Laparoscopic Assisted Surgery for Crohn''''s Disease an Initial Experience and Results

SurgicaltreatmentisoftenrequiredforpatientswithCrohn'sdiseasewhohaveintestinalstrictureand/orfistula[4.1o.13].Rapidevolutionoflaparoscopicintestinalsurgery,continuousadvancementofinstru-mentation,performanceofmoreextensiveandcom-p1exprocedureshaveledtotheapplicationoflaparo-scopictechniquesinthetreatmentofCrohn'sdis-ease[3'9'12J.Recentreportshavedemonstratedthat,comparedwithtraditional"open"resection,laparo-scopicintestinalsurgeryresultsindecreasedpostoper-ativepain,earlierreturnofintestinalf…     

Relation between prepublication release of clinical trial results and the practice of carotid endarterectomy

Context  Little is known about how clinical practice is affected by disseminating results of clinical trials prior to publication in peer-reviewed journals. Objective  To determine whether prepublication release of carotid endarterectomy (CEA) trial results via National Institutes of Health Clinical Alerts was associated with prompt changes in patient care that were consistent with the new medical evidence. Design, Setting, and Patients  Longitudinal data series analysis using acute care hospital discharge data from the Healthcare Cost and Utilization Project for patients who had CEA performed in acute care hospitals in 7 states (New York, California, Pennsylvania, Florida, Colorado, Illinois, and Wisconsin). The trials were the North American Symptomatic Carotid Endarterectomy Trial (NASCET clinical alert released February 1991) and the Asymptomatic Carotid Atherosclerosis Study (ACAS clinical alert released September 1994). Main Outcome Measure  Carotid endarterectomy rate during each month from 1989 (2 years before the NASCET clinical alert) to 1996 (2 years after the ACAS clinical alert), adjusted for age and sex. Because both trials were limited to patients 80 years or younger in hospitals with low mortality, we also stratified CEA rates by patient age and hospital mortality rate. Results  From 1989 through 1996, 272,849 CEAs were performed in the acute care hospitals in these 7 states, with the annual number increasing from 22,300 to 51,495. After the NASCET clinical alert, the adjusted CEA rate increased 3.4% per month (95% confidence interval [CI], 1.6%-5.3%) during the following 6 months and then increased 0.5% per month (95% CI, 0.2%-0.8%; P<.04) after journal publication of the NASCET study. After the ACAS clinical alert, the CEA rate increased 7.3% per month (95% CI, 6.0%-8.5%) during the following 7 months and then decreased by 0.44% per month (95% CI, -0.86% to -0.0002%; P<.04) after journal publication of the ACAS study. After the ACAS clinical alert, the CEA rate increased more in patients aged 80 years or older than in younger patients; whereas, after journal publication of ACAS, the CEA rate decreased more rapidly in the older population. The overall proportion of CEAs performed in low-mortality hospitals did not change substantially after release of the clinical alerts or after journal publication. Conclusion  In this study, prepublication dissemination of CEA trial results with clinical alerts was associated with prompt and substantial changes in medical practice, but the observed changes suggest that the results were extrapolated to patients and settings not directly supported by the trials.      

Datenschutz innerhalb des länderübergreifenden Deutschen Zentralregisters für kindliche Hörstörungen

Zusammenfassung Das Deutsche Zentralregister für kindliche H?rst?rungen (DZH) verarbeitet bundesweit Daten von verschiedenen audiologischen Einrichtungen. Die Bew?ltigung der anfallenden Datenmengen, die nachfolgende Datenverwaltung und -analyse erfordern neben einer differenzierten und kontrollierbaren Verarbeitung ein H?chstma? an Datensicherheit. Vor allem die l?nderübergreifende Struktur eines Registers erfordert schon bei der Planung engste Zusammenarbeit mit dem zust?ndigen Landesdatenschutzbeauftragten und auch mit den Landesdatenschutzbeauftragten anderer beteiligter Bundesl?nder. Am Beispiel des DZH wird demonstriert, wie eine kooperative Zusammenarbeit pragmatisch realisiert werden kann. Besonderheiten bei der Datenerhebung, Datentransfer, Speicherung und L?schung von Daten, technische Datenschutzma?nahmen, Sicherstellung von Anonymit?t durch Codierungsstrategien, Duplikatsprüfung, Datentrennung und automatisierte Datenauswertung werden an Beispielen erl?utert. Eingegangen am 13. August 1997 Angenommen am 18. Dezember 1997     

Wird die Diagnose bei persistierenden kindlichen Hörstörungen immer noch zu spät gestellt?

Zusammenfassung Das Deutsche Zentralregister (DZH) für kindliche H?rst?rungen hat seit 1994 Patientendatens?tze von 1500 Kindern erfa?t und kann mittlerweile u.a. Aussagen und Ergebnisse zum Diagnosezeitpunkt persistierender kindlicher H?rst?rungen in der Bundesrepublik Deutschland vorlegen. Nach wie vor ist das mittlere Alter bei der Diagnose persistierender kindlicher H?rst?rungen sehr hoch. Das Diagnosealter korreliert stark mit dem Grad der H?rst?rung, d.h. an Taubheit grenzende und hochgradige H?rst?rungen werden deutlich früher diagnostiziert als leichte und mittlere. So werden leichte H?rst?rungen im Durchschnitt erst mit 6;2 Jahren diagnostiziert, mittlere mit 4;4 Jahren, hochgradige mit 2;5 Jahren und an Taubheit grenzende mit 1;9 Jahren. Dies entspricht den Ergebnissen bereits vorliegender regionaler deutscher Studien [1–2]. Aus anderen europ?ischen L?nderen sind zumindest regional deutlich frühere Diagnosezeitpunkte bekannt [3–5]. Bei 36% der im DZH erfa?ten Kinder liegt zwischen dem ersten Verdacht auf Vorliegen einer persistierenden kindlichen H?rst?rung und der Sicherstellung der Diagnose ein Jahr und mehr. Eingegangen am 23. Dezember 1997 Angenommen am 16. April 1998     

Susac syndrome.

OBJECTIVE: The objective of this study was to describe the clinical manifestations; radiographic, audiometric, and retinal fluorescein angiography findings; pathogenesis and treatment of Susac syndrome with review of the literature. STUDY DESIGN: We conducted a retrospective case review. SETTING: This study was conducted at a tertiary referral center. PATIENT: A 50-year-old woman presented with recurrent episodes of neurologic symptoms, bilateral sensorineural hearing loss, and silent retinal artery occlusion. INTERVENTIONS: The patient underwent complete evaluation, including magnetic resonance image studies, audiometric tests, and retinal fluorescein angiography. She was treated initially with corticosteroids and later with other immunosuppressive agents. RESULTS: The patient was initially diagnosed with left sudden sensorineural hearing loss. Despite comprehensive clinical and laboratory studies that did not reveal systemic disease, 3 weeks later, the patient developed vertigo, sensorineural hearing loss, and tinnitus in the opposite ear. The neurologic involvement and the bilateral audiologic manifestations raised the possibility of Susac syndrome. CONCLUSION: Susac syndrome is a rare disorder of unknown origin characterized by the triad of encephalopathy, fluctuating hearing loss, and visual loss resulting from microangiopathy of the brain, cochlea, and retina. The multiple organ involvement seen in Susac syndrome raises a differential diagnosis ranging from autoimmune disease, through systemic vasculitis, to multiple sclerosis. Otolaryngologists should be aware of this syndrome as a result of the vestibulocochlear manifestations and the multidisciplinary evaluation that is required.     

Diagnostik und Therapie der auditorischen Synaptopathie/Neuropathie

Pathological auditory brainstem responses (lack of responses, elevated thresholds and perturbed waveforms) in combination with present otoacoustic emissions are typical audiometric findings in patients with a hearing impairment that particularly affects speech comprehension or complete deafness. This heterogenous group of disorders first described as “auditory neuropathy” includes dysfunction of peripheral synaptic coding of sound by inner hair cells (synaptopathy) and/or of the generation and propagation of action potentials in the auditory nerve (neuropathy). This joint statement provides prevailing background information as well as recommendations on diagnosis and treatment. The statement focuses on the handling in the german language area but also refers to current international statements.     

Isoflurane preconditions myocardium against infarction via activation of inhibitory guanine nucleotide binding proteins

BACKGROUND: Isoflurane-induced myocardial protection during ischemia is mediated by adenosine triphosphate-regulated potassium (KATP) channels; however, the intracellular signal transduction cascade responsible for this process has been incompletely evaluated. The authors tested the hypothesis that isoflurane reduces myocardial infarct size through a Gi protein-mediated process. METHODS: Forty-eight hours after pretreatment with vehicle (0.9% saline) or the Gi protein inhibitor pertussis toxin (10 microg/kg intravenously), barbiturate-anesthetized dogs (n = 43) were instrumented for measurement of aortic and left ventricular pressures and maximum rate of increase of left ventricular pressure. All dogs were subjected to a 60-min left anterior descending coronary artery occlusion followed by 3-h reperfusion. In four separate groups, vehicle- or pertussis toxin-pretreated dogs were studied with or without administration of 1 minimum alveolar concentration isoflurane. In two additional groups, dogs received the direct KATP channel agonist nicorandil (100 microg/kg bolus and 10 microg x kg-1 x min-1 intravenous infusion) in the presence or absence of pertussis toxin pretreatment. Myocardial perfusion and infarct size were measured with radioactive microspheres and triphenyltetrazolium staining, respectively. RESULTS: Isoflurane significantly (P < 0.05) decreased infarct size to 7 +/- 2% of the area at risk compared with control experiments (26 +/- 2%). Pertussis toxin pretreatment alone had no effects on myocardial infarct size (31 +/- 4%) but blocked the beneficial effects of isoflurane (21 +/- 3%). Nicorandil decreased infarct size (11 +/- 2%), but, in contrast to isoflurane, this effect was independent of pertussis toxin pretreatment (11 +/- 1%). CONCLUSION: Isoflurane reduces myocardial infarct size by a Gi protein-mediated mechanism in vivo.     

'Low dose' 99mTc-Sestamibi for radioguided surgery of primary hyperparathyroidism.

AIM: In this study, we evaluated the efficacy of low dose (99m)Tc-Sestamibi administration for radioguided parathyroid surgery in patients with primary hyperparathyroidism (PHPT). METHODS: Three hundred consecutive PHPT patients were studied between September, 1999 and July, 2003. Pre-operative work-up included (99m)Tc-pertechnetate/(99m)Tc-Sestamibi subtraction scintigraphy and high resolution ultrasonography (US). 37MBq of (99m)Tc-Sestamibi was injected i.v. in the operating suite approximately 10 min prior to the beginning of the surgical procedure for intraoperative radiolocalization; quick parathyroid hormone (QPTH) assays were performed. RESULTS: Two hundred and seven of the 211 patients selected for minimally-invasive radioguided parathyroidectomy (MIRP) were successfully treated for a solitary parathyroid adenoma (PA) through a 2-2.5 cm skin incision (mean operative time 35 min, mean hospital stay 1.2 days). In the 89 patients selected for traditional bilateral neck exploration (BNE), radioguided surgery was not as successful in the identification of the PA, especially in patients with (99m)Tc-Sestamibi-avid thyroid nodules. Nevertheless, the combination of probe and QPTH measurement was very helpful in patients with multigland disease. CONCLUSIONS: Low-dose (99m)Tc-Sestamibi administered few minutes before surgery is sufficient for MIRP in patients with high likelihood of a solitary PA and without concomitant (99m)Tc-Sestamibi-avid thyroid nodules. The combination of radioguided surgery and QPTH measurements is very useful in the early identification of unanticipated multigland disease.     

Coincubation of tissue slices, a new way to study metabolic cooperation between organs: hepatorenal cooperation in the biotransformation of CGP 47 969 A

INTRODUCTION: There is limited information on in vitro/ex vivo tools to be used for studying interorgan metabolic cooperation. We report here the use of the tissue slice technique for this purpose. METHODS: Rat liver and kidney slices were used to study metabolic cooperation for the metabolism of CGP 47 969, a potential anti-inflammatory compound which in vivo is extensively conjugated with glutathione and subsequently degraded via the mercapturic acid pathway. RESULTS: Upon incubation with liver slices, CGP 47 969 was extensively conjugated with GSH whilst degradation of the GSH conjugate was moderate. Upon incubation with kidney slices, conjugation of CGP 47 969 with GSH was moderate but degradation of the GSH conjugate was complete. Upon coincubation of CGP 47 969 with liver and kidney slices, both conjugation with GSH and its subsequent degradation were almost complete. Thus, coincubation of liver and kidney slices permitted the efficient in vitro reproduction of the complete biotransformation of CGP 47 969 via its GSH conjugate to the ultimate mercapturic acid metabolite in a one step procedure. DISCUSSION: This novel slice coincubation culture could serve as an in vitro model for interorgan cooperation in multistep metabolic processing.