. DESIGN: Randomized, prospective clinical study. SETTING: Tertiary care university hospital, elective peripheral trauma-related orthopedic surgery. PATIENTS: 72 adult, ASA physical status I, II, and III patients scheduled for elective peripheral trauma-related orthopedic surgery requiring general anesthesia. INTERVENTIONS: Patient airways were managed using either a Laryngeal Mask Airway (LMA) or an endotracheal tube (ETT) in the hands of anesthesiologists experienced in both. They were not informed as to the primary intention of the study. All perioperative data, including the preoperative and postoperative outpatient stay at the outpatient surgical ward, were recorded with an anesthesia information management system. MEASUREMENTS: The primary outcome measures were: time needed for anesthesia induction and emergence from anesthesia. All manual recording into the anesthesia information management system during anesthesia was accomplished by nurses who were uninformed as to the aim of the study. MAIN RESULTS: Anesthesia induction was significantly (p < 0.01) shorter using LMAs (means +/- SD, medians, [interquartile ranges]) (LMA: 5.8 +/- 1.5, 5, [5;7] vs. ETT: 7.4 +/- 1.8, 7, [7;8] min), whereas emergence from anesthesia was not different (LMA: 11.8 +/- 3.3, 11, [9;14] vs. ETT: 13.2 +/- 4.8; 12, [10;16] min). CONCLUSION: The clinical relevance of reduced anesthesia induction time using LMA is questionable. The lack of difference in emergence time could be a result of the use of total intravenous anesthesia.     

Stimulatory effect of antidepressants on the production of IL-6

A body of evidence indicates that the therapeutic activity of antidepressants is connected with their modulatory effect on the inflammatory response system and cell-mediated immunity. The present study was carried out to examine the effects of antidepressant agents, such as imipramne, venlafaxine, l-5-hydroxytryptophan, fluoxetine and a combination of l-5-hydroxytryptophan and fluoxetine, on the production of the pleotrophic cytokines TNF-alpha and IL-6. Diluted whole blood from fluoxetine-treated patients with treatment-resistant depression (TRD) (mean age: 50.6+/-3.9 years), age-matched healthy controls (mean age: 51.6+/-1.7 years) and younger healthy volunteers (mean age: 35.4+/-1.7 years) was stimulated with phytohemagglutinin (PHA) and lipopolysaccharide (LPS) for 48 h with or without incubation with the antidepressants at 10(-6) and 10(-5) M. The major findings of this study are: (1). imipramine and venlafaxine (at the higher concentration), 5-HTP (at lower and higher concentrations) and a combination of 5-HTP and fluoxetine (both at the lower concentration) increased the production of IL-6; (2). all drugs used did not affect TNF-alpha production. IL-6 production was significantly higher in depressed patients than in age-matched volunteers, whereas TNF-alpha production was significantly higher in older volunteers than in younger ones. We speculate that the therapeutic activity of these antidepressants is at least partly connected with their effect on the cytokine network and IL-6 production.