Ethical Issues in the Management of Geriatric Cardiac Patients

Ethical Issue: The patient's pneumonia required assisted ventilation. After weaning, a second intubation is necessary. The patient's "living will" asks for no artificial life support     

Does the surgical approach in cochlear implantation influence the occurrence of postoperative vertigo?

OBJECTIVE: To investigate the impact of different cochleostomy techniques on vestibular receptor integrity and vertigo after cochlear implantation. STUDY DESIGN: Retrospective cohort study. SUBJECTS: A total of 62 patients (17 to 84 years of age) underwent implantation via an anterior or round window insertion approach. METHODS: Two groups of cochlear implant patients were compared with respect to their pre- and postoperative vestibular function and the occurrence of postoperative vertigo. The data were related to the different cochleostomy techniques. The patients were tested by a questionnaire (dizziness handicap inventory, DIH), caloric irrigation (vestibulo-ocular reflex, VOR) for the function of the lateral SCC and by vestibular evoked myogenic potential (VEMP) recordings for saccular function. RESULTS: Significant differences of postoperative VEMP responses (50% vs 13%) and electromystagmography (ENG) results (42.9% vs 9.4%) were found with respect to the 2 different insertion techniques. The number of patients with vertigo after the surgery as evidenced by DHI (23% vs 12.5%) was significantly different. CONCLUSION: The used round window approach for electrode insertion should be preferred to decrease the risk of loss of vestibular function and the occurrence of vertigo.     

Subrupture tendon fatigue damage

The mechanical and microstructural bases of tendon fatigue, by which damage accumulates and contributes to degradation, are poorly understood. To investigate the tendon fatigue process, rat flexor digitorum longus tendons were cyclically loaded (1–16 N) until reaching one of three levels of fatigue damage, defined as peak clamp‐to‐clamp strain magnitudes representing key intervals in the fatigue life: i) Low (6.0%–7.0%); ii) Moderate (8.5%–9.5%); and iii) High (11.0%–12.0%). Stiffness, hysteresis, and clamp‐to‐clamp strain were assessed diagnostically (by cyclic loading at 1–8 N) before and after fatigue loading and following an unloaded recovery period to identify mechanical parameters as measures of damage. Results showed that tendon clamp‐to‐clamp strain increased from pre‐ to post‐fatigue loading significantly and progressively with the fatigue damage level (p ≤ 0.010). In contrast, changes in both stiffness and hysteresis were significant only at the High fatigue level (p ≤ 0.043). Correlative microstructural analyses showed that Low level of fatigue was characterized by isolated, transverse patterns of kinked fiber deformations. At higher fatigue levels, tendons exhibited fiber dissociation and localized ruptures of the fibers. Histomorphometric analysis showed that damage area fraction increased significantly with fatigue level (p ≤ 0.048). The current findings characterized the sequential, microstructural events that underlie the tendon fatigue process and indicate that tendon deformation can be used to accurately assess the progression of damage accumulation in tendons. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27:264–273, 2009     

Anesthesia for children in Sub-Saharan Africa – a description of settings, common presenting conditions, techniques and outcomes

Anesthesia in developing countries deserves special attention. The most common technique is general anesthesia (with spontaneous or manually assisted ventilation). Nonmedical anesthetists with limited training and supervision and lacking the most common drugs and anesthetic equipment administer anesthesia, usually for emergency surgery. There are important safety issues, especially for pediatric anesthesia. Regarding pediatric surgery, the major workload is due to abdominal emergencies, mainly neonatal bowel obstruction or peritonitis due to typhoid perforation. The morbidity and mortality rate for these conditions is high.