Entfernung des Primärtumors bei hämatogen metastasierter Tumorerkrankung

Primarily treating metastatic malignancies systemically was an untouchable dogma for decades. Accordingly local therapy was reserved for localized disease only. However, in some oncological entities this apodictic principle could be disproved. In metastatic renal cell carcinoma cytoreductive nephrectomy is the current standard of care for appropriately selected patients but there is a lack of robust data for radical prostatectomy in patients with hematogenous spread from prostate cancer. Therefore, surgical treatment is not recommended outside clinical trials for the latter indication.     

Combined lidocaine and salbutamol inhalation for airway anesthesia markedly protects against reflex bronchoconstriction

BACKGROUND: Lidocaine inhalation, in subjects with bronchial hyperreactivity, attenuates evoked bronchoconstriction but also irritates airways. Whether salbutamol pretreatment can mitigate airway irritation and whether combined treatment offers more protection than treatment with either drug alone is unknown. Therefore, we evaluated the effects of the inhalation of lidocaine, salbutamol, lidocaine and salbutamol combined, and placebo on an inhalational histamine challenge. METHODS: Fifteen patients with mild asthma were selected by a screening procedure (ie, a provocative concentration of a substance [histamine aerosol of < 18 mg/mL] causing a 20% fall in FEV(1) [PC(20)]). On 4 different days after pretreatment with the inhalation of lidocaine (5 mg/kg), inhalation of salbutamol (1.5 mg), combined treatment, or placebo, the histamine challenge was repeated. RESULTS: The baseline FEV(1) after lidocaine inhalation but prior to the histamine challenge decreased by > 5% in 7 of 15 volunteers, with a mean (+/- SD) decrease from 3.82 +/- 0.90 to 3.54 +/- 0.86 L (p = 0.0054). The baseline PC(20) for histamine was 6.4 +/- 4.3 mg/mL. Both lidocaine and salbutamol inhalation significantly increased PC(20) more than twofold (14.9 +/- 13.7 and 16.8 +/- 10.9 mg/mL, respectively; p = 0, 0007) at a lidocaine plasma concentration of 0.7 +/- 0.3 microg/mL. Combined treatment quadrupled the PC(20) to 29.7 +/- 20.3 mg/mL (vs lidocaine, p = 0.002; vs salbutamol, p = 0.003). CONCLUSIONS: Thus, histamine-evoked bronchoconstriction, as a model of reflex bronchoconstriction, can be significantly attenuated by salbutamol or lidocaine inhalation. However, lidocaine inhalation causes significant initial bronchoconstriction. The combined inhalation of salbutamol and lidocaine prevents the initial bronchoconstriction observed with lidocaine alone and offers even more protection to a histamine challenge than either lidocaine or salbutamol alone. Therefore, the combined inhalation of lidocaine and salbutamol can be recommended to mitigate bronchoconstriction when airway instrumentation is required.     

Multitask electrical stimulation for cortical language mapping: Hints for necessity and economic mode of application

Purpose:   Electrical stimulation mapping (ESM) is the gold standard for identifying language-relevant cortex prior to neurosurgical resections near the eloquent cortex. However, its application mode is not standardized, as some procedures rely on a single task, whereas others depend on task batteries. In this study, we examine whether multitask ESM is necessary, quantify the information loss that occurs from restricting the number of applied tasks, and search for a procedure that allows for time-efficient, multitask ESM.
Methods:   Thirty-eight epilepsy and 11 brain tumor patients with subdural grid electrodes receive extraoperative ESM for language cortex at 1,890 stimulation sites. The applied test battery includes counting, naming, repeating, reading, Token Test, and body commands. Correlation analysis and principal component analysis are used to identify the functional overlap between tasks. Sensitivity analysis is the basis for determining the optimal task order, which requires a minimum number of stimulations for identifying language loci.
Results:   Correlation coefficients between tasks are −0.17 to 0.63; frontal and temporoparietal language cortex are organized differently. Naming is the most sensitive task, but 31% (temporoparietal) to 43% (frontal) of language sites remained undetected after naming alone. The optimal procedure starts with naming and the Token Test and differs thereafter between frontal and temporoparietal cortex. Omitting the Token Test and body commands from the battery results in up to 26% information loss.
Discussion:   Despite considerable overlap between different tasks, multitask ESM appears necessary to avoid missing language relevant cortex. Applying the tasks in an optimal order allows economizing the procedure.     

Heritable and pharmacological influences on pauses and apneas in inbred mice during anesthesia and emergence

Inherited differences in response to hypercapnia are augmented by volatile anesthetics. Therefore, the authors tested the hypotheses that (1) the incidence of pauses and apneas also increase under anesthesia; (2) there is a difference in the incidence between mouse strains; and (3) there is a difference in the incidence of pauses and apneas depending on the volatile agent. The authors assessed respiratory pauses and apneas at rest; during anesthesia with isoflurane, sevoflurane, and desflurane; and at recovery in C3, B6, and F1 mice. The results are compared using analysis of variance (ANOVA) (P<.05). Awake, there was no difference between mouse strains (Bb, 0.3+/-0.7 P min(-1), C3, 0.4+/-0.7 P min(-1) and F1, 0.4+/-0.5 P min(-1)). In contrast, during anesthesia C3 mice showed a significantly higher incidence of pauses and apneas. There was no increase for B6 and F1 mice. There was no difference depending on the volatile agent. These results indicate an inheritance of a susceptibility to pauses and apneas under the influence of volatile anesthetics, albeit independent of the agent used. This response seems to be independent from the inherited response to hypercapnia.     

Corticosteroids and inhaled salbutamol in patients with reversible airway obstruction markedly decrease the incidence of bronchospasm after tracheal intubation

BACKGROUND: In patients with bronchial hyperreactivity, airway instrumentation can evoke life-threatening bronchospasm. However, the best strategy for the prevention of bronchospasm has not been defined. Therefore, in a randomized, prospective, placebo-controlled study, the authors tested whether prophylaxis with either combined salbutamol-methylprednisolone or salbutamol alone (1) improves lung function and (2) prevents wheezing after intubation. METHODS: Thirty-one patients with partially reversible airway obstruction (airway resistance > 180%, forced expiratory volume in 1 s [FEV1] < 70% of predicted value, and FEV1 increase > 10% after two puffs of salbutamol), who were naive to anti-obstructive treatment, were randomized to receive daily for 5 days either 3 x 2 puffs (0.2 mg) of salbutamol alone (n = 16) or salbutamol combined with methylprednisolone (40 mg/day orally) (n = 15). Lung function was evaluated daily. Another 10 patients received two puffs of salbutamol 10 min before anesthesia. In all patients, wheezing was assessed before and 5 min after tracheal intubation. RESULTS: Within 1 day, both salbutamol and salbutamol-methylprednisolone treatment significantly improved airway resistance (salbutamol, 4.3+/- 2.0 [SD] to 2.9+/-1.3 mmHg x s x l(-1); salbutamol-methylprednisolone, 5.5+/-2.9 to 3.4+/-1.7 mmHg x s x l(-1)) and FEV1 (salbutamol, 1.79+/-0.49 to 2.12+/-0.61 l; salbutamol-methylprednisolone, 1.58+/-0.66 to 2.04+/-1.05 l) to a steady state, with no difference between groups. However, regardless of whether single-dose salbutamol preinduction or prolonged salbutamol treatment was used, most patients (8 of 10 and 7 of 9) experienced wheezing after intubation. In contrast, only one patient receiving additional methylprednisolone experienced wheezing (P = 0.0058). CONCLUSIONS:: Pretreatment with either salbutamol alone or salbutamol combined with methylprednisolone significantly and similarly improves lung function within 1 day. However, only combined salbutamol-methylprednisolone pretreatment decreases the incidence of wheezing after tracheal intubation. Therefore, in patients with bronchial hyperreactivity, preoperative treatment with combined corticosteroids and salbutamol minimizes intubation-evoked bronchoconstriction much more effectively than the inhaled beta2-sympathomimetic salbutamol alone.     

Complications of bronchoscopically guided percutaneous dilational tracheostomy: beyond the learning curve

OBJECTIVE: To assess the complication rate of bronchoscopically guided percutaneous dilational tracheostomy (PDT), with tracheal tube suture fixation and no elective tracheostomy tube exchange, after experience had been gained. DESIGN: Prospective clinical study. SETTING: Anaesthesiological ICU with mixed surgical and medical patients in a university hospital. PATIENTS: Hundred thirty-three mechanically ventilated patients (mean age: 54.8 years, range: 13-87 years) with indication for PDT, many with thrombocytopenia and/or coagulation deficits. INTERVENTIONS: Hundred thirty-six consecutive PDTs performed by residents under bronchoscopic guidance with stepwise dilation ( n=114, Ciaglia's conventional system) or conic dilation ( n=22, "Blue Rhino" approach) and supervision of experienced staff anaesthesiologists. Tracheostomy tubes were fixed to the skin with a suture and no routine exchange of tracheostomy tubes was performed. Complications were categorised and the results were also compared to an earlier prospective study. RESULTS: The incidence of tracheostomy tube-related complications (hypoxaemia, cannula misplacement, accidental decannulation, cuff rupture and hernia, or posterior tracheal wall lesion) was low (0.7%) and significantly less (6.2%, p=0.01) than in our earlier study. No patient died of PDT-associated complications. We recorded four (2.9%) clinically relevant bleeding episodes. Insertion of tracheal tubes was easy or only moderately difficult in 86.7%. CONCLUSION: With experience in performing PDT, fixation of the tracheal cannula, and omission of routine change of tracheostomy tubes complication rate of PDT is low.     

"Highlights" in emergency medicine -- severe head trauma, polytrauma and cardiac arrest

According to scientific publications focusing on emergency medicine and published in international journals in the past few months, new and clinically important results can be identified. In patients with severe head trauma (SHT), application of hypertonic solutions is possible; long term outcome, however, is not improved by this measure. Prehospital capnometry is important, because otherwise up to 40 % of all mechanically ventilated patients are hypoventilated. In a study in 200 patients with prehospital cardiac arrest and ventricular fibrillation as initial cardiac rhythm, subgroup analysis (alarm-response time > 5 min) showed an increase in survival rate (14 % vs. 2 %), if defibrillation was proceeded by 3 min of conventional cardiopulmonary resuscitation (CPR) for reperfusion. If ACD ("active compression decompression")-CPR is combined with a specific ventilatory valve ("inspiratory impedance threshold device", ITD) which does not allow passive inspiration, survival rate after cardiac arrest is increased for up to 24 h. Such a device facilitates an increase in venous return to the heart during decompression of the thorax. High-dose adrenalin for intrahospital CPR in children is not associated with better survival but with worse outcome. Comparison of an emergency medical service (EMS) system from U.K. with paramedics and a physician-staffed German EMS system demonstrated that survival rate following prehospital cardiac arrest is markedly increased with doctors on board. The European multicentre trial comparing vasopressin vs. adrenalin as first vasopressor during CPR in 1219 patients did not reveal any differences between both groups. In subgroup analyses of patients with asystoly and prolonged CPR, vasopressin was superior without being associated with a benefit on neurological outcome. Further subgroup analyses revealed beneficial effects of amiodarone and thrombolysis during CPR. Thrombolysis during CPR apears to be associated with an increased rate of haemodynamic stabilisation without increased risk of bleeding complications. In a very clear advisory statement, the "International Liaison Committee on Resuscitation" (ILCOR) has recommended mild therapeutic hypothermia (i. e., cooling of cardiac arrest victims to 32 - 34 degrees C central body temperature for 12 - 24 h following cardiac arrest of cardiac etiology) not only for unconciuous patients with ventricular fibrillation as initial prehospital rhythm, but also for all other adult patients (other rhythms, intrahospital CPR) following cardiac arrest. In randomised controlled clinical trials, this therapy has markedly improved survival rate and neurological outcome. Such therapeutic cooling can be initiated nearly everywhere and with simple methods - like the infusion of ice-cold cristalloid solutions.     

Patient anxiety and satisfaction in coloproctological operations

BACKGROUND: Patients' emotional internal views related to coloproctological operations were examined, especially the relation between anxieties and satisfaction with treatment, including possible moderator variables such as age, gender, and control beliefs. PATIENTS and METHODS: For 328 patients with operations on the rectum versus colon operations, intensity of anxiety, quality of anxiety, and their course was assessed. Likewise, satisfaction with medical care, subjective success of treatment, as well as control beliefs regarding illness and health were measured. The data were analyzed by means of analysis of (co-)variance, regression analysis, and discriminatory analysis. RESULTS: The emotional internal view turned out to have a greater influence than the objective severity of the operation. This also concerns specific, coloproctology-related contents of anxiety (e.g., anxieties concerning an anus praeter). For coping with anxiety, variables of a "talking medicine" are relevant. For this purpose, engaged communicative nursing care is important, though it cannot compensate for deficiencies in doctor-patient-communication. The latter must take into account the higher intensity of anxiety among younger patients as well as feelings of insecurity related to the hospital dismissal. CONCLUSION: These findings suggest the following improvements: the information provided by the physician should be more sophisticated, the clarification of diagnosis should take place as soon as possible, and the communication of the diagnosis should be combined with the reinforcement of internal control beliefs. This should apply to the transition to outpatient treatment as well.