[Psychological stressors, resources and well-being of surgeons in Germany : A cross-sectional study]

BACKGROUND

Psychological stress at work is associated with detrimental and health-impairing consequences for employees.

OBJECTIVE

In this study major stress factors and the resource job control at the workplace of surgeons and facets of mental health were examined and compared to benchmark results of a large reference sample.

METHOD

Data were collected by a representative online survey among surgeons throughout Germany who were contacted via the Professional Association of German Surgeons. In total 643 surgeons from different organizations and different disciplines completed the questionnaire that was developed using well-validated instruments.

RESULTS

Time pressure was the most meaningful stress factor for surgeons. Moreover, the results for medical assistants showed adverse stress combinations of high goal uncertainty and low job control as well as high emotional exhaustion and low job satisfaction. In addition, the results indicated that surgeons in single and group practices as well as in outpatient healthcare centers have less stressors and more job resources.

CONCLUSION

The survey results suggest high levels of burnout risk for German surgeons, especially among medical assistants and medical specialists from large hospitals. In order to maintain a high quality in the surgical disciplines, a concerted effort by all players in the healthcare system is necessary.

Power of Judgment: The Significance of Kant's Philosophy for the Medical System Today

The ways of thinking in the manufacturing sciences are increasingly determining the rationality within medicine as a practical or action-based science. This "technological paradigm" infiltrates the field of medicine with the promise of increasing efficiency while simultaneously improving quality at various points in the system. Simple linear causal relationships generally need to be taken into account when manufacturing products. Even complex manufacturing processes can be broken down into the smallest units and, therefore, also be automated. The situation in complex systems such as the human body, however, is completely different. In order for doctors to be able to carry out their actions within this complex system, medicine as a science provides the physician with rules on the means that should be used to decide which remedy should be used, when and how. This judgment of which remedy should be used, when and how, what is known as the indication, is a central medical moment. This requires a power of judgment sharpened by experience. The indication, in turn, essentially determines the course of a disease and thus the quality of the treatment or the quality of result so often referred to these days.

Clinical characteristics of pain in patients with pituitary adenomas

OBJECTIVE

Clinical presentation of pituitary adenomas frequently involves pain, particularly headache, due to structural and functional properties of the tumour. Our aim was to investigate the clinical characteristics of pain in a large cohort of patients with pituitary disease.

DESIGN

In a cross-sectional study, we assessed 278 patients with pituitary disease (n=81 acromegaly; n=45 Cushing's disease; n=92 prolactinoma; n=60 non-functioning pituitary adenoma).

METHODS

Pain was studied using validated questionnaires to screen for nociceptive vs neuropathic pain components (painDETECT), determine pain severity, quality, duration and location (German pain questionnaire) and to assess the impact of pain on disability (migraine disability assessment, MIDAS) and quality of life (QoL).

RESULTS

We recorded a high prevalence of bodily pain (n=180, 65%) and headache (n=178, 64%); adrenocorticotropic adenomas were most frequently associated with pain (n=34, 76%). Headache was equally frequent in patients with macro- and microadenomas (68 vs 60%; P=0.266). According to painDETECT, the majority of the patients had a nociceptive pain component (n=193, 80%). Despite high prevalence of headache, 72% reported little or no headache-related disability (MIDAS). Modifiable factors including tumour size, genetic predisposition, previous surgery, irradiation or medical therapy did not have significant impact neither on neuropathic pain components (painDETECT) nor on headache-related disability (MIDAS). Neuropathic pain and pain-related disability correlated significantly with depression and impaired QoL.

CONCLUSIONS

Pain appears to be a frequent problem in pituitary disease. The data suggest that pain should be integrated in the diagnostic and therapeutic work-up of patients with pituitary disease in order to treat them appropriately and improve their QoL.

First experiences with laparoscopic adjustable gastric banding (LAGB) in the treatment of patients with childhood craniopharyngioma and morbid obesity

Craniopharyngiomas are embryogenic malformations which lead to eating disorders and morbid obesity due to hypothalamic involvement in about 50% of all patients with pediatric craniopharyngioma. The experience with laparoscopic adjustable gastric banding (LAGB) in obese craniopharyngioma patients is limited. We are reporting on four patients with childhood craniopharyngioma diagnosed at age 2, 11, 12, and 21 years. BMI-SDS at diagnosis was +0.9, +4.5, +4.7 and -0.1 SD. During follow-up, all patients developed morbid obesity (BMI-SDS: +13.9, +10.3, +11.4, +7.3) so that 11, 6, 9 and 3 years after diagnosis LAGB were performed. After a follow-up of 4.5, 1.5, 3.0 and 2.5 years BMI decreased or stabilized continuously in all patients (BMI-SDS at latest visit: +9.9, +9.7, +9.5, +5.9 SD). The eating behavior changed in all patients profoundly. The addiction to food and especially sweets significantly improved based on self-assessment. In two patients a dislocation of the LAGB occurred and resulted in weight gain. We conclude that LAGB could be effective in weight reduction of obese craniopharyngioma patients with hypothalamic syndrome. Close follow-up is necessary in order to analyze long-term effects and complications of LAGB in patients with childhood craniopharyngioma and morbid obesity.

Comparative evaluation of a new bedside faecal occult blood test in a prospective multicentre study

BACKGROUND

Faecal occult blood testing is an established method of colorectal neoplasia screening. Guaiac-based tests are limited by poor patient compliance, low sensitivity, specificity and positive predictive value. Newer immunochemical-based tests, accurate but tedious, require a well-established laboratory set up. There is need for simpler immunochemical tests that can be performed at the out-patient clinic.

AIM

To compare the performance characteristics of a new bedside immunological test strip device with a sensitive Guaiac-based and established immunochemical test for detection of faecal occult blood in patients undergoing colonoscopy.

METHODS

A total of 389 consecutive patients from four centres who were referred for colonoscopy also provided the stool samples for detection of occult blood without dietary restrictions. Stool tests performed were (i) Guaiac-based, (ii) immunochemical enzyme-linked immunosorbent assay and (iii) bedside immunochemical strip test.

RESULTS

At the optimal threshold level, the sensitivity and specificity of the beside immunochemical strip test for detection of significant colorectal neoplasia (adenomas >1.0 cm and carcinomas) were 60% and 95%, respectively.

CONCLUSIONS

This bedside immunochemical strip test proved to be a simple, convenient, non-cumbersome and accurate tool with similar performance characteristics for detection of any bleeding lesion including colorectal neoplasia when compared with an established immunochemical faecal occult blood test.

Simplified microvascular suture techniques for rat liver transplantation as a microsurgical model with arterial blood supply

The methods for liver transplantation in the rat mainly used do not include reconstruction of the arterial blood supply to the liver. Furthermore, to ensure a short anhepatic phase these methods almost all entail specially developed cuff anastomoses in the recipient operation instead of the conventional microvascular suture technique. Thus an acceptable survival rate can be attained in the experimental animals. This detailed description of simplified microvascular suture techniques is intended to present an alternative to the cuff anastomoses used almost exclusively. In the donor operation with this method, the liver is dissected with an arterial pedicle including the abdominal segment of the aorta, and the liver is flushed in situ not only via the portal vein, but also via the hepatic artery. The organ is implanted in the recipient animal using simplified microvascular suture reconstruction of the arterial blood supply to the liver. Use of telescopic spectacles with 2-fold magnification has proven to be adequate for the entire procedure. With mastery of this method of rat liver transplantation, the average duration of the anhepatic phase is about 20 min, substantially below the 30-min limit which is critical for the survival of the experimental animals. The donor operation requires about 60 min, and the recipient operation 70 to 80 min. With this method, the spectrum of investigations on liver transplantation which are possible in the rat is substantially extended in that clinical conditions can be reproduced very much more exactly by combination of portal and arterial in-situ flushing in the donor operation and rearterialization of the transplant in the recipient operation, as compared to the transplanted rat liver being supplied only with portal venous blood.

[The MEDAN database: patients with abdominal septic shock]

Septic shock still has an unacceptable high mortality rate. To lowering this high mortality rate in the long run, we built a database that is unique in its data amount. Until now we have transferred 282 handwritten patient records into our database. Data were collected retrospectively from 1997 to 2001, based on voluntary cooperation of 62 hospitals. With the preprocessed data of our database we give mainly an epidemiologic overview and make first statistical evaluations. Thereby we noticed that some diagnoses and operations appear significantly higher for deceased patients than for survivors. At the end we discuss the future potential of the database.

Transoesophageal echocardiography shows high risk of gas embolism during laparoscopic hepatic resection under carbon dioxide pneumoperitoneum

BACKGROUND

The ultrasonically activated scalpel (UAS) enables safe and effective laparoscopic tissue dissection, making hepatic resection feasible. This study compared blood loss and risk of gas embolism using the UAS during open hepatic resection and laparoscopic hepatic resection.

METHODS

Female pigs were divided into two groups for laparoscopic (n = 7) and open (n = 5) left hepatic lobectomy. The UAS was used for both tissue cutting and coagulation. Laparoscopic liver resection was performed under carbon dioxide pneumoperitoneum (intraperitoneal pressure 12 mmHg). During surgery animals were monitored haemodynamically by an arterial line and Swan-Ganz catheter. Two-dimensional transoesophageal echocardiography (2D-TEE) was used to detect gas emboli with special attention to the right atrium and ventricle. Gas emboli were graded according to size, and correlated with haemodynamic and blood gas data.

RESULTS

During open and laparoscopic hepatic resection the UAS resulted in minimal blood loss and effective tissue dissection. No air embolism was seen during open surgery. With laparoscopic hepatic resection 2D-TEE revealed gas embolism in all animals. Gas embolism was accompanied by cardiac arrhythmia in four of seven animals. No direct correlation was observed between embolism episodes and blood gas variables. There were no deaths after episodes of embolization. A significant decrease in arterial partial pressure of oxygen was seen at the end of the laparoscopic procedure in all animals.

CONCLUSION

The UAS causes minimal blood loss during both open and laparoscopic hepatic resection. Laparoscopic liver dissection under carbon dioxide pneumoperitoneum carries a high risk of gas embolism.

Effect of fibrin glue occlusion of the hepatobiliary tract on thioacetamide-induced liver failure

BACKGROUND

Expression and activation of hepatocyte growth factor (HGF) is stimulated by a complex system of interacting proteins, with thrombin playing an initial role in this process. The impact of temporary occlusion of the hepatobiliary tract with fibrin glue (major component thrombin) on the HGF system in acute and chronic liver damage in a rat model was investigated.

METHODS

Chronic liver damage was induced in 40 rats by daily intraperitoneal application of thioacetamide (100 mg/kg) for 14 days. After 7 days half of them received an injection of 0.2 mL fibrin glue into the hepatobiliary system. Daily intraperitoneal administration of thioacetamide continued for 7 consecutive days. The rats were then sacrificed for blood and tissue analysis. Acute liver failure was induced in 12 rats by intraperitoneal administration of a lethal dose of thioacetamide (500 mg/kg per day for 3 days) after an injection with 0.2 mL fibrin glue into their hepatobiliary tract. Survival rates and histological outcome were investigated and compared with control animals.

RESULTS

Fibrin glue occluded rats showed significantly lower liver enzyme activities and serum levels of bilirubin, creatinine and urea nitrogen. Immunohistochemistry revealed a significant increase in c-met-, HGFalpha- and especially HGFbeta-positive cells. Rats subjected to a lethal dose of thioacetamide survived when fibrin glue was applied 24 hours prior to the toxic challenge. These animals showed normal liver structure and no clinical abnormalities.

CONCLUSION

Fibrin glue occlusion of the hepatobiliary tract induces therapeutic and prophylactic effects on chronic and acute liver failure by stimulating the HGF system. Therefore, fibrin glue occlusion might be useful in treating toxic liver failure.

Impact of cyclosporine and low-dose steroid therapy on insulin sensitivity and beta-cell function in patients with long-term liver grafts

To examine whether factors controlling glucose tolerance, i.e., insulin sensitivity (SI) and first-(phi1) and second-phase insulin secretion (phi2), are impaired in after orthotopic liver transplantation (OLT), they were assesssed in patients that had undergone OLT for cirrhosis (n = 10) with cyclosporin A and low-dose steroid therapy (5 mg prednisone per day) and were compared with those of healthy matched control subjects (n = 10). These factors were determined by means of computer-based analysis of frequently sampled intravenous glucose tolerance tests (FSIGTT). Glucose and insulin profiles (posthepatic insulin) did not differ between both groups, whereas C-peptide levels (prehepatic insulin) were elevated in the transplant group after the FSIGTT, indicating an increased hepatic insulin degradation. SI and (phi1 did not differ between both groups. phi2, however, was significantly enhanced (23.94 +/- 2.63 vs 13.88 +/- 1.25 min(-1), P < 0.05). These results indicate that cyclosporine and low-dose steroid therapy do not impair SI and phi1. However, enhanced phi2 compensates the increased hepatic insulin clearance.

Granulocyte-colony stimulating factor in the prevention of postoperative infectious complications and sub-optimal recovery from operation in patients with colorectal cancer and increased preoperative risk (ASA 3 and 4). Protocol of a controlled clinical trial developed by consensus of an international study group. Part three: individual patient, complication algorithm and quality manage

GENERAL DESIGN

Presentation of a new type of a study protocol for evaluation of the effectiveness of an immune modifier (rhG-CSF, filgrastim): prevention of postoperative infectious complications and of sub-optimal recovery from operation in patients with colorectal cancer and increased preoperative risk (ASA 3 and 4). A randomised, placebo controlled, double-blinded, single-centre study is performed at an University Hospital (n = 40 patients for each group). This part presents the course of the individual patient and a complication algorithm for the management of anastomotic leakage and quality management.

OBJECTIVE

In part three of the protocol, the three major sections include: The course of the individual patient using a comprehensive graphic display, including the perioperative period, hospital stay and post discharge outcome. A center based clinical practice guideline for the management of the most important postoperative complication--anastomotic leakage--including evidence based support for each step of the algorithm. Data management, ethics and organisational structure.

CONCLUSIONS

Future studies with immune modifiers will also fail if not better structured (reduction of variance) to achieve uniform patient management in a complex clinical scenario. This new type of a single-centre trial aims to reduce the gap between animal experiments and clinical trials or--if it fails--at least demonstrates new ways for explaining the failures.

[Robot-assisted laparoscopic cholecystectomy and fundoplication--initial experiences with the Da Vinci system]

We report on our first five robot-assisted laparoscopic cholecystectomies and one fundoplication (Da Vinci system). No postoperative complications were observed. For the cholecystectomies (three elective and two acute cases) mean operation time was 1 h 35 min, and mean hospital stay was 5 days; for fundoplication the operation time was 2 h 15 min. The main advantages seem to be improved visualization by using a stereo camera und ease of precise dissection by micromechanical instruments directed by masterslaves from a distant console. The main disadvantage is the high cost. To fully evaluate the benefit for the patient, prospective clinical trials are warranted.

[The SOFA score in evaluating septic illnesses. Correlations with the MOD and APACHE II score]

The SOFA score, a new system for patients with sepsis-related diseases, was introduced in 1994 by the "Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine." The purpose of this study was to compare the new SOFA score with the APACHE II and MOD scores. The data on 874 patients from a surgical intensive care unit in an university hospital were analyzed using commercially available software (SPSS for Windows, Version 7.5.2 and MS Excel '97). To compare the different scores, receiver-operating characteristics (ROC)--analyses were applied. The study demonstrated clear correlation between an elevated SOFA score and the mortality of the patients during their ICU stay (score 0-->mortality 0%, 1-->3.6%, 2-->22.5%, 3-->86.7%, respectively r = 0.445; P = 0.01). The ROC analyses of the APACHE II, the MOD and the SOFA scores were comparable (area under the curve: APACHE II 0.73, MOD 0.77, SOFA 0.71). In conclusion, the SOFA score is reliable and might be useful in the daily routine of an intensive care unit.

[Insular carcinoma of the thyroid: a differentiated thyroid carcinoma with poor prognosis]

Insular carcinoma of the thyroid is a low differentiated type constituting about 5% of all thyroid cancers. Higher aggressiveness has been suggested as an important clinical feature. The value of preoperative fine-needle aspiration biopsy is not clearly proven for insular carcinoma. The criteria for histological diagnosis have been outlined by Carcangiu et al. Because of its aggressiveness, radical treatment at primary surgery appears advisable. Its clear distinction from undifferentiated (anaplastic) and medullary (C cell) cancers is important, as thyroglobulin is regularly synthesized by cancer cells. Enrichment of radioactive iodine makes such treatment feasible postoperatively and at relapse. Follow-up should be performed as in highly differentiated papillary and follicular thyroid cancer. A patient series of eight cases is presented. While all cancers were advanced at the initial diagnosis, the observed disease courses were in agreement with the assumption that insular carcinoma is a more aggressive form of differentiated thyroid cancer.

Markov cohort simulation study reveals evidence for sex-based risk difference in intensive care unit patients

BACKGROUND

Despite great advances in intensive care medicine, sepsis still is the leading cause of death. Different strategies have been developed to file the patient data into scoring systems, primarily to predict the outcome. The Markov simulation-predominantly used in economic science to describe chains of events depending on and influencing each other-seems to be an interesting and new approach in analyzing the course of disease of critically ill patients in an intensive care unit (ICU). Using such a Markov model, this study analyzes data from 660 surgical ICU patients, 44 of whom died of sepsis.

METHODS

A three-state Markov model (integrating sepsis, adult respiratory distress syndrome, and mortality) was constructed to describe the course of disease of critically ill patients in defined cycles and to develop the risk profile of different groups of patients. The model enables the comparison between age- and sex-related survival rates and shows the difference in life expectancy compared with an average untreated standard population.

RESULTS

Women aged up to 30 years (G1F) show the best prognosis (mortality after 19 cycles 8.3%). On the contrary, the corresponding male group (G1M) demonstrates the worst outcome (mortality after 19 cycles 57.7 %).

CONCLUSIONS

The findings of this study fit into the current discussion that female patients are better positioned to meet the challenge of sepsis.

Hepatocyte growth factor effects on motility of stone-diseased and stone-free human gallbladders

Hepatocyte growth factor (HGF) has unique morphogenic activity for several cell types. Besides its major effect upon liver regeneration, its motogenic activity to enhance motility has not been verified for smooth muscles. Therefore we evaluated the impact of HGF in an in-vitro model of human gallbladder motility. Twelve stone-diseased and eight stone-free muscle strips were preincubated with HGF (100 ng/ml, 200 ng/ml). For the analysis of motility, cholecystokinin (CCK) was added (0.1 nM, 0.5 nM, 2 nM, 10 nM, and 100 nM). Twelve stone-diseased and eight stone-free strips without HGF incubation served as the control group. The tone of healthy (tone/100 nM CCK: control group, 12.4 +/- 3.6 mN; HGF group, 19.5 +/- 4.5 mN) and stone-diseased (tone/100 nM CCK: control group, 10.8 +/- 3.8 mN; HGF group, 17.3 +/- 4.8 mN) muscle strips, preincubated with HGF, was increased, with a higher sensitivity to CCK. Our results suggest that there is a clear motogenic response of stone-diseased human gallbladders to HGF.

Endothelin-induced contraction of the portal vein in cirrhosis

Endothelin (ET) is one of the most potent vasoconstrictors known so far. It has been proposed that the ET-induced contraction of hepatic stellate cells (Ito, endothelial cells) is an important mechanism for the development of portal hypertension. The purpose of this study was to investigate in an in vitro model whether ET causes a contraction of the portal vein which can contribute to portal hypertension in cirrhosis. Portal veins from normal and cirrhotic rats were used for experiments. Measurements were performed in vitro for cumulative concentrations of ET-1 and ET-3 (1, 5, 10, 50 and 100 nM). Both ETs caused a dose-dependent increase in portal venous tension; the maximal tension (Tmax) was measured at 50 nM. The measured Tmax was higher for cirrhotic (ET-1: Tmax = 189%; ET-3: Tmax = 175%) than for normal rats (ET-1: Tmax = 130%; ET-3: Tmax = 151%). ET-3 produced a higher tension of portal veins in normal rats than ET-1. In conclusion, this study shows that portal veins from cirrhotic rats react more sensitively to ET than those from normal rats. Besides the ET-induced contraction of hepatic stellate cells, contraction of the portal vein and its intrahepatic branches, especially in cirrhotic individuals, has to be considered as a further mechanism of ET contributing to portal hypertension.

Surgical strategies -- anastomosis or stoma, a second look -- when and why?

INTRODUCTION

The indication for performing a primary anastomosis or an intestinal stoma has to be confirmed or negated for every individual case of intestinal ischemia.

DISCUSSION

In right-sided colonic emergency, primary anastomosis is possible except when associated with generalized peritonitis. In left-sided colonic ischemia and necrosis, delayed anastomosis is the preferred alternative. In ischemia following surgery for abdominal aortic aneurysms, primary anastomosis is contraindicated. In ischemia of the small bowel, an end-to-end anastomosis should be established whenever possible.

CONCLUSION

In the case of intestinal ischemia, a second-look laparotomy is mandatory 24-48 h after initial surgery to ensure bowel viability. This second look should be performed regardless of the patient's postoperative clinical status. Laparoscopy has been successfully used for reexploration in intestinal ischemia, but one has to be aware of the present limitations of experience using this technique.

[Segmental anatomy of the liver--a sonomorphological viewpoint]

The liver is an ideal organ for ultrasonography. In this context, intrahepatic structures allow the identification of segments according to Couinaud by ultrasonography. This article describes, step by step, the ultrasonographic segmental anatomy of the liver.

Late results of heterotopic autotransplantation of splenic tissue into the greater omentum

There is still controversy about the beneficial effects of splenic autotransplantation. As a result, replantation of the spleen has almost been abandoned for surgical treatment of splenic injuries. To learn more about the long-term effects we have analyzed eight patients 9.2 +/- 1.2 years after autotransplantation of the spleen into the greater omentum. Splenic replants could be detected by scintigraphy in seven patients (87.5%). Splenic size, measured by single-photon emission computed tomography, varied between 19.344 and 471.705 units of volume (Uov). Two patients with the smallest replants had pathologic changes of leukocytes and lymphocyte subsets in 12 of 16 measurements (75%). These changes closely resembled a spleenless state and were similar to those in the patient with no detectable splenic autograft. In contrast, five patients with large splenic replants (49.192-471.705 UoV) revealed pathologic findings in only 2 of 40 measurements (5%). Based on an extensive review of the literature and our own results, it can be concluded that splenic autotransplantation into the greater omentum is superior to splenectomy but undoubtedly less effective than in situ preservation of the spleen. Therefore splenic replantation should still be considered, particularly in pediatric surgery, when in situ preservation of the spleen is not possible by other techniques.

Impairment of peroxisomal structure and function in rat liver allograft rejection: prevention by cyclosporine

BACKGROUND

During allograft rejection, cytokines and lipid mediators contribute to cell injury and organ failure. Peroxisomes play a crucial role in lipid metabolism, including the degradation of lipid mediators by peroxisomal beta-oxidation. Therefore, we investigated the alterations of hepatic peroxisomes after allogeneic rat liver transplantation.

METHODS

MHC-incompatible Dark Agouti (RT1a) donor rats and Lewis (RT1(1)) recipient rats were used for allogeneic transplantation. For immunosuppression, a group of these animals received cyclosporine (CsA) intraperitoneally (1 mg/kg body weight per day). Lewis rats were used for isogeneic transplant combination. Ten days after transplantation, livers were investigated using morphometrical methods for determination of peroxisomal diameter and volume density. The activities of peroxisomal catalase (CAT) and acyl-coenzyme A oxidase (AOX) were determined, and the corresponding proteins were evaluated by quantitative immunocytochemistry and immunoblotting. The expressions of mRNAs encoding CAT and AOX were investigated by Northern blotting.

RESULTS

The volume density and diameter of peroxisomes were significantly decreased in allogeneic transplanted livers but were unchanged in CsA-treated animals. Both the activities of CAT and AOX and their protein levels were significantly reduced in liver allografts. Moreover, the corresponding mRNA levels of CAT and AOX were decreased significantly in liver allografts, whereas CsA treatment led to an increase of those mRNAs. Isogeneic transplanted livers showed only a slight reduction of the corresponding enzyme values.

CONCLUSIONS

Peroxisomes are severely affected both morphologically and functionally after allogeneic liver transplantation. These results suggest that impairment of peroxisomal lipid beta-oxidation could contribute to the pathogenesis of the rejection process by decreased catabolism of lipid mediators involved in the regulation of the inflammatory response. CsA, in addition to its immunosuppressive effects, may contribute to allograft survival by maintenance of those important peroxisomal functions.

[Epidemiology of systemic inflammatory response syndrome, infection and septic shock in surgical intensive care patients]

This paper uses definitions of a consensus conference (ACCP/CCM) describing the epidemiology of SIRS, sepsis and septic shock in surgical ICU patients. During a period of 2 years a total of 656 patients were prospectively enrolled into the study. 335 patients (51.1% of the total population) developed SIRS (systemic inflammatory response syndrome); in 65 of these patients infection could be documented, i.e. they met the criteria of sepsis, 47 of these 65 septic patients developed septic shock, with mortality of 53.2%. SIRS is associated with a high sensitivity but a low specificity in predicting the outcome of ICU patients. Moreover, SIRS and sepsis appear to be of minor clinical relevance. On the contrary, septic shock describes a very high risk group of patients which should be characterized more closely in future studies.

Time course-dependent evolution of nitric oxide-mediated arterial hyporeactivity to phenylephrine in rats with ligated bile duct

BACKGROUND

Nitric oxide (NO) may be heavily involved the phenomenon of arterial vasodilation in cirrhosis. However, the subject is still controversial.

AIM

This study therefore characterizes the dynamic role of the NO system during development of experimental cirrhosis.

METHODS

The contractile response to phenylephrine of thoracic rat aortic rings was studied in vitro before and after nitric oxide blockade. Experiments were performed 1, 2, 3, and 4 weeks after induction of cirrhosis via bile duct ligation with an appropriate control group.

RESULTS

In bile duct-ligated rats reduction of the maximum contractile response to phenylephrine was 4.4 +/- 7.3% after 1 week, 22.7 +/- 8.7% after 2 weeks, 48.4 +/- 8.3% after 3 weeks, and 64.6 +/- 8.9% after 4 weeks, in comparison with the control group. This reduction in contractility to phenylephrine was completely reversed by blocking NO synthesis.

CONCLUSION

The data presented indicate a dynamic decrease in contractile response to phenylephrine even at an early stage of secondary cirrhosis. Reversibility of the effect after NO synthesis blockade suggests that increased NO synthesis is a major factor in vascular hyporeactivity to vasoconstrictors in cirrhosis.

[Individual prognosis of critically ill patients with septic shock by neural network?]

From 1. 11. 93 to 30. 3. 97, 1149 patients were prospectively studied during their ICU stay. Of them, 114 met the criteria of septic shock, with lethality of 47.3%. A neural network was trained with datasets from 91 of these 114 patients. Testing the trained neural network with the remaining 23 patients, the following result was obtained: all 10 patients dying from septic shock were correctly predicted; of 13 surviving patients, 12 were correctly identified (sensitivity 100%; specificity 92.3%).

[Incidence and prognosis of postoperative jaundice in surgical intensive care patients]

Jaundice in critically ill patients may be difficult to explain. This study analyzes pathophysiologically relevant data, and discusses the prognostic value of hyperbilirubinemia. A total of 1275 patients were prospectively enrolled; 7.6% developed hyperbilirubinemia of at least 2 mg/dl. Mortality in icteric patients was significantly higher (29%) than in the non-icteric group. Sepsis, shock and the number of blood transfusions are very important in hyperbilirubinemia. Nevertheless, in critically ill patients, jaundice per se is not a sign of poor outcome; indeed it only reflects the underlying disease.

[Nonadrenergic noncholinergic regulation of gallstone containing and gallstone free human gallbladders]

This study is to determine the role of nitric oxide (NO), as primary neurotransmitter of the non-adrenergic noncholinergic (NANC) innervation, of stone-diseased and stone-free human gallbladders. Human gallbladder muscle strips were mounted in modified Krebs-Henseleit-solution with atropine (1 microM), guanethidine sulf. (5 microM) and aerated with Carbogen. Electrical field stimulation (EFS, 70V, 0.5 ms, 100 pulses) was used at frequencies of 1, 3, 10 Hz to activate NANC nerves, L-omega-nitro-L-arginine (L-NNA, 100 microM), L-arginine (L-ARG, 120 microM) was used to manipulate the NO-synthase. Gallbladder slices of 3 microns were stained by means of APAAP-method (alkaline phosphatase anti alkaline phosphatase) for histological examination. In the control group (basal tone = 8.94 +/- 1.17 mN) EFS caused a frequency dependent reduction of basal tone (1 Hz = 5.73 +/- 0.81 mN; 3 Hz = 5.18 +/- 0.65 mN; 10 Hz = 4.63 +/- 0.49 mN). Incubation with L-NNA increased the tone (7.63 +/- 0.76 mN). Contractor group (basal tone = 7.79 +/- 0.93 mN) reacted like the control group but frequency independent and additionally with spontaneous phasic contractions. In the non-contractor group (basal tone 4.13 +/- 0.65 mN) EFS only decreased the frequency of spontaneous phasic contractions. L-NNA caused an increase in tone (5.97 +/- 0.84 mN) and frequency, L-Arginine significantly reversed this effect.

HISTOLOGY

Contractor group showed wrinkled mucosal membrane and mild grade of inflammation. Shallow mucosa, necrosis and high grade of inflammation were found in the non-contractor group.

CONCLUSIONS

1. In vitro, NANC-relaxation of human gallbladder is NO dependent. 2. Motility of stone-diseased gallbladders is modulated by NO and seems to depend on the degree of scarrification.

Local immunosuppression with budesonide after liver transplantation in the rat: a preliminary histomorphological analysis

BACKGROUND

In this study we have analyzed the local immunosuppression with budesonide, a topically selective glucocorticosteroid, in rats after orthotopic liver transplantation. Because of its high first-pass hepatic clearance budesonide can be given orally, achieving high intrahepatic and low systemic concentrations.

METHODS

Using an acute rejection model from Dark Agouti (DA) to Lewis rats, the histomorphological degree of rejection was assessed on histological sections at the ninth postoperative day.

RESULTS

Livers of the DA to Lewis study group without immunosuppression revealed severe allograft rejection with vast cellular infiltrates, massive endothelialitis, and hepatocyte necrosis. In the three budesonide study groups (250 microg, 500 microg, and 1 mg/kg/day) a moderate to mild liver allograft rejection was seen. Rejection was most prominent in the 250 microg group, whereas the 1 g group showed almost no signs of rejection, similar to the Lewis to Lewis control group. Aspartate and alanine transaminase (sGOT, sGPT) as well as alkaline phosphatase serum levels correlated with the degree of rejection, achieving highest levels in the DA to Lewis group without immunosuppression. Animals treated with 1 g of budesonide had serum levels similar to Lewis to Lewis control animals.

CONCLUSIONS

These results implicate a beneficial effect of local immunosuppression with budesonide in rats based on the histomorphological degree of liver allograft rejection.

[Etiology and clinical relevance of hyponatremia in general surgery intensive care patients]

For 1 year all patients in the Department of General Surgery who were transferred to the intensive care unit (n = 237) were prospectively studied as to the development of hyponatremia. Relevant hyponatremia developed in 6.3% of the patients. The lowest sodium concentration observed was 121 mmol/l, the mean duration was 1.2 days. In general, hyponatremia is related to hypovolemia and diuretics are often involved. In no patient were there any clinical consequences.

Significant increase of Kuppfer cells associated with loss of Na+,K+-ATPase activity in rat hepatic allograft rejection

BACKGROUND

Cholestasis is a complication that occurs during the rejection of liver transplants. The aim of this study was to investigate the association of activated Kupffer cells (KCs) and Na+,K+-ATPase activity for taurocholate cotransport and bile canalicular (BC) Mg++-ATPase activity for hepatobiliary excretion in rat liver allograft.

METHODS

Quantitative analyses of KC number and size in relationship to enzyme activity of Na+,K+-ATPase and of BC Mg++-ATPase were conducted in rejected liver after allogenic transplantation and after prevention of rejection using cyclosporine.

RESULTS

The animals were examined on the 10th postoperative day. In the rejection group, the number of KCs significantly increased more than fourfold in comparison with the number of KCs in the control livers. Some KCs were found in the sinusoids, but the majority were located in the space of Disse. Na+,K+-ATPase activity vanished from the basolateral plasma membrane, whereas BC Mg++-ATPase activity was restored in the apical domain. With immunosuppression, KCs showed the same behavior as in the control group, and activity of both ATPases was observed as strong electron-dense precipitates in basolateral and apical plasma membrane domains.

CONCLUSIONS

In this study, we demonstrate that activated KCs migrate into the donor liver and release cytokines, which leads to the loss of Na+,K+-ATPase activity in the rejection group. BC Mg++-ATPase activity was not influenced by these mediators of activated macrophages. Since Na+,K+-ATPase is the cotransporter for hepatocyte taurocholate uptake, these data may contribute to understanding the mechanisms for cholestasis during hepatic allograft rejection.