[Comparison of different prediction models for the occurrence of nausea and vomiting in the postoperative phase : A systematic qualitative comparison based on prospectively defined quality indicators]

BACKGROUND

Various prognostic prediction models exist for evaluating the risk of nausea and vomiting in the postoperative period (PONV). So far, no systematic comparison of these prognostic scores is available.

METHOD

A systematic literature search was carried out in seven medical databases to find publications on prognostic PONV models. Identified scores were assessed against prospectively defined quality criteria, including generalizability, validation and clinical relevance of the models.

RESULTS

The literature search revealed 62 relevant publications with a total of 81,834 patients which could be assigned to 8 prognostic models. The simplified Apfel score performed best, primarily because it was extensively validated. The Van den Bosch score and Sinclair score tied for second place. The simplified Koivuranta score was in third place.

CONCLUSION

The qualitative analysis highlights the strengths and weaknesses of each prediction system based on predetermined standardized quality criteria.

[Intensive care management of acute diseases of the aorta]

Acute aortic diseases represent a group of complex severe and often fatal medical conditions. Although they are significantly rarer than cardiac or thromboembolic events, they are an important differential diagnosis to be ruled out, e.g., in the clinical work-up of acute chest pain.Treatment, especially surgical interventions, depends on the progression, extent and size of the pathology and whenever possible should be performed in specialized centers with the appropriate experience.Intensive care monitoring is advisable as a range of peracute complications can occur even in initially stable patients. Depending on the clinical presentation and affected structures, a number of severe complications need to be anticipated by critical care physicians. Additionally, a notable symptom is severe and refractory hypertension, especially in the acute phase. This article provides a summary of the most frequent clinical pictures and corresponding treatment options. Furthermore, the principles of initial patient stabilization and treatment as well as the perioperative management of complex surgical procedures on the aorta are discussed.

Oophorectomy and rate of dementia: a prospective cohort study

OBJECTIVE

Globally, dementia disproportionally affects women, which is not fully explained by higher female longevity. Oophorectomy at any age leads to the permanent loss of ovarian sex steroids, potentially increasing the risk of dementia. We aimed to investigate the association between oophorectomy and dementia and whether this was conditional on age at oophorectomy, hysterectomy or use of hormone therapy (HT).

METHODS

A prospective study of 24,851 female nurses from the Danish Nurse Cohort. Nurses were followed from age 60 years or entry into the cohort, whichever came last, until date of dementia, death, emigration or end of follow-up (December 31, 2018), whichever came first. Poisson regression models with log-transformed person-years as offset were used to estimate the associations.

RESULTS

During 334,420 person-years of follow-up, 1,238 (5.0%) nurses developed dementia and 1,969 (7.9%)/ 1,016 (4.1%) contributed person-time after bilateral-/unilateral oophorectomy. In adjusted analyses, an 18% higher rate of dementia was observed following bilateral oophorectomy (aRR 1.18: 95% CI, 0.89-1.56) and 13% lower rate (aRR 0.87: 95% CI, 0.59-1.23) following unilateral oophorectomy compared to nurses who retained their ovaries. Similar effects were detected after stratification according to age at oophorectomy. No statistically significant modifying effects of hysterectomy or HT were detected (Pinteraction≥0.60).

CONCLUSIONS

Bilateral, but not unilateral, oophorectomy was associated with an increased rate of incident dementia. We were unable to establish whether this association was conditional on hysterectomy or HT use. Although an increase in dementia after bilateral oophorectomy is biologically plausible, limited statistical power hampers the precision of the estimates.

The long-term association between bilateral oophorectomy and depression: a prospective cohort study

OBJECTIVE

Depression is a leading cause of disability globally and affects more women than men. Ovarian sex steroids are thought to modify depression risk in women and interventions such as bilateral oophorectomy that permanently change the sex steroid milieu may increase the risk of depression. This study aimed to investigate the associations between unilateral and bilateral oophorectomy and depression over a 25-year period (1993-2018) and whether this varied by age at oophorectomy or use of menopausal hormone therapy.

METHODS

Twenty-five thousand one hundred eighty-eight nurses aged ≥45 years from the Danish Nurse Cohort were included. Nurses with depression prior to baseline were excluded. Poisson regression models, with log-transformed person-years as offset, were used to assess the associations between oophorectomy and incident depression. Nurses who retained their ovaries were the reference group.

RESULTS

Compared with nurses with retained ovaries, bilateral oophorectomy was associated with a slightly higher rate of depression (rate ratio [RR], 1.08; 95% confidence interval [CI], 0.95-1.23), but without statistical significance. However, when stratified by age at oophorectomy, compared with nurses with retained ovaries, bilateral oophorectomy at age ≥51 years was associated with higher rates of depression (RR 1.16; 95% CI, 1.00-1.34), but not bilateral oophorectomy at age <51 years (RR 0.86; 95% CI, 0.69-1.07); P value for difference in estimates = 0.02. No association between unilateral oophorectomy and depression was observed.

CONCLUSIONS

In this cohort of Danish female nurses, bilateral oophorectomy at age ≥51 years, but not at younger ages, was associated with a slightly higher rate of depression compared with those who retained their ovaries.

Bilateral oophorectomy and rate of colorectal cancer: A prospective cohort study

Worldwide, colorectal cancer is the second most common cancer and third cause of cancer death in women. Estrogen exposure has been inversely associated with colorectal cancer. Oophorectomy reduces circulating estrogen, but the effect on colorectal cancer remains uncertain. The aim of this study was to examine the association between unilateral and bilateral oophorectomy and subsequent risk of colorectal cancer, and whether this association varied by menopausal status at time of oophorectomy, use of hormone replacement therapy (HRT) at baseline, hysterectomy and baseline body mass index (BMI). The study included 25 698 female nurses (aged ≥45 years) participating in the Danish Nurse Cohort. Nurses were followed from baseline until date of colorectal cancer, death, emigration or end of follow-up at December 31, 2018, whichever came first. We examined the association between oophorectomy and colorectal cancer (all ages and stratified by menopausal status). The potential modifying effects of hysterectomy, HRT use at baseline and BMI were investigated. During 542 140 person-years of follow-up, 863 (3.4%) nurses were diagnosed with colorectal cancer. Bilateral oophorectomy was associated with a 79% increased colorectal cancer rate, adjusted rate ratio (aRR) (95% confidence interval [CI]): 1.79 (1.33-2.42). Effect estimates following unilateral oophorectomy also showed higher rate of colorectal cancer, although less pronounced and nonstatistically significant (aRR) (95% CI): 1.25 (0.86-1.82). Similar results were seen when stratifying by menopausal status. The association was not modified by baseline HRT use, hysterectomy or BMI. Oophorectomy was associated with increased rate of colorectal cancer, with highest rates among women with bilateral oophorectomy.

OUP accepted manuscript

BACKGROUND

Globally, the ages at pubertal onset for girls and boys have been decreasing during recent decades, partly attributed to excess body fat accumulation. However, a growing body of literature has recognized that endocrine disrupting chemicals (EDCs) may play an important role in this global trend, but the association has not yet been fully established.

OBJECTIVE AND RATIONALE

EDCs can interfere with normal hormone function and metabolism and play a role in pubertal onset. We aimed to systematically identify and evaluate the current evidence on the timing of pubertal onset in girls and boys following prenatal or postnatal exposures to xenobiotic EDCs.

SEARCH METHODS

Following PRISMA guidelines, we performed a systematic literature search of original peer-reviewed publications in the PubMed database through a block search approach using a combination of index MeSH and free text search terms. Publications were considered if they covered biomarkers of prenatal or postnatal exposures to xenobiotic EDCs (European Commission's list of category 1 EDCs) measured in maternal or child biospecimen and pubertal onset defined by the progression of the following milestones (and assessed in terms of the following measures): menarche (age), thelarche (Tanner staging) and pubarche (Tanner staging), in girls, and genital stage (Tanner staging), testicular volume (ml) and pubarche (Tanner staging), in boys.

OUTCOMES

The literature search resulted in 703 references, of which we identified 52 publications fulfilling the eligibility criteria for the qualitative trend synthesis and 23 publications for the meta-analysis. The qualitative trend synthesis provided data on 103 combinations of associations between prenatal or postnatal exposure to EDC compounds groups and puberty outcomes and the meta-analysis enabled 18 summary risk estimates of meta-associations.

WIDER IMPLICATIONS

Statistically significant associations in the qualitative trend synthesis suggested that postnatal exposure to phthalates may be associated with earlier thelarche and later pubarche. However, we did not find consistent evidence in the meta-analysis for associations between timing of pubertal onset in girls and boys and exposures to any of the studied xenobiotic EDCs. We were not able to identify specific pre- or postnatal windows of exposure as particularly critical and susceptible for effects of EDCs. Current evidence is subject to several methodological challenges and inconsistencies and evidence on specific exposure-outcome associations remains too scarce to firmly confirm EDC exposure as a risk factor for changes in age of pubertal onset in the general child population. To create a more uniform foundation for future comparison of evidence and to strengthen pooled studies, we recommend the use of more standardized approaches in the choice of statistical analyses, with exposure transformations, and in the definitions and assessments of puberty outcomes. The impact of mixtures of EDC exposures on the association also remains unestablished and would be valuable to elucidate for prenatal and postnatal windows of exposure. Future large, longitudinal epidemiological studies are needed to clarify the overall association.

[Does NoL monitoring affect opioid consumption during da Vinci prostatectomy?]

BACKGROUND

Administration of opioids to suppress pain plays a major role in modern anesthesia. Measuring depth of hypnosis and neuromuscular recovery are already well established, and devices for pain monitoring are available. Nonetheless pain monitoring is rare in clinical practice. Recently, the pain monitoring device PMD200 (Medasense Biometrics™ , Israel) was introduced. It non-invasively measures heart rate, heart rate variability, skin resistance, resistance variability, temperature and movement to calculate a nociception level (NoL) index. The NoL index range starts at zero, which is equivalent to being painless, and goes up to a value of 100. The validity and reliability of NoL monitoring is the content of current studies.

OBJECTIVE

We tested the hypothesis if the use of the PMD200 significantly reduces opioid consumption during da Vinci prostatectomy.

MATERIAL AND METHODS

A total of 50 male patients were included in this randomized, single blinded study. Exclusion criteria were arrhythmia because the pain monitoring device requires a sinus rhythm for reliable results. Patients received a weight-adjusted sufentanil bolus (0.3 µg/kg ideal body weight) during induction of anesthesia. Additionally, they received 10 µg of sufentanil before skin incision. Both groups received total intravenous anesthesia with propofol and continuous muscle relaxation through cis-atracurium. In the control group (CONT; n = 26), a standardized sufentanil bolus of 10 µg were administered by common criteria (heart rate/blood pressure increase, lacrimation, gut feeling) at the anesthesiologist's discretion. In the intervention group (INT; n = 24), patients received the standardized sufentanil bolus when the NoL index was above 25 for 2 min, which corresponds to the manufacturer's recommendation. The NoL index and bolus administrations were recorded for every patient. In the control group, the display of the pain monitor showing the NoL index was not visible for the anesthesiologist. Postoperatively, pain/nausea scores and piritramide consumption were taken every 10 min for 1h in the recovery room. None of the patients had prior chronic pain with long-term use of painkillers. Statistics were done using Mann-Whitney U‑test, Kolmogorov-Smirnov test and Levene test.

RESULTS

Sufentanil bolus administrations, normalized for duration of surgery, were not significantly lower in the intervention group (p = 0.065). We noticed a significant difference in variation of opioid administrations (p = 0.033). Sufentanil boluses per hour in the INT were normally distributed (p = 0.2), whereas in CONT they were not (p = 0.003). Postoperative data like nausea, opioid consumption and pain scale showed no differences between groups.

CONCLUSION

The use of PMD200 did not significantly reduce cumulative opioid consumption. Following on we must reject the initial hypothesis. The difference in sufentanil bolus variances may point to an individualized antinociceptive therapy when NoL monitoring is used. We suppose patients with high opioid demands are detected and patients with low opioid demands did not receive unnecessary opioids. This assumption is only true if the PMD200 measures the entity pain. Further studies with more participants during surgery with higher tissue damage could lead to more convincing data and conclusions.

[Organ donation-Not only a responsibility of intensive care medicine]

Im Jahr 2019 starben in Deutschland 756 Menschen, während sie auf der Warteliste für ein Spenderorgan standen. Sowohl im Eurotransplant-Verbund als auch weltweit gehört Deutschland mit 10,8 Organspendern/Mio. Einwohner im Jahr 2019 zur Schlussgruppe. Sämtliche politischen Versuche, die Spenderzahlen zu steigern, scheinen bislang ohne Effekt geblieben zu sein. Darüber hinaus hat die durch das „severe acute respiratory syndrome coronavirus 2“ (SARS-CoV-2) ausgelöste Pandemie zum weiteren Rückgang der Spenderzahlen geführt. Der Intensivmedizinerin kommt im Prozess der Erkennung möglicher Spender sowie als erste Ansprechpartnerin für die Angehörigen eine zentrale Rolle zu. Jedoch existieren nicht nur in den gesellschaftlichen und medialen Diskussionen um das Thema Organspende viele Unklarheiten, sondern auch bei den intensivmedizinisch tätigen Ärzten. Viele Annahmen und Hypothesen, die mit den niedrigen Spenderzahlen in einen Zusammenhang gebracht werden, lassen sich wissenschaftlich jedoch nicht belegen und sollen in diesem Beitrag diskutiert werden.

Endocrine Disrupting Chemicals and Risk of Testicular Cancer: A Systematic Review and Meta-analysis

The incidence of many hormone-dependent diseases, including testicular cancer, has sharply increased in all high-income countries during the 20th century. This is not fully explained by established risk factors. Concurrent, increasing exposure to antiandrogenic environmental endocrine disrupting chemicals (EDCs) in fetal life may partially explain this trend. This systematic review assessed available evidence regarding the association between environmental EDC exposure and risk of testicular cancer (seminomas and nonseminomas). Following PRISMA guidelines, a search of English peer-reviewed literature published prior to December 14, 2020 in the databases PubMed and Embase® was performed. Among the 279 identified records, 19 were eligible for quality assessment and 10 for further meta-analysis. The completeness of reporting was high across papers, but over 50% were considered subject to potential risk of bias. Mean age at diagnosis was 31.9 years. None considered effects of EDC multipollutant mixtures. The meta-analyses showed that maternal exposure to combined EDCs was associated with a higher risk of testicular cancer in male offspring [summary risk ratios: 2.16, (95% CI:1.78-2.62), 1.93 (95% CI:1.49-2.48), and 2.78 (95% CI:2.27-3.41) for all, seminoma, and nonseminoma, respectively]. Similarly, high maternal exposures to grouped organochlorines and organohalogens were associated with higher risk of seminoma and nonseminoma in the offspring. Summary estimates related to postnatal adult male EDC exposures were inconsistent. Maternal, but not postnatal adult male, EDC exposures were consistently associated with a higher risk of testicular cancer, particularly risk of nonseminomas. However, the quality of studies was mixed, and considering the fields complexity, more prospective studies of prenatal EDC multipollutant mixture exposures and testicular cancer are needed.

Cardiovascular mortality after bilateral oophorectomy: a prospective cohort study

OBJECTIVES

Bilateral oophorectomy permanently reduces endogenous estrogen exposure and may increase cardiovascular mortality in women. This study aimed to investigate the association between bilateral oophorectomy and cardiovascular mortality and whether this association was conditional on hysterectomy or on the use of hormone therapy at the time of study entry.

METHODS

A prospective cohort study of 25,338 female nurses aged ≥ 45 years within the Danish Nurse Cohort. Nurses were enrolled in 1993 or 1999 and followed until death, emigration, or end of follow-up on December 31, 2018, whichever came first. Exposure was bilateral oophorectomy. Outcome was cardiovascular mortality. Associations were estimated using Poisson regression models with log person-years as the offset.

RESULTS

A total of 2,040 (8.1%) participants underwent bilateral oophorectomy. During a mean follow-up of 21.2 (SD: 5.6) years, 772 (3.0%) nurses died from cardiovascular disease. In adjusted analyses, a 31% higher rate of cardiovascular mortality was observed after bilateral oophorectomy (aMRR 1.31; 95% CI, 0.88-1.96) compared with women who retained their ovaries. No evidence of effect modification by use of hormone therapy at baseline or by hysterectomy on the association between bilateral oophorectomy and cardiovascular mortality was observed.

CONCLUSION

Bilateral oophorectomy may be associated with cardiovascular mortality in women, but the estimate was not statistically significant. Additionally, we were unable to make firm conclusions regarding the possible modifying role of hormone therapy and hysterectomy on this potential association. Additional studies are needed to replicate this work.

Prenatal exposure to maternal stressful life events and earlier age at menarche: the Raine Study

STUDY QUESTION

Is there an association between prenatal exposure to stressful life events and age at menarche, and does childhood BMI mediate this association?

SUMMARY ANSWER

Girls exposed to prenatal stress had a slightly earlier age at menarche, but this association did not show a dose-response effect and was not mediated by childhood offspring BMI.

WHAT IS ALREADY KNOWN

Prenatal stress may impact on reproductive function in females including age at menarche, but human data are very limited. High childhood BMI is known to be associated with earlier age at menarche. Only one small study has measured the association between maternal stress and age at menarche and reported that childhood BMI mediated the association between maternal stress and earlier age at menarche. However, neither maternal stress nor age at menarche was prospectively recorded and the study was limited to 31 mother-daughter pairs.

STUDY DESIGN, SIZE, DURATION

The Raine Study is a large prospective population-based pregnancy cohort study (n = 1414 mother-daughter pairs) continuously followed from prenatal life through to adolescence. In the present study, we examined the association between exposure to maternal stressful life events during early, late and total gestation and age at menarche in offspring using 753 mother-daughter pairs with complete case information.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mothers prospectively reported stressful life events during pregnancy at 18 and 34 weeks using a standardized 10-point questionnaire. Exact date of menarche was assessed using a purpose-designed questionnaire at 8, 10, 14 and 17 years of age. Complete information on exposure, outcome and confounding variables was obtained from 753 mothers-daughter pairs. Multivariate linear regression complete case analysis was used to examine associations between maternal stressful life event exposure and age at menarche. Potential selection bias was evaluated using multiple imputations (50 datasets). The mediating effects of offspring childhood BMI (ages 5, 8, or 10 years) on these associations were measured in separate sub-analyses.

MAIN RESULTS AND ROLE OF CHANCE

Most (580/753, 77%) daughters were exposed to at least one prenatal stressful life event. Exposure to maternal stressful life events during the entire pregnancy was associated with a non-linear earlier age at menarche. Exposure to one event and two or more psychological stressful events was associated with a 3.5 and 1.7-month earlier onset of puberty, respectively when compared to the reference group with no exposure maternal stressful life events. The estimates from multiple imputation with 50 datasets were comparable with complete case analysis confirming the existence of an underlying effect. No separate significant effects were observed for exposure during early or late gestation. The association between prenatal stressful events and age at menarche was not mediated by childhood BMI in the offspring.

LIMITATIONS, REASONS FOR CAUTION

Stressful life events may have affected pregnant women in different ways and self-perceived maternal stress severity may have provided a more precise estimate of gestational psychological stress. The observed non-linear U-shape of the association between maternal psychological stress and age at menarche did not reflect a dose-response. This suggests that the first exposure to prenatal stress exerts a greater effect on fetal reproductive development. A potential mechanism is via dramatic initial activation of the hypothalamic-pituitary-adrenal (HPA) axis following the first stressful life event which is greater than that observed following subsequent exposure to two or more maternal stressful life events. Whilst we adjusted for a priori chosen confounders, we cannot exclude residual confounding or confounding by factors we did not include. Maternal age at menarche was not available so the effects of familial history/genetics could not be assessed. There was a large loss due to the number of girls with no information on date of menarche and missing confounder information implying risk of selection bias and multiple imputation analyses did not fully exclude this risk (similar direction but slightly weaker estimate magnitude).

WIDER IMPLICATIONS OF THE FINDINGS

Menarche is a sentinel reproductive event and earlier age at menarche carries implications for psychological, social and reproductive health and for long-term risk of common non-communicable diseases. Understanding the factors regulating age at menarche has extensive health implications. This is the first population-based cohort study in humans to demonstrate that prenatal psychological stress might directly modify age at menarche.

STUDY FUNDING/COMPETING INTEREST(S)

Dr. Bräuner and Trine Koch's salaries were supported by Doctor Sofus Carl Emil Friis and spouse Olga Doris Friis foundation, The Danish Cancer Society (Kræftens Bekæmpelse, RP15468, R204-A12636, Denmark) and The Danish Health Foundation (Helsefonden, F-22181-23, Denmark). Martha Hickey was funded by NHMRC Practitioner Fellowships. The funding bodies played no role in the design, collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. Dr. Hart has received personal fees in his function as the Medical Director of Fertility Specialists of Western Australia and received educational sponsorship grants from MSD, Merck-Serono and from Ferring Pharmaceuticals. Dr Hart has also received personal fees from Shareholders in Western IVF outside the submitted work.

TRIAL REGISTRATION NUMBER

NA.

Breast cancer rate after oophorectomy: A Prospective Danish Cohort Study

The association between oophorectomy and risk of breast cancer in the general population is uncertain. The aim of our study was to determine the breast cancer rate in women from the general population after oophorectomy (performed before/after menopause), and whether this varies by use of hormone replacement therapy (HRT), hysterectomy, body mass index (BMI) and shift work. The study included 24 409 female nurses (aged ≥45 years) participating in the Danish Nurse Cohort. Nurses were followed from cohort entry until date of breast cancer, death, emigration or end of follow-up at 31 December 2018, whichever came first. Poisson regression with log-transformed person-years as the offset examined the association between oophorectomy and breast cancer (all ages and stratified by menopausal status at time of oophorectomy). The potential modifying effect of HRT use, hysterectomy, BMI and shift work on the associations was estimated. During 502 463 person-years of follow-up, 1975 (8.1%) nurses were diagnosed with breast cancer. Bilateral oophorectomy was associated with a reduced breast cancer rate compared to nurses with preserved ovaries, adjusted rate ratio (95% confidence interval): 0.79 (0.64; 0.99). Similar associations (magnitude and direction) were detected for unilateral oophorectomy and when stratifying according to menopausal status at time of oophorectomy, but without statistical significance. Unilateral and bilateral oophorectomy is associated with a reduced breast cancer rate in women from the general population. This association is not modified by use of HRT, hysterectomy, BMI or shift work.

Treatment of intraoperative hypotension with cafedrine/theodrenaline versus ephedrine : A prospective, national, multicenter, non-interventional study-the HYPOTENS trial

BACKGROUND

Sympathomimetic drugs are a therapeutic cornerstone for the management of hypotensive states like intraoperative hypotension (IOH). While cafedrine/theodrenaline (C/T) is widely used in Germany to restore blood pressure in patients with IOH, more research is required to compare its effectiveness with alternatives such as ephedrine (E) that are more commonly available internationally.

METHODS

HYPOTENS (NCT02893241, DRKS00010740) was a prospective, national, multicenter, open-label, two-armed, non-interventional study that compared C/T with E for treatment of IOH. We describe a prospectively defined cohort of patients ≥50 years old with comorbidities undergoing general anesthesia induced with propofol and fentanyl. Primary objectives were to examine treatment precision, rapidity of onset and the ability to restore blood pressure without relevant increases in heart rate. Secondary endpoints were treatment satisfaction and the number of required additional boluses or other accompanying measures.

RESULTS

A total of 1496 patients were included in the per protocol analysis. Overall, effective stabilization of blood pressure was achieved with both C/T and E. Post-hoc analysis showed that blood pressure increase from baseline was more pronounced with C/T. Fewer additional boluses or other accompanying measures were required in the C/T arm. The incidence of tachycardia was comparable between groups. Post-hoc analysis showed that E produced dose-dependent elevated heart rate values. By contrast, heart rate remained stable in patients treated with C/T. Physicians reported a higher level of treatment satisfaction with C/T, with a higher proportion of anesthetists rating treatment precision and rapidity of onset as good or very good when compared with E.

CONCLUSION

Neither drug was superior in restoring blood pressure levels; however, post-hoc analyses suggested that treatment is more goal-orientated and easier to control with C/T. Heart rate was shown to be more stable with C/T and fewer additional interventions were required to restore blood pressure, which could have contributed to the increased treatment satisfaction reported by anesthetists using C/T.

In utero exposure to maternal stressful life events and risk of polycystic ovary syndrome in the offspring: The Raine Study

BACKGROUND

PCOS is the most common endocrine disorder in reproductive age women. The origins of PCOS are unknown but experimental and limited human evidence suggests that greater prenatal exposure to androgens may predispose to PCOS. Experimental evidence suggests that maternal stressors may affect reproductive function in the offspring via changes in prenatal androgen exposure. In this present study, we aim to investigate whether maternal stressful life events during pregnancy are associated with polycystic ovary morphology (PCOM) or polycystic ovary syndrome (PCOS) in adolescent offspring.

METHOD

In a large population-based pregnancy cohort study (The Raine Study) continuously followed from prenatal life through to adolescence we examined the association between maternal stressful life events during pregnancy in both early and late gestation, and subsequent circulating concentrations of ovarian and adrenal androgens, PCOM and PCOS in the normal menstrual cycle of offspring age 14-16 years. Maternal stressful life events were prospectively recorded during pregnancy at 18 and 34 weeks using a 10-point questionnaire. Female offspring (n = 223) completed a questionnaire about their menstrual cycles, underwent a clinical examination for hirsutism (Ferriman-Gallwey score) and transabdominal pelvic ultrasound examination to determine ovarian morphology according to standardized criteria for classification of PCOM. Plasma samples were obtained at day 2-6 of the normal menstrual cycle for measurement of androgens. PCOM was defined according to the international consensus definition, 2003 and the evidence-based guideline for the assessment and management of PCOS, 2018. PCOS was diagnosed according to Rotterdam criteria and National Institute of Health (NIH) criteria. Multivariate linear and logistic regression analyses were used to examine the associations between maternal stressful life event exposure and ovarian morphology (PCOM), circulating ovarian and adrenal androgens (clinical and biochemical hyperandrogenism (hirsutism)) and presence of PCOS.

RESULTS

Of 223 recruited adolescent girls, 78 (35.9%) and 68 (31.3%) had PCOM by the 2003 and 2018 criteria respectively, while 66 (29.6%) and 37 (16.6%) had PCOS, using Rotterdam and NIH criteria, respectively. Most girls (141/223, 63.2%) were exposed to at least one stressful life event in early gestation and around half (121/223, 54.3%) were exposed to at least one stressful life event in late gestation. Maternal stressful life events in early gestation were associated with a statistically significant lower prevalence of PCOM when applying the 2003 criteria [adjusted odds ratio [aOR] and 95% confidence intervals (CI): 0.74 (95% CI: 0.55; 0.99)], and a similar association was detected when applying the 2018 PCOM criteria (aOR, 0.69, 95% CI: 0.50; 0.95)]. Maternal stressful life events in early gestation were also associated with lower circulating concentrations of testosterone (β = -0.05, 95% CI: -0.09; -0.004) and androstenedione (β = -0.05, 95% CI: -0.10; -0.002) in the offspring. No similar effects for PCOM or circulating androgens were detected in late gestation. No statistically significant associations between maternal stressful life events in early or late gestation with PCOS (neither Rotterdam nor NIH criteria) in adolescence were detected. The prospective collection of maternal stressful life events during both early and late gestation and direct measurement of PCOM, PCOS and circulating androgens in adolescence and key co-variates implies minimal possibility of recall, information bias and selection bias.

CONCLUSION

Maternal exposure to stressful life events in early gestation is associated with significantly reduced circulating ovarian and adrenal androgen concentrations in adolescence (testosterone and androstenedione), and an indication of fewer cases of polycystic ovary morphology (PCOM) defined by the 2003 international consensus definition and by the 2018 international evidence-based guideline, but has no effect on polycystic ovary syndrome (PCOS), diagnosed using either Rotterdam or NIH criteria.

The association between in utero exposure to maternal psychological stress and female reproductive function in adolescence: A prospective cohort study

Background

Method

Results

Conclusion

•

Animal studies suggest reproductive function is influenced by maternal stress.

•

Human evidence is sparse and inconsistent.

•

We used a population-based pregnancy cohort of 228 mother female offspring.

•

Exposure to maternal psychological stress in late gestation affects uterine volume and ovarian AFC.

Increased risk of acute stroke among patients with severe COVID-19: a multicenter study and meta-analysis

BACKGROUND AND PURPOSE

Recent observations linked coronavirus disease 2019 (COVID-19) to thromboembolic complications possibly mediated by increased blood coagulability and inflammatory endothelial impairment. We aimed to define the risk of acute stroke in patients with severe and non-severe COVID-19.

METHODS

We performed an observational, multicenter cohort study in four participating hospitals in Saxony, Germany to characterize consecutive patients with laboratory-confirmed COVID-19 who experienced acute stroke during hospitalization. Furthermore, we conducted a systematic review using PubMed/MEDLINE, Embase, Cochrane Library and bibliographies of identified papers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines including data from observational studies of acute stroke in COVID-19 patients. Data were extracted by two independent reviewers and pooled with multicenter data to calculate risk ratios (RRs) and 95% confidence intervals (95% CIs) for acute stroke related to COVID-19 severity using a random-effects model. Between-study heterogeneity was assessed using Cochran's Q and I2 statistics. International Prospective Register of Systematic Reviews registration number: CRD42020187194.

RESULTS

Of 165 patients hospitalized for COVID-19 (49.1% males, median age = 67 years [57-79 years], 72.1% severe or critical) included in the multicenter study, overall stroke rate was 4.2% (95% CI: 1.9-8.7). Systematic literature search identified two observational studies involving 576 patients that were eligible for meta-analysis. Amongst 741 pooled COVID-19 patients, overall stroke rate was 2.9% (95% CI: 1.9-4.5). Risk of acute stroke was increased for patients with severe compared to non-severe COVID-19 (RR = 4.18, 95% CI: 1.7-10.25; P = 0.002) with no evidence of heterogeneity (I2  = 0%, P = 0.82).

CONCLUSIONS

Synthesized analysis of data from our multicenter study and previously published cohorts indicates that severity of COVID-19 is associated with an increased risk of acute stroke.

Marked Increase in Incident Gynecomastia: A 20-Year National Registry Study, 1998 to 2017

CONTEXT

Gynecomastia, the proliferation of mammary glandular tissue in the male, is a frequent but little-studied condition. Available prevalence data are based on selected patient populations or autopsy cases with their inherent bias.

OBJECTIVE

The objective of this work is to evaluate the age-related incidence and secular trends in gynecomastia in the general population.

DESIGN

An observational, 20-year national registry study was conducted.

SETTING

This population-based study used nationwide registry data.

PARTICIPANTS

Participants included all Danish males (age 0-80 years) with a first-time diagnosis of gynecomastia.

MAIN OUTCOME MEASURES

All Danish males (age 0-80 years) were followed up for incident diagnosis of gynecomastia in the Danish National Patient Registry from 1998 to 2017 using the International Codes of Diseases, 10th revision, and the Danish Health Care Classification System. Age-specific incidence rates were estimated. The hypothesis tested in this study was formulated prior to data collection.

RESULTS

Overall, a total 17 601 males (age 0-80 years) were registered with an incident diagnosis of gynecomastia within the 20-year study period, corresponding to 880 new cases per year and an average 20-year incidence of 3.4 per 10 000 men (age 0-80 years). The average annual incidence was 6.5/10 000 in postpubertal males age 16 to 20 years and 4.6/10 000 in males age 61 to 80 years, with a respective 5- and 11-fold overall increase in these 2 age groups over the 20-year period.

CONCLUSIONS

The incidence of gynecomastia has dramatically increased over the last 20 years, implying that the endogenous or exogenous sex-steroid environment has changed, which is associated with other adverse health consequences in men such as an increased risk of prostate cancer, metabolic syndrome, type 2 diabetes, or cardiovascular disorders.

Trends in the Incidence of Central Precocious Puberty and Normal Variant Puberty Among Children in Denmark, 1998 to 2017

IMPORTANCE

There has been a worldwide secular trend toward earlier onset of puberty in the general population. However, it remains uncertain if these changes are paralleled with increased incidence of central precocious puberty (CPP) and normal variant puberty (ie, premature thelarche [PT] and premature adrenarche [PA]) because epidemiological evidence on the time trends in the incidence of these puberty disorders is scarce.

OBJECTIVE

To provide valid epidemiological data on the 20-year secular trend in the incidence rates of CPP and normal variant puberty.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, 20-year cohort study used national registry data for all youth in Denmark registered with an incident diagnosis of CPP, PT, or PA in the Danish National Patient Registry from 1998 to 2017 (N = 8596) using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). We applied the maximum diagnostic age limit for precocious puberty (ie, onset of puberty before age 8 years for girls and age 9 years for boys) with and without a 12-month lag to address time from first contact to final registration in the Danish National Patient Registry. Data analysis was conducted in 2019.

EXPOSURES

Diagnosis of CPP, PT, or PA.

MAIN OUTCOMES AND MEASURES

The age-specific and sex-specific incidence rates of first-time diagnosis of CPP, PT, and PA were estimated using data from the Danish National Patient Registry from 1998 to 2017, and information about the total number of children at risk within the same age groups and sex from Statistics Denmark. Incidences were stratified according to immigration group (Danish origin, first-generation immigrant, second-generation immigrant).

RESULTS

Overall a total 8596 children (7770 [90.4%] girls; median [interquartile] age at diagnosis for boys, 8.0 [7.1-9.0] years; for girls, 8.0 [7.6-8.5] years) were registered with an incident diagnosis of CPP, PT, or PA, of whom 7391 (86.0%) had Danish origin (6671 [90.3%] girls), corresponding to 370 new cases in children with Danish origin per year. The 20-year mean annual incidence rates of CPP, PT, PA, and all 3 conditions per 10 000 girls with Danish origin were 9.2 (95% CI, 8.0 to 10.3), 1.1 (95% CI, 0.7 to 1.5), 1.3 (95% CI, 0.9 to 1.7), and 11.5 (95% CI, 10.3 to 12.8), respectively. For boys with Danish origin, the 20-year mean annual incidence rates per 10 000 boys were lower: 0.9 (95% CI, 0.6 to 1.2), 0.2 (95% CI, 0.1 to 0.4), and 1.1 (95% CI, 0.7 to 1.4) for CPP, PA, and the sum, respectively. There was a 6-fold increase in incidence for girls with Danish origin (from 2.6 per 10 000 to 14.6 per 10 000) and a 15-fold increase for boys with Danish origin (from 0.1 per 10 000 to 2.1 per 10 000). The 20-year mean incidence of CPP and PA among girls in the first-generation and second-generation immigrant groups were greater than that of girls with Danish origin. The incidence rate for CPP per 10 000 girls in the first-generation and second-generation groups were 13.7 (95% CI, 9.3 to 18.2) and 14.2 (95% CI, 4.6 to 23.9), respectively; the incidence rate for PA per 10 000 girls in the first-generation and second-generation groups were 2.0 (95% CI, 0.3 to 3.6) and 1.5 (95% CI, -1.6 to 4.7), respectively. No differences associated with immigration status were observed among boys.

CONCLUSIONS AND RELEVANCE

Our findings suggest that the annual incidence of CPP and normal variant puberty has substantially increased in Denmark during the last 20 years. These findings have implications for short-term and long-term health and potentially for the international classification of the reference age of puberty.

Changes in net ecosystem exchange over Europe during the 2018 drought based on atmospheric observations

The 2018 drought was one of the worst European droughts of the twenty-first century in terms of its severity, extent and duration. The effects of the drought could be seen in a reduction in harvest yields in parts of Europe, as well as an unprecedented browning of vegetation in summer. Here, we quantify the effect of the drought on net ecosystem exchange (NEE) using five independent regional atmospheric inversion frameworks. Using a network of atmospheric CO₂ mole fraction observations, we estimate NEE with at least monthly and 0.5° × 0.5° resolution for 2009–2018. We find that the annual NEE in 2018 was likely more positive (less CO₂ uptake) in the temperate region of Europe by 0.09 ± 0.06 Pg C yr⁻¹ (mean ± s.d.) compared to the mean of the last 10 years of −0.08 ± 0.17 Pg C yr⁻¹, making the region close to carbon neutral in 2018. Similarly, we find a positive annual NEE anomaly for the northern region of Europe of 0.02 ± 0.02 Pg C yr⁻¹ compared the 10-year mean of −0.04 ± 0.05 Pg C yr⁻¹. In both regions, this was largely owing to a reduction in the summer CO₂ uptake. The positive NEE anomalies coincided spatially and temporally with negative anomalies in soil water. These anomalies were exceptional for the 10-year period of our study.

This article is part of the theme issue ‘Impacts of the 2018 severe drought and heatwave in Europe: from site to continental scale’.

A history of cryptorchidism is associated with impaired testicular function in early adulthood: a cross-sectional study of 6376 men from the general population

STUDY QUESTION

Is there a difference in testicular function in early adulthood between men born with cryptorchidism and men born with normally descended testes?

SUMMARY ANSWER

In men from the general population, a history of cryptorchidism was associated with lower total testis volume and impaired semen quality as well as altered serum levels of reproductive hormones.

WHAT IS KNOWN ALREADY

The association between cryptorchidism and testicular function is well documented in studies based on sub-fertile or infertile men recruited from a clinical setting. However, the association has not previously been investigated in men from the general population, who were unselected regarding fertility status.

STUDY DESIGN, SIZE, DURATION

This is a cross-sectional population-based study of 6376 young Danish men examined from 1996 to 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This study is based on young men from the greater Copenhagen area, Denmark (median age of 19 years) who were unselected regarding fertility status and semen quality. The young men delivered a semen sample, had a blood sample drawn and underwent a physical examination including assessment of testis volume. Participants completed a questionnaire regarding cryptorchidism at birth, current lifestyle and their mother’s pregnancy, after consulting their mother. The differences in markers of testicular function, including testis volume, semen parameters and reproductive hormones between men with and without a history of cryptorchidism were investigated with multiple linear regression analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

The participation rate was 24% for the entire study period. Overall, a history of cryptorchidism was associated with reduced testicular function. In the adjusted models, a history of cryptorchidism was associated with a 3.5 ml lower total testis volume, determined by orchidometer (P &lt; 0.001), 28% lower sperm concentration (95% CI: −37 to −20) and 26% lower inhibin B/FSH ratio (95% CI: −50 to −22) compared to men without a history of cryptorchidism, suggesting a reduced spermatogenetic capacity. Men with a history of cryptorchidism also had a slightly reduced Leydig cell function expressed as a 6% lower testosterone/LH ratio (95% CI: −12 to −0.7). The significant effect sizes and different markers of testicular function pointing in the same direction across the different models based on a large sample size support that the results are not chance findings.

LIMITATIONS, REASONS FOR CAUTION

Information on cryptorchidism at birth and treatment modus was obtained by retrospective self-report, and each participant only delivered one semen sample.

WIDER IMPLICATIONS OF THE FINDINGS

The results suggest that men with a history of cryptorchidism could be at increased risk of experiencing fertility problems. However, among these men there is a wide variation in semen quality and further research is needed in order to identify the subgroup of boys born with cryptorchidism who are at the greatest risk of impaired semen quality when reaching adulthood.

STUDY FUNDING/COMPETING INTEREST(S)

The study received financial support from the Research fund of Rigshospitalet, Copenhagen University Hospital; the European Union (Contract numbers BMH4-CT96-0314, QLK4-CT-1999-01422, QLK4-CT-2002-00603. FP7/2007-2013, DEER Grant agreement no. 212844); the Danish Ministry of Health; the Danish Environmental Protection Agency; A.P. Møller and wife Chastine McKinney Møllers Foundation; and Svend Andersens Foundation. None of the founders had any role in the study design, collection, analysis or interpretation of data, writing of the paper or publication decisions. The authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

[Is the discipline associated with self-confidence in handling rational antibiotic prescription? : Results from the MR2 study in German hospitals]

BACKGROUND

Besides public awareness and specialist knowledge and training of physicians, their self-confidence plays a key role for clinical decision-making in the respective area.

OBJECTIVE

This exploratory study investigated the influence of the discipline on differences in self-confidence in dealing with antibiotics and in the self-rated knowledge.

METHODS

In 2015 the multi-institutional reconnaissance of practice with multiresistant bacteria (MR2) questionnaire containing items on antibiotic prescription and multiresistant pathogens was sent out to 1061 physicians working in departments for internal medicine, general surgery, gynecology and obstetrics and urology. In 2017 a similar MR2 survey was sent to 1268 specialist and assistant physicians in anesthesiology in Germany. Besides demographic data 4 items on self-confidence in the use of antibiotic treatment and 11 items concerning self-rated knowledge about rational antibiotic therapy and multiresistant pathogens were included in the present analysis. Logistic regression analysis, the χ²-test and the Kruskal-Wallis test were used for statistical analysis of the influence of the discipline on these items.

RESULTS

The response rates were 43% (456 out of 1061) from the non-anesthetists and 56% (705 out of 1268) from the anesthetists. Of the non-anesthetists 44% and 57% of the anesthetists had had no advanced training on antibiotic stewardship during the year before the study. In the overall analysis anesthetists (mean±SD: 2.53±0.54) were significantly less self-confident about antibiotics than colleagues from other departments (internal medicine: 3.10±0.50, general surgery: 2.97±0.44, gynecology and obstetrics: 3.12±0.42 and urology: 3.15±0.44) in the unadjusted (all p<0.001) and adjusted comparison. The analysis of self-rated knowledge about rational antibiotic prescription showed similar results. Senior consultant status and advanced training in infectiology were significantly associated with self-confidence and self-rated knowledge about antibiotics.

CONCLUSION

Anesthetists showed significantly less self-confidence in dealing with antibiotics than colleagues from other disciplines. Advanced training on a rational prescription of antibiotics was associated with a greater self-confidence, so that the implementation of compulsory courses on rational antibiotic stewardship in the respective residency curriculum needs to be considered.

Quo Vadis PCA? A Review on Current Concepts, Economic Considerations, Patient-Related Aspects, and Future Development with respect to Patient-Controlled Analgesia

This review assesses four interrelating aspects of patient-controlled analgesia (PCA), a long-standing and still widely used concept for postoperative pain management. Over the years, anaesthesiologists and patients have appreciated the benefits of PCA alike. The market has seen new technologies leveraging noninvasive routes of administration and, thus, further increasing patient and staff satisfaction as well as promoting safety aspects. Pharmaceutical research focuses on the reduction or avoidance of opioids, side effects, and adverse events although influence of these aspects appears to be minor. The importance of education is still eminent, and new educational formats are tested to train healthcare professionals and patients likewise. New PCA technology can support the implementation of efficient processes to reduce workload and human errors; however, these new products come with a cost, which is not necessarily reflected through beneficial budget impact or significant improvements in patient outcome. Although first steps have been taken to better recognize the importance of postoperative pain management through the introduction of value-based reimbursement, in most western countries, PCA is not specifically compensated. PCA is still an effective and valued technique for postoperative pain management. Although there is identifiable potential for future developments in various aspects, this potential has not materialized in new products.

Measurement of relative lung perfusion with electrical impedance and positron emission tomography: an experimental comparative study in pigs

BACKGROUND

Electrical impedance tomography (EIT) with indicator dilution may be clinically useful to measure relative lung perfusion, but there is limited information on the performance of this technique.

METHODS

Thirteen pigs (50-66 kg) were anaesthetised and mechanically ventilated. Sequential changes in ventilation were made: (i) right-lung ventilation with left-lung collapse, (ii) two-lung ventilation with optimised PEEP, (iii) two-lung ventilation with zero PEEP after saline lung lavage, (iv) two-lung ventilation with maximum PEEP (20/25 cm H₂O to achieve peak airway pressure 45 cm H₂O), and (v) two-lung ventilation under unilateral pulmonary artery occlusion. Relative lung perfusion was assessed with EIT and central venous injection of saline 3%, 5%, and 10% (10 ml) during breath holds. Relative perfusion was determined by positron emission tomography (PET) using ⁶⁸Gallium-labelled microspheres. EIT and PET were compared in eight regions of equal ventro-dorsal height (right, left, ventral, mid-ventral, mid-dorsal, and dorsal), and directional changes in regional perfusion were determined.

RESULTS

Differences between methods were relatively small (95% of values differed by less than 8.7%, 8.9%, and 9.5% for saline 10%, 5%, and 3%, respectively). Compared with PET, EIT underestimated relative perfusion in dependent, and overestimated it in non-dependent, regions. EIT and PET detected the same direction of change in relative lung perfusion in 68.9-95.9% of measurements.

CONCLUSIONS

The agreement between EIT and PET for measuring and tracking changes of relative lung perfusion was satisfactory for clinical purposes. Indicator-based EIT may prove useful for measuring pulmonary perfusion at bedside.

[The Role of Air Pollutants for Health - A Reply to the Expert Opinion of the International Society for Environmental Epidemiology (ISEE) and the European Respiratory Society (ERS)]

In Deutschland gibt es regionale Fahrverbote für ältere Dieselfahrzeuge ohne SCR-Katalysator bei Überschreitung der Grenzwerte für NO2. Dies hat zu einer intensiven Diskussion über die Rolle der Luftschadstoffe für die Gesundheit geführt. In der Replik wird dargestellt, dass die Daten zur Wirkung von Stickstoffdioxid (NO2) und Feinstaub (PM10 und PM2,5) nicht ausreichen, um die Fahrverbote zu begründen.

Für NO2 gibt es passagere Reaktionen bei unbehandelten Asthmatikern ab 500 µg/m3. Die deutschen Grenzwerte (Jahresmittelwert 40 µg/m3) fußen im Wesentlichen auf einer Metaanalyse von 9 Studien aus Innenraumbelastungen wobei nur in 4 Studien NO2 gemessen wurde. In der großen europäischen Escape-Studie von 2014 wurde kein Einfluss von NO2 auf die Mortalität gefunden.

Als Surrogatparameter für andere Schadstoffe ist NO2 ebenfalls nicht mehr geeignet, da seit Einführung der Partikelfilter bei Dieselautos (etwa ab 2000) der KFZ-Anteil am Feinstaub an der Straße unter 10 % liegt. Der Feinstaub besteht im Wesentlichen aus Aufwirbelung von mineralischen, organischen Bodensubstanzen sowie Reifenabrieb und wird am stärksten durch Wetterphänomene, vor allen Dingen durch Sonneneinstrahlung beeinflusst.

Die Grenzwerte für NO2 und Feinstaub werden errechnet aus epidemiologischen Beobachtungsstudien. Es findet sich zumeist eine schwache Assoziation zwischen der Konzentra-tion und zahlreichen Erkrankung sowie der Mortalität. Epidemiologische Beobachtungsstudien erlauben nur die Bildung einer Hypothese. Permanente Wiederholungen der Beobachtungsstudien betätigen nur, dass manche gefundenen Phänomene nicht zufällig sind. Eine Kausalität kann daraus nicht abgeleitet werden, da es zahlreiche Erklärungsmodelle neben dem NO2 und Feinstaub gibt. Dazu wären Interventionsstudien im Niedrigdosisbereich sowie Tierexperimente erforderlich. Diese Daten fehlen nahezu komplett bzw. sind, soweit vorhanden, allesamt negativ.

Nie diskutiert wird eine starke Widerlegung der Hypothese der Gefährdung von NO2 und Feinstaub im Grenzwertbereich durch das Inhalationsrauchen. Die Raucher stellen quasi einen inhalationstoxikologischen Großversuch dar. Der Zigarettenrauch enthält sehr hohe Feinstaub-, Stickstoffmonoxid- (NO) und NO2-Konzentrationen, die vom Organismus erstaunlich gut toleriert werden. Das hängt damit zusammen, dass NO ein Naturstoff ist, der in den Zellen oder auch in den Nasennebenhöhlen in z. T. sehr hohen Konzentrationen (über 30 000 µg/m3) vorkommt. Eines der Abbauprodukte von NO ist NO2, was im Wasser zu Nitrat und Nitrit disproportioniert wird. Ein Teil von NO2 wird zur Synthese von Fettsäuren verwendet.

Zigaretten haben ein Kondensat von ca. 7 – 10 mg. Nimmt man als Vergleich eine lebenslange Dauerbelastung durch Feinstaub und NO2 in den Grenzwertkonzentrationen an, müssten alle Raucher nach wenigen Tagen bis Monaten zahlreiche Erkrankungen entwickeln, die dem Feinstaub und NOx angelastet werden. Auch die Mortalität müsste drastisch erhöht sein; nahezu alle Raucher müssten bereits nach 1 packyear verstorben sein. Der Unterschied wird noch größer, wenn man die nachgewiesene Toxizität und Kanzerogenität des Zigarettenrauchs im Vergleich zu dem i. d. R. deutlich weniger gefährlichen Feinstaub an der Straße ins Verhältnis setzt.

Epidural needle insertion : A large registry analysis

BACKGROUND

Dural puncture, paraesthesia and vascular puncture are the most common complications of epidural catheter insertion. Their association with variation in midline needle insertion depth is unknown.

OBJECTIVE

This study evaluated the risk of dural and vascular punctures and the unwanted events paraesthesia and multiple skin punctures related to midline needle insertion depth.

MATERIAL AND METHODS

A total of 14,503 epidural catheter insertions including lumbar (L1-L5; n = 5367), low thoracic (T7-T12, n = 8234) and upper thoracic (T1-T6, n = 902) insertions, were extracted from the German Network for Regional Anaesthesia registry between 2007 and 2015. The primary outcomes were compared with logistic regression and adjusted (adj) for confounders to determine the risk of complications/events. Results are presented as odds ratios (OR, [95% confidence interval]).

MAIN RESULTS

Midline insertion depth depended on body mass index, sex, and spinal level. After adjusting for confounders increased puncture depth (cm) remained an independent risk factor for vascular puncture (adjOR 1.27 [1.09-1.47], p = 0.002) and multiple skin punctures (adjOR 1.25 [1.21-1.29], p < 0.001). In contrast, dural punctures occurred at significantly shallower depths (adjOR 0.73 [0.60-0.89], p = 0.002). Paraesthesia was unrelated to insertion depth. Body mass index and sex had no influence on paraesthesia, dural and vascular punctures. Thoracic epidural insertion was associated with a lower risk of vascular puncture than at lumbar sites (adjOR 0.39 [0.18-0.84], p = 0.02).

CONCLUSION

Variation in midline insertion depth is an independent risk factor for epidural complications; however, variability precludes use of depth as a reliable guide to insertion in individual patients.

Lethal outcome after pelvic salvage radiotherapy in a patient with prostate cancer due to increased radiosensitivity : Case report and literature review

BACKGROUND

In general, late side effects after salvage radiotherapy (RT) for prostate cancer are below 10%. Patients with impaired DNA repair ability and genetic instability can have significantly increased reactions after RT.

CASE, CLINICAL FOLLOW-UP, AND EXAMINATION

We present a patient who experienced severe side effects after additive RT for prostate cancer and died from the complications 25 months after RT. Imaging (MR) is shown as well as three-color fluorescence in situ hybridization. The blood sample testing revealed that radiosensitivity was increased by 35-55%. We undertook a review of the literature to give an overview over the tests established that are currently considered useful.

CONCLUSION

This case highlights that the identification of patients with increased radiosensitivity is an important task in radiation protection. Groups of patients who should be screened have to be found and corresponding research facilities have to be set up.

[Management of anesthesia in endovascular interventions]

Cardiovascular diseases are one of the leading causes of morbidity and mortality in Germany. In these patients, the high-risk profile necessitates an interdisciplinary and multimodal approach to treatment. Endovascular interventions and vascular surgery have become established as an important element of this strategy in the past; however, the different anatomical localizations of pathological vascular alterations make it necessary to use a wide spectrum of procedural options and methods; therefore, the requirements for management of anesthesia are variable and necessitate a differentiated approach. Endovascular procedures can be carried out with the patient under general or regional anesthesia (RA); however, in the currently available literature there is no evidence for an advantage of RA over general anesthesia regarding morbidity and mortality, although a reduction in pulmonary complications could be found for some endovascular interventions. Epidural and spinal RA procedures should be carefully considered with respect to the risk-benefit ratio and consideration of the recent guidelines on anesthesia against the background of the current study situation and the regular use of therapy with anticoagulants. The following article elucidates the specific characteristics of anesthesia management as exemplified by some selected endovascular interventions.

Tunnelling of thoracic epidural catheters is associated with fewer catheter-related infections: a retrospective registry analysis

BACKGROUND

Catheter-related infections are a serious complication of continuous thoracic epidural analgesia. Tunnelling catheters subcutaneously may reduce infection risk. We thus tested the hypothesis that tunnelling of thoracic epidural catheters is associated with a lower risk of catheter-related infections.

METHODS

Twenty-two thousand, four hundred and eleven surgical patients with continuous thoracic epidural analgesia included in the German Network for Regional Anaesthesia registry between 2007 and 2014 were grouped by whether their catheters were tunnelled (n=12 870) or not (n=9541). Catheter-related infections in each group were compared with Student's unpaired t and χ(2) tests. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with logistic regression, adjusting for potential confounding factors, including age, ASA physical status score, use of catheter for ≥4 days, multiple skin puncture, hospital, and surgical department.

RESULTS

There were fewer catheter-related infections in patients with tunnelled catheters (4.5 vs 5.5%, P<0.001). Mild infections were also less common (4.0 vs 4.6%, P=0.009), as were moderate infections (0.4 vs 0.8%, P<0.001). After adjustment for potential confounding factors, tunnelling remained an independent prevention for any grade of infection (adjusted OR 0.51, 95% CI 0.42-0.61, P<0.001) and for mild infections (adjusted OR 0.54, 95% CI 0.43-0.66, P<0.001) and moderate and severe infections (adjusted OR 0.44, 95% CI 0.28-0.70, P=0.001).

CONCLUSION

Tunnelling was associated with a lower risk of thoracic epidural catheter-related infections.

IgM-enriched solution BT086 improves host defense capacity and energy store preservation in a rabbit model of endotoxemia

Introduction

The therapeutic value of intravenous immunoglobulin (IVIG) as an adjuvant therapy in sepsis remains debatable. We hypothesized that intravenous administration of BT086, a predominantly IgM IVIG solution, would improve host defense in an established rabbit model of endotoxemia and systemic sepsis.

Methods

New Zealand white rabbits were randomized into the following four groups: (1) the negative control group without lipopolysaccharide (LPS, control), (2) the positive control group with LPS infusion (LPS group), (3) the albumin‐treated LPS group (ALB+LPS group), and (4) the BT086‐treated LPS group (BT086 + LPS group). A standardized amount of E. coli was intravenously injected into all of the animals. The vital parameters, the concentration of E. coli in the blood and other organs, the residual granulocyte phagocytosis activity, and the levels of the inflammatory mediators were measured. Histological changes in the lung and liver tissue were examined following autopsy.

Results

The elimination of E. coli from the bloodstream was expedited in the BT086‐treated group compared with the LPS‐ and albumin‐treated groups. The BT086 + LPS group exhibited higher phagocytic activity of polymorphonuclear neutrophils (PMNs) than the control and ALB+LPS groups. The liver energy stores were higher in the BT086 + LPS group than in the other groups.

Conclusion

Our data suggest that the IgM‐enriched IVIG has the potential to improve host defense in a rabbit model of endotoxemia. Studies using different animal models and dosages are necessary to further explore the potential benefits of IgM‐enriched IVIG solutions.

[Concurrent Endoscopic Sinus Surgery (FESS) with Septorhinoplasty - Indication, Risks and Chances]

BACKGROUND

Patients with a chronic rhinosinusitis (CRS) and a concurrent deformity of the outer nose often require a septorhinoplasty (SRP) for functional or aesthetic reasons, combined with functional endoscopic sinus surgery (FESS). Aim of this study was to rule out the benefit of this combined approach.

PATIENTS AND METHODS

In a prospective study of 55 patients (30 m, 25 f, age 16-77 years) with a chronic rhinosinusitis with or without polyps combined with a deformity of the outer nose we performed a FESS together with a SRP using a closed or open approach. The control group included 55 patients (18 m, 37 w, age 18-62 years) with SRP alone. All patients got the same type of anestesia and an antibiotic prophylaxis with clindamycin. We compared the rates of inflammation and other complications of surgery.

RESULTS

The only difference between study group and control group was the period of time for surgery. There was neither a relevant inflammation in both groups nor any other significant complication (bleeding, edema, etc). Also the rate of minor revisions after SRP was almost the same in both groups.

CONCLUSIONS

The combined FESS and SRP is a safe and effective method without an increased risk of complications compared with SRP alone.

Obesity in regional anesthesia--a risk factor for peripheral catheter-related infections

BACKGROUND

Obesity is believed to increase the risk of surgical site infections and possibly increase the risk of catheter-related infections in regional anesthesia. We, therefore, analyzed the influence of obesity on catheter-related infections defined within a national registry for regional anesthesia.

METHODS

The German Network for Regional Anesthesia database with 25 participating clinical centers was analyzed between 2007 and 2012. Exactly, 28,249 cases (13,239 peripheral nerve and 15,010 neuraxial blocks) of patients ≥ 14 years were grouped in I: underweight (BMI 13.2-18.49 kg/m(2) , n = 597), II: normal weight (BMI 18.5-24.9 kg/m(2) , n = 9272), III: overweight (BMI 25.0-29.9 kg/m(2) , n = 10,632), and IV: obese (BMI 30.0-70.3 kg/m(2) , n = 7,744). The analysis focused on peripheral and neuraxial catheter-related infections. Differences between the groups were tested with non-parametric ANOVA and chi-square (P < 0.05). Binary logistic regression was used to compare obese, overweight, or underweight patients with normal weight patients. Odds ratios (OR and 95% confidence interval) were calculated and adjusted for potential confounders.

RESULTS

Confounders with significant influence on the risk for catheter-related infections were gender, age, ASA score, diabetes, preoperative infection, multiple skin puncture, and prolonged catheter use. The incidence (normal weight: 2.1%, obese: 3.6%; P < 0.001) and the risk of peripheral catheter-related infection was increased in obese compared to normal weight patients [adjusted OR: 1.69 (1.25-2.28); P < 0.001]. In neuraxial sites, the incidence of catheter-related infections differed significantly between normal weight and obese patients (normal weight: 3.2%, obese: 2.3%; P = 0.01), whereas the risk was comparable [adjusted OR: 0.95 (0.71-1.28); P = 0.92].

CONCLUSION

This retrospective cohort study suggests that obesity is an independent risk factor for peripheral, but not neuraxial, catheter-related infections.

Functional plasticity of the N/OFQ-NOP receptor system determines analgesic properties of NOP receptor agonists

Despite high sequence similarity between NOP (nociceptin/orphanin FQ opioid peptide) and opioid receptors, marked differences in endogenous ligand selectivity, signal transduction, phosphorylation, desensitization, internalization and trafficking have been identified; underscoring the evolutionary difference between NOP and opioid receptors. Activation of NOP receptors affects nociceptive transmission in a site-specific manner, with antinociceptive effects prevailing after peripheral and spinal activation, and pronociceptive effects after supraspinal activation in rodents. The net effect of systemically administered NOP receptor agonists on nociception is proposed to depend on the relative contribution of peripheral, spinal and supraspinal activation, and this may depend on experimental conditions. Functional expression and regulation of NOP receptors at peripheral and central sites of the nociceptive pathway exhibits a high degree of plasticity under conditions of neuropathic and inflammatory pain. In rodents, systemically administered NOP receptor agonists exerted antihypersensitive effects in models of neuropathic and inflammatory pain. However, they were largely ineffective in acute pain while concomitantly evoking severe motor side effects. In contrast, systemic administration of NOP receptor agonists to non-human primates (NHPs) exerted potent and efficacious antinociception in the absence of motor and sedative side effects. The reason for this species difference with respect to antinociceptive efficacy and tolerability is not clear. Moreover, co-activation of NOP and μ-opioid peptide (MOP) receptors synergistically produced antinociception in NHPs. Hence, both selective NOP receptor as well as NOP/MOP receptor agonists may hold potential for clinical use as analgesics effective in conditions of acute and chronic pain.

Darstellung, 11B-, 13C -, 1H-NMR- und Schwingungsspektren von 2,2' -Bipyridylundecahydro-closo-dodecaborat(1-) sowie Kristallstruktur von (Ph4As)[(2,2′-C10H8N2)B12Hn ]·CH3CN / Synthesis, 11B, 13C, 1H NMR and Vibrational Spectra of 2 ,2'-Bipyridyl-undecahydro-closo-dodecaborate(1-) and Crystal Structure of (Ph4As)[(2 ,2'-C10H8N2)B12H11]-CH3CN

By reaction of (n-Bu4N)2[B12H12] with 2,2′-bipyridine at 190 °C the 2,2′-bipyridyl-undecahydro- closo-dodecaborate anion [(2,2′-C10H8N2)B12H11]− is formed which can be seperated from excess [B12H12]2− by ion exchange chromatography on diethylaminoethyl (DEAE) cellulose. The X-ray structure determination of (Ph4As)[(2, 2′-C10H8N2)B12H11] (monoclinic, space group P21/c with a = 13.3190(9), b = 10.1532(14), c = 28.788(3′) Å, β = 96.761(7)°, Z = 4) reveals that the bipyridyl substituent is bonded via one nitrogen atom. The 11B NMR spectrum exhibits a 1:5:5:1 pattern with ipso-B1 at -0.3, B2-B6 at -14.5, B7-B11 at -15.3 and antipodal-B12 at -15.9 ppm. The 13C and 1H NMR spectra show the characteristic patterns of the bipyridyl group in the range of 124.5 to 158.6 (13C) and 7.4 to 9.6 ppm (1H) respectively. The IR and Raman spectra exhibit characteristic BH stretching vibrations between 2445 and 2568 cm-1 and the stretching of the CC and CN bonds in the range of 1427 to 1619 cm-1 .

Abstract P2-15-02: Trastuzumab treatment of early breast cancer: Long-term results from a prospective observation study, including a large cohort of elderly patients

Purpose: Trastuzumab (T; Roche) is part of the standard treatment in patients (pts) of any age with early stage, HER2+ breast cancer, in addition to (neo)adjuvant chemotherapy (CT) and locoregional treatment. After its registration in Germany in 2006, this prospective observation study was started in order to assess the generalizability of the results from the randomized studies, specifically with respect to elderly age cohorts.

Methods: 4027 pts were enrolled between 2006 and 2012. 87 were non-eligible due to M1 and/or negative HER2 status. There were no restrictions for recruitment with respect to age or concomitant/sequential adjuvant medication. The long-term relapse/survival status of pts was retrieved by fax forms collected once a year. Safety assessment was limited to the treatment period. Data base cut-off was May 2013.

Results: Among the 3940 evaluable pts, there were 1013 elderly pts (EP) ≥ 65 years (y) of age (26%). This contrasts to the pivotal studies, e.g. with a proportion of only 6% beyond 65 y in the NSABP B-31 and NCCTG N9831 studies. The rate of EP steadily increased during the period from 2006 to 2009, remaining stable thereafter. More than half of the pts had pT≥2, with EP more often presenting with a larger tumor (56% vs. 48%,p&lt;.0001). 52% had a grade 3 tumor. Hormone receptor positivity was recorded in 63%. As to be expected, performance status was more impaired in elderly compared to younger pts (ECOG 0: 53 vs 65%,p&lt;.0001). 94% received CT, 78% as adjuvant, 14% as neoadjuvant treatment (in EP only 8%), while 2% received both modalities. In the vast majority (87%), T was administered sequentially to CT, with no differences among the age cohorts. The proportion without any adjuvant CT was higher in EP (8 vs. 5%). 56% of pts were treated with adjuvant endocrine medication, 78% with irradiation. T treatment was stopped prematurely in only 9% of pts, but more often in EP (11% vs 8%, p = .014).

After a follow-up period of up to a maximum of 8 y, 370 relapses were reported so far. The estimated recurrence-free survival is 94.7% (95% CI: 94-96%), 89.8% (89-91%), and 82.9% (81-85%) after 2, 3 and 5 y, respectively. Numeric results in EP are only slightly lower with 93.9 (92-96%), 89.3% (87-92%), and 81.6% (78-85%), not statistically significant (p = 0.18, HR = 1.17 [95% CI: 0.93 - 1.47]). Adverse effects with respect to cardiac function were reported in overall 153 pts (3.9%), with the majority of these cases of NCI grade 1 (39%) or 2 (38%). 23% of these events were of grade 3/4, but life-threatening in only 2 pts. Thus, the overall incidence of acute grade 3/4 cardiac function toxicity was 0.9%. In the EP subgroup the incidence across all NCI grades was only slightly increased (4.6%), but grade 3/4 cases were more common (1.6%).

Conclusion: Overall, the maturing follow-up data of this observational study confirm the beneficial results from the randomized studies. In addition, the data from more than thousand pts ≥ 65 y of age show that a similar anti-tumor efficiency can be achieved in elderly pts, and suggest that minor age-related differences detected with respect to adjuvant treatment duration, aggressiveness and toxicity do not impair the long-term clinical outcome.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-15-02.

Small bowel toxicity after high dose spot scanning-based proton beam therapy for paraspinal/retroperitoneal neoplasms

PURPOSE

Mesenchymal tumours require high-dose radiation therapy (RT). Small bowel (SB) dose constraints have historically limited dose delivery to paraspinal and retroperitoneal targets. This retrospective study correlated SB dose-volume histograms with side-effects after proton radiation therapy (PT).

PATIENTS AND METHODS

Between 1997 and 2008, 31 patients (mean age 52.1 years) underwent spot scanning-based PT for paraspinal/retroperitoneal chordomas (81%), sarcomas (16%) and meningiom (3%). Mean total prescribed dose was 72.3 Gy (relative biologic effectiveness, RBE) delivered in 1.8-2 Gy (RBE) fractions. Mean follow-up was 3.8 years. Based on the pretreatment planning CT, SB dose distributions were reanalysed.

RESULTS

Planning target volume (PTV) was defined as gross tumour volume (GTV) plus 5-7 mm margins. Mean PTV was 560.22 cm(3). A mean of 93.2% of the PTV was covered by at least 90% of the prescribed dose. SB volumes (cm(3)) receiving doses of 5, 20, 30, 40, 50, 60, 70, 75 and 80 Gy (RBE) were calculated to give V5, V20, V30, V40, V50, V60, V70, V75 and V80 respectively. In 7/31 patients, PT was accomplished without any significant SB irradiation (V5=0). In 24/31 patients, mean maximum dose (Dmax) to SB was 64.1 Gy (RBE). Despite target doses of >70 Gy (RBE), SB received >50 and >60 Gy (RBE) in only 61 and 54% of patients, respectively. Mean SB volumes (cm(3)) covered by different dose levels (Gy, RBE) were: V20 (n=24): 45.1, V50 (n=19): 17.7, V60 (n=17): 7.6 and V70 (n=12): 2.4. No acute toxicity ≥ grade 2 or late SB sequelae were observed.

CONCLUSION

Small noncircumferential volumes of SB tolerated doses in excess of 60 Gy (RBE) without any clinically-significant late adverse effects. This small retrospective study has limited statistical power but encourages further efforts with higher patient numbers to define and establish high-dose threshold models for SB toxicity in modern radiation oncology.