Koronarrevaskularisation: Off-pump versus On-pump - Verhalten der biochemischen kardialen Isch?miemarker im Vergleich

Summary Background Recently, coronary artery bypass grafting (CABG) on the beating heart with avoidance of extracorporeal circulation (off-pump CABG technique) has been gaining increasing importance in modern cardiac surgery. The object of this prospective study was to compare postoperative kinetic and patterns of cardiac troponin I (cTnI), T (cTnT), and creatine kinase MB (CKMB) activities after off-pump CABG versus conventional on-pump CABG. Methods We studied 106 patients who underwent first-time elective on-pump (group I, n=69, 56 male, 13vfemale, mean age: 64.3Nj.9 years, mean ejection fraction: 56ᆣ%) or off-pump (group II, n=37, 24 male, 13vfemale, mean age: 68.4Nj.1 years, mean ejection fraction: 57ᆡ%) CABG surgery via median sternotomy. CTn I and cTnT levels, total creatine kinase (CK) and CK-MB activities in the serum were measured before operation, up on arrival at the ICU and 6, 12, 24, 48 and 120 hours later. Serial 12-lead ECGs were recorded preoperatively and on days 1, 2 and 5. Results Serum concentrations of cardiac troponins in all patients were preoperatively either not detectable or in the normal range and significantly increased after surgery. In groupI, one patient developed a Q wave myocardial infarction, one patient a non-Q wave infarction and two patients a new left bundle branch block on the ECG. One patient of group II developed a new Q-wave myocardial infarction and another patient permanent atrial fibrillation associated with a continuous arrhythmia. All patients with a myocardial infarction in the ECG showed significant elevation of concentrations or activities of these biochemical markers. The median postoperative peak values for cTnI were measured at 24 h in both groups (2.77g/l, 95%-CI: [2.2,3.2] in group I and 1.17g/l, 95%-CI:[0.5,1.3] in group II). CTnT postoperatively presented an earlier median peak of 0.1287g/l at 12h in group II (95%-CI:[0.041,0.146]) than in group I at 48 h (0.2987g/l, 95%-CI: [0.254,0.335]). Conclusions All patients undergoing CABG surgery with or without extracorporeal circulation postoperatively showed an increase of cardiac troponin levels. After uncomplicated coronary revascularization, patients with the off-pump CABG technique continuously presented lower serum cardiac troponin concentrations than those with the on-pump CABG technique. CTnI showed the same patterns of release in both groups with different median postoperative peak values at 24 h. The patterns off cTnT release following CABC surgery with or without extracorporal circulation were different: CTnT reaches its postoperative peak value in patients with the off-pump CABG technique earlier than those with the on-pump CABG technique (12h postoperatively versus 48h). Zusammenfassung In der modernen Herzchirurgie gewinnt neben koronarchirurgischen Bypassoperationen mit der Herz-Lungen-Maschine (On-pump) die Koronarrevaskularisation am schlagenden Herzen ohne Herz-Lungen-Maschine (Off-pump) immer mehr an Bedeutung. Ziel unserer Studie war ein Vergleich des postoperativen Verlaufsmusters und der Kinetik der kardialen Troponine als spezifische Indikatoren für eine intraoperative Myokardzellschädigung bei beiden Operationstechniken. In diesen Vergleich wurden auch die “etablierten” Ischämiemarker (CK und CKMB) mit einbezogen. Material und Methodik In die Studie eingeschlossen wurden 2 Gruppen von insgesamt 106 Patienten mit koronarer Herzkrankheit, die sich einer elektiven Koronarrevaskularisation unterzogen. Gruppe I (n=69, Alter: 64,4Nj,9 Jahren, 13 w/56 m, Ejektionsfraktion: 56ᆣ%) wurde mit Herz-Lungen-Maschine und Gruppe II (n=37, Alter: 68,4Nj,1 Jahren, 13 w/24 m, Ejektionsfraktion: 57ᆡ%) am schlagenden Herzen ohne HLM operiert. Bei allen Patienten wurden kardiales Troponin I (cTnI), T (cTnT), CK und CKMB präoperativ, bei Ankunft auf Intensivstation, 6, 12, 24, 48 und 120 h postoperativ bestimmt. Die Dokumentation eines 12-Kanal-EKGs erfolgte präoperativ, am Operationstag sowie am ersten, 2ten und 5ten postoperativen Tag. Ergebnisse In beiden Gruppen waren cTnI und cTnT im Serum präoperativ nicht nachweisbar bzw. im Normbereich und stiegen postoperativ signifikant an. In Gruppe I wurden ein Q- wave und ein Non-Q-wave-Infarkt sowie zwei neu aufgetretene Linksschenkelblöcke festgestellt. In Gruppe II wurde ein Q-wave-Infarkt festgestellt. Ein Patient dieser Gruppe verlor seinen präoperativen Sinusrhythmus. Die Infarktpatienten beider Gruppen zeigten einen signifikant höheren Spiegel beider Troponine. CTnI erreichte seinen medianen Gipfel in beiden Gruppen nach 24h. (2,77g/l, 95%-KI:[2,2, 3,2] in Gruppe I; 1,17g/l 95%-KI:[0,5, 1,3] in Gruppe II), cTnT erreichte hingegen seinen medianen Gipfel in Gruppe II bereits nach 12h: (0,1287g/l, 95%-KI: [0,041, 0,146]), in der Gruppe I erst nach 48h: (0,2987g/l, 95%-KI: [0,254, 0,335]). Schlussfolgerung Bei sämtlichen Patienten beider Gruppen ist ein postoperativer Anstieg kardialer Troponine festzustellen. Bei komplikationslosen Verläufen wiesen Patienten, bei denen die Off-pump-Technik angewendet wurde, eine niedrigere Troponinkonzentration auf als Patienten, die mit Herz-Lungen-Maschine operiert wurden. Während in beiden Gruppen cTnI postoperativ das gleiche Verlaufsmuster aufweist, erreicht cTnT In der Off-pump-Gruppe sein Maximum früher, nämlich 12 Stunden postoperativ, in der Gruppe mit Herz-Lungen-Maschine jedoch erst 48 Stunden postoperativ.     

次氯酸钠对隐孢子虫卵囊在体外脱囊的影响

隐孢子虫卵囊的无菌化及体外脱囊是进行虫体体外细胞培养不可缺少的环节，本试验通过使用不同浓度次氯酸钠提前处理卵囊，在不同脱囊液的条件下比较各处理组的脱囊率。试验结果表明，未经任何处理的卵囊，在37C的温度下可发生脱囊，但脱囊率只有15．5％（脱囊时间90min）；经100％bleach（含5．25％次氨酸钠）作用30min，对卵囊的活性有很大的影响，在T＋TDC（Trypsin＋taurodeoxycholicacid）脱囊液中，其脱囊率只有17％（约正常卵囊的20％）；5％～20％的bleach对卵囊的活性没有明显的影响，反而有很强的刺激脱囊作用，卵囊经这一浓度范围的bleach处理后．即使没有酶的存在，其脱囊率也可达到80％以上。单独使用酶或bleach均有很好的脱囊作用，但两者合并使用，并不能提高新鲜卵囊的脱囊率。对用于细胞培养的卵囊，推荐用10％～20％bleach处理30min，这一处理，既可得到无菌化的卵囊，又有高的脱囊率。     

Technetium-99m SPECT/US Hybrid Imaging Compared with Conventional Diagnostic Thyroid Imaging with Scintigraphy and Ultrasound

Side-by-side evaluation of thyroid ultrasound (US) and ^99mTcO₄ scintigraphy can lead to uncertainties in the correct topographic assignment of thyroid nodules. The aim of this study was to evaluate ^99mTcO₄ single-photon emission computed tomography/ultrasound (SPECT/US) fusion imaging. Seventy-nine patients were prospectively investigated. If conventional diagnostics of the thyroid gland (B-mode-US, scintigraphy) produced unclear findings, SPECT was performed and transferred to a US device for real-time sensor-navigated 3-D fusion US investigation. The data sets were manually matched according to their contours. Finally, SPECT/US versus conventional diagnostics was rated using an ordinal 4-point scale (SPECT/US >> conventional diagnostics, SPECT/US > conventional diagnostics, SPECT/US?=?conventional diagnostics, SPECT/US < conventional diagnostics). SPECT/US was superior (>>, >) in 84% and equivalent (=) in 16% of the cases, respectively. No statistically significant differences were observed for uni-, bi- and multinodular goiters (p ≥ 0.3). In 67%, the respective problem that arose after conventional diagnostics was clarified by SPECT/US. SPECT/US was feasible and was helpful for the clarification of uncertain functionality assessments of thyroid nodules.     

Nine-year Experience: Prophylactic Cranial Irradiation in Extensive Disease Small-cell Lung Cancer

Background

In 2007, the European Organization for Research and Treatment of Cancer (EORTC) study (ClinicalTrials.gov identifier, NCT00016211) demonstrated a beneficial effect on overall survival (OS) with the use of prophylactic cranial irradiation (PCI) for extensive disease (ED) small-cell lung cancer (SCLC). Nevertheless, debate is ongoing regarding the role of PCI, because the patients in that trial did not undergo magnetic resonance imaging (MRI) of the brain before treatment. Also, a recent Japanese randomized trial showed a detrimental effect of PCI on OS in patients with negative pretreatment brain MRI findings.

Alterations of sleep stage patterns in humans and carry-over effects under estazolam / 1st comm.: effects of estazolam on sleep disturbed by jet fly-over noise (author's transl)

Effects of the benzodiazepine derivative 8-chloro-6-phenyl-4H-s-triazolo(4,3-a)-(1,4)benzodiazepine (estazolam, BAY k 4200) on sleep stage patterns of 10 subjects were studied in the laboratory under double-blind conditions during quiet and noise-disturbed nights. The noise of 17-20 jet fly-overs was presented during sleep. The mean peak level of the noise was 97 dB(A) measured indoors near the sleeper's head. Intermittent wakefulness, stage 1 and movement time (MT) increased during noise-disturbed nights. Estazolam suppressed the phases of intermittent wakefulness during the quiet night and reduced stage 1 and MT. Arousal reactions by jet noise were milder and shorter under estazolam. Both effects resulted in equal amounts of intermittent wakefulness, stage 1 and MT during the noise-disturbed night under estazolam and during the quiet night under placebo. The dosage of 2 mg estazolam had no significant effect on stage REM, but delta-sleep decreased. Hints of carry-over effects were found in the sleep stage patterns. Effects of estazolam were seen in the estimations of sleep quality and mood by the subjects in the morning after awakening.     

Screening of beta-2 agonists and confirmation of fenoterol, orciprenaline, reproterol and terbutaline with gas chromatography-mass spectrometry as tetrahydroisoquinoline derivatives

A new method for a comprehensive screening and confirmation of beta-2 agonists in human urine is presented based on gas chromatography-low-resolution mass spectrometry (GC-MS) using electron impact ionisation (EI). After hydrolysis of the conjugates with beta-glucuronidase/arylsulfatase a derivatisation step with formaldehyde converts fenoterol, orciprenaline, reproterol and terbutaline to one derivative, a tetrahydroisoquinoline, while the other beta-2 agonists remain unchanged. Liquid-liquid extraction and trimethylsilylation follow. The tetrahydroisoquinoline derivatives show good gas chromatographic and mass spectrometric behaviour. The detection limit of these four beta-2 agonists in the screening using low-resolution mass spectrometry is 10 ng/ml of urine. The other beta-2 agonists are detected as parent compounds with the same recovery after sample preparation with and without formaldehyde. The EI mass spectra of the tetrahydroisoquinoline derivatives are presented.     

Ultrasound-guided caudal blockade and sedation for paediatric surgery: a retrospective cohort study

Data on safety and success rates of ultrasound-guided caudal blockade, performed on sedated children with an uninstrumented airway, are scarce. We performed a retrospective observational study of validated data from April 2014 to December 2020 in a paediatric cohort where the initial plan for anaesthetic management was sedation and caudal epidural without general anaesthesia or airway instrumentation. We examined success rates of this approach and rates of block failure and block-related complications. In total, 2547 patients ≤ 15 years of chronological age met inclusion criteria. Among the 2547 cases, including 453 (17.8%) former preterm patients, caudal-plus-sedation success rate was 95.1%. The primary anaesthesia plan was abandoned for general anaesthesia in 124 cases. Pain-related block failure in 83 (3.2%) was the most common cause for conversion. Complications included 39 respiratory events and 9 accidental spinal anaesthetics. Higher odds of pain-related block failure were associated with higher body weight (adjusted OR 1.063, 95%CI 1.035–1.092, p < 0.001) as well as with mid-abdominal surgery (e.g. umbilical hernia repair) (adjusted OR 15.11, 95%CI 7.69–29.7, p < 0.001), whereas extreme (< 28 weeks) former prematurity, regardless of chronological age, was associated with higher odds (adjusted OR 3.62, 95%CI 1.38–9.5, p = 0.009) for respiratory problems. Ultrasound-guided caudal epidural, performed under sedation with an uninstrumented airway, is an effective technique in the daily clinical routine. Higher body weight and mid-abdominal surgical procedures are risk factors for pain-related block failure. Patients who, regardless of chronological age, had been born as extreme preterm babies are at the highest risk for respiratory events.