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Background: Predicting the exact extent of a breast tumor is of great importance for oncologic treatment strategies. Different types of elastography can be used as new tools for measuring lesion size.Purpose: To provide evidence regarding the accuracy of tumor size measurement of strain elastography (SE), two-dimensional (2D) and three-dimensional (3D) shear wave elastography (SWE), and conventional B-image ultrasound.Material and Methods: In this prospective study, the diameter of 105 malignant breast lesions was measured by SE, 2D and 3D SWE, and B-mode ultrasound. The histopathological lesion size was compared to all imaging-based measuring methods.Results: The mean lesion size of all breast carcinomas was 1.54 cm. B-mode ultrasound underestimates breast cancer size in 65.7 % of all cases in this study ( P < 0.0001). Mean lesion size was more accurately determined by SE, 2D and 3D SWE compared to B-mode ultrasound. Absolute differences between measured and actual lesion are smaller for B-mode ultrasound (0.26 cm) than for SE (0.41 cm) and 2D and 3D SWE (0.41 cm and 0.44 cm, respectively).Conclusion: B-mode ultrasound allows more accurate lesion size measurement than SE and 2D or 3D SWE but has a significantly higher risk of underestimating tumor size which could lead to incomplete margins during surgery. 3D SWE was not superior to 2D SWE or SE but by trend more precise in predicting the size of invasive lobular carcinoma. [ABSTRACT FROM AUTHOR]

Cocoa (Theobroma cacao) contributes significantly to Ghana’s GDP and has made Ghana a recognized leader in the cocoa industry. However, there are myriad problems associated with Ghana’s cocoa bean quality. One such problems stems from farmers paying less attention to the required postharvest activities (fermentation and drying) which contributes significantly to bean quality losses. This study investigated the effect of the duration of the traditional heap fermentation period and different drying methods: solar biomass hybrid dryer (SBHD) and traditional sun drying method (TSDM) on the bean quality of two cocoa varieties (hybrid cocoa and Amazonia). Quality attributes of cocoa beans such as pH, moisture content, fat content, crude protein, free fatty acids, phenolic contents, colour, and bean size were examined. The statgraphics statistical tool was used to analyse data and the least significant difference (LSD) was used to compare treatment means. Purple beans incidence was observed to be lower in hybrid with a value of 21.90% in the solar biomass hybrid dryer after 5 days of fermentation. Hybrid recorded the highest flavonoid value of 6069.74 mg QE/g DW in the traditional sun drying after 7 days of fermentation. Hybrid as well recorded the highest total phenolic value of 711.44 mg GAE/g DW in the solar biomass hybrid dryer under 5 days of fermentation. Results also indicated that using the solar biomass hybrid dryer resulted in the best moisture content removal and was very efficient compared with the traditional sun drying method in ensuring high-quality beans per international market standards. Cocoa beans dried under SBHD had the overall highest purity and were of better quality compared to those dried directly in the sun. There were no significant differences (p≤0.24) in percentage purity among the cocoa samples studied.

Alongside mammography, breast ultrasound is an important and well-established method in assessment of breast lesions. With the "Best Practice Guideline", the DEGUM Breast Ultrasound (in German, "Mammasonografie") working group, intends to describe the additional and optional application modalities for the diagnostic confirmation of breast findings and to express DEGUM recommendations in this Part II, in addition to the current dignity criteria and assessment categories published in Part I, in order to facilitate the differential diagnosis of ambiguous lesions.The present "Best Practice Guideline" has set itself the goal of meeting the requirements for quality assurance and ensuring quality-controlled performance of breast ultrasound. The most important aspects of quality assurance are explained in this Part II of the Best Practice Guideline., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose:  The aim of the present study was to determine the accuracy of breast cancer measurement with 2 D shear wave elastography (2 D SWE), B-mode ultrasound, and mammography by comparing these methods with the actual histopathological tumor size., Materials and Methods:  135 patients with proven malignant breast lesions at two centers were included in a prospective study. The maximum lesion diameter was measured by 2 D SWE, B-mode ultrasound, and mammography. After surgery, the histopathological tumor size was measured by a pathologist., Results:  The mean difference in tumor size on 2 D SWE, B-mode ultrasound, and mammography on the one hand, and the actual tumor size on the other, was -0.03 cm, 0.16 cm and 0.10 cm, respectively. Lesion size on histopathological investigation was overestimated by 2 D SWE (p = 0.004) and underestimated by B-mode imaging (p < 0.001). All three imaging methods underestimated the size of invasive lobular cancers and lesions > 15 mm; 2 D SWE was most accurate in this regard., Conclusion:  2 D SWE predicted lesion size more precisely than B-mode ultrasound or mammography. In cases of invasive lobular carcinoma, all three imaging methods underestimated lesion size, with 2 D SWE coming closest to the actual tumor size., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

The analysis of heart rate (HR) variability offers a noninvasive method to investigate autonomic nervous system activity in comatose patients. We analyzed three components of the HR variability in a group of comatose patients: the low-frequency band (LF), representing mainly sympathetic influence, the mid-frequency band (MF), representing sympathetic and parasympathetic influence, and the high-frequency band (HF), representing the parasympathetic influence. A value for sympathovagal balance was defined as LF/HF and MF/HF ratio. Moreover, the skin conductance level (SCL) and the skin conductance resistance (SCR) variability were recorded. The patient group consisted of 22 patients with traumatic brain injuries. Coma depth was assessed by the Glacow Coma Scale and artifact-free HR, SCL, and SCR were measured 75 times in the patient group. The results documented a significant gain in sympathetic nervous system activity corresponding with the state of emerging from coma. This gain was most pronounced in the HF component of the HR and in the sympathovagal balance between LF/HF. The findings in SCL and SCR variability endorsed this result. It is concluded that emerging from coma is accompanied by an increasing influence of the sympathetic nervous system on HR control. This leads to a change in the sympathovagal balance, i.e., a reintegration of parasympathetic and sympathetic activity.

Unlabelled: Spinal anaesthesia for outpatients is a method that is not favoured in several reports without having representative data. It was our desire to investigate whether this method could be used without having dangerous side effects., Method: After knee arthroscopy in spinal anaesthesia, patients received a questionnaire. The questions could be answered anonymously in a "yes-no" fashion. Additionally, the patients received an accompanying explanation concerning the so-called health-structure law., Results: Of a total of 85 patients; 70 sent back the questionnaire. Temporary neck stiffness was seen in 1 case, hypotension in 5, nausea in 2, emesis in 5, and fever in 3. Twelve patients had headaches, 67 were in good condition upon leaving the clinic. Sixty-four would prefer spinal anaesthesia for a subsequent similar procedure. Nine patients treated themselves at home, which is not permitted in outpatient procedures; 7 of these had headaches that may have been secondary to the dural puncture. No severe side effects were seen., Conclusions: 1. Spinal anaesthesia is a method that can also be performed in out-patients. 2. an increased incidence of post-dural-puncture headaches may be seen due to the early mobilisation of the patients; 3. the patient must be treated by a second person; 4. premedication must be performed 2 days before the procedure to determine ASA status; and 5.better co-operation between surgeons and anaesthesiologists must be sought.

We report an oesophageal foreign body in a patient with a seizure disorder secondary to encephalitis disseminata who was transferred to our department of neurosurgery because of rising intracranial pressure. He presented with confusion, motor aphasia, and dysphagia. However, the diagnosis of increased intracranial pressure could not be confirmed clinically or by computed tomography. A routine chest X-ray film showed a dental prosthesis projecting on the area of the hypopharynx. Bronchoscopy and oesophagoscopy showed the denture to be lodged in the hypopharynx, but it was impossible to remove it endoscopically. Therefore, an oesophagopharyngotomy was performed and the foreign body extracted. The postoperative course was complicated by pneumonia, which responded well to antibiotic treatment. The patient made an otherwise uneventful recovery and was able to eat without difficulty.

The combination of two rare complications in intensive care caused an acute life-threatening situation. Following puncture of the left subclavian vein a pneumothorax developed over the course of a couple of days. The inserted thoracic drain dislocated into the subcutaneous tissue. During the induction of anaesthesia and controlled ventilation a tension pneumothorax developed. A decrease in oxygen saturation and an increase in the ventilation pressure led first to the diagnosis "malposition of the double lumen endotracheal tube", but its correct position could be confirmed by bronchoscopy. Finally, the tension pneumothorax was diagnosed by x-ray of the chest. This life-threatening situation could be treated by the insertion of a thoracic drain. The operation could be performed without any problems.

Necrotizing fasciitis and myositis due to Lancefield group A beta-haemolytic streptococcal infection is a medical emergency. Survival depends on aggressive early wound management as well as high-dose intravenous antibiotics. We report about a 28-year-old man with fulminant necrotizing fasciitis and myositis of his right arm, in whom many features of the toxic shock syndrome were present, including profound hypotension and renal failure. After extensive surgical debridement with amputation of his arm in combination with high-dose intravenous penicillin G the patient recovered from this serious infection.

This study looks at the question of whether anaesthetic gases are sufficiently moistened in a semi-closed system by the partial recycling of expired air with simultaneous absorption of CO2. During the inspiration phase only a maximum of 42% relative humidity at a temperature of 24.8 degrees C was reached. These values lie far below the demands of the American National Standard Institute (ANSI) of 70% relative humidity at 30 degrees C. When various heat and moisture exchangers were used, the relative humidity improved to 99% at a maximum temperature of 30.3 degrees C (HME Edith; Engström Corporation). The maximum values of the BB 12-15, Pall Corporation, and SH 150 from Siemens were slightly lower. A marked fall was noticed when using the Humid Vent I of the Medimex Corporation, especially in the initial phase. An improved version, the Humid Vent II, has been produced. Physiological values (37 degrees C, 100% relative humidity) are not achieved by any heat and moisture exchangers. This problem could possibly be solved by using infra-red light when warming the gases.

Heart transplantation was performed in a 24-year-old man suffering from dilated cardiomyopathy who was also infected with hepatitis B virus and had not yet seroconverted. Most likely due to the immunosuppression, the hepatitis exacerbated and soon led to hepatic dystrophy and precoma. In this phase of congruent rejection of the heart transplant, liver transplantation was performed. During the procedure the patient had stable circulatory parameters and a reduced cardiac output. The heart rate and cardiac output stabilized after release of the anastomosis of the hepatic vessels. The patient survived for 6 months and died at home with signs of a myocardial infarction.

Recording of cavernous electric activity was performed in 178 patients with erectile dysfunction and in 37 normal patients. In 34/37 normal patients, potentials of a uniform shape were recorded during flaccidity: At cut-off frequencies of 0.5-500 Hz, the length was 8-18 (mean 12.8, SD 2.8), the amplitude 250-750 (mean 444, SD 109) microV, and the polyphasity 8-22 (mean 13.8, SD 3.3). In impotent patients with upper motor neuron lesions or peripheral lesions, specific types of potentials were observed. In 11/14 impotent patients with insulin-dependent diabetes for over 20 years and clinical findings of cavernous myopathy, potentials showed low amplitude, irregular shape, and slow depolarizations. In 51% of the consecutive impotent patients, abnormal findings of cavernous electric activity were recorded. Our clinical study suggests that single potential analysis of cavernous electric activity (SPACE) may be useful in the diagnosis of cavernous autonomic neuropathy and cavernous smooth muscle myopathy.

In a small study (n = 9) central venous catheters were positioned in front of the right atrium using ECG. ECG was registered using a soft J-wire inside of the catheter. Big vessels were cannulated and in all cases cannulation was successful. ECG and x-ray control showed good agreement.

Liver transplantation opens the view on the border lines of medicine. Its performance requires great surgical and anaesthesiological experiences. Based on the authors' own experience the selection of liver donors and the indications for liver transplantations are pointed out. Special pathophysiological aspects of liver transplantation as well as the anaesthesiological procedure and the intensive care in the early postoperative period are described. The results of liver transplantation can be improved by further research on preservation of explanted organs, early recognition of complications after transplantation and immunological suppression.

Diazepam (0.21 mg/kg; group 1) and midazolam (0.03 mg/kg; group 2) was applied for sedation in two groups of urological patients (n = 10 in each) requiring transurethral resection (urine bladder, prostata) using spinal or peridural anaesthesia. Before anaesthetic procedure, 500 ml hydroxyethyl starch were administered for precluding severe vascular depression. Patients receiving midazolam began to sleep within one minute. Heart rate dropped in both groups after injection of both benzodiazepines which was considered a physiological sleeping effect. No hypotensive reactions were registered. Using this therapy maximum PaO2 values of 14.9 kPa in group 1 (diazepam) were registered and of 14.0 kPa in group 2 (midazolam). During the operation all patients were arousable. Side-effects such as nausea, vomiting and confusion were not observed.

A female of 17 years with a brain-damage was short-term respirated within the operation. After this procedure tracheotomia was performed for long term respiration. Fourteen months after the accident a synechia of the vocal cord was seen which caused impossibility of intubation. The reason for this synechia may be granuloma after tracheotomia with accompanying dysarthria of the vocal cord and reduced movement.

Among a total of 1038 operations for early and advanced gastric cancer, 257 patients were older than 70 years. The resection rate in this group was 64.2%, 95 subtotal and 70 total gastrectomies were performed. Postoperative complications were caused primarily by concomitant respiratory and cardiac diseases, whereas the overall operative mortality amounted to 16.9%. Depending on the stage of tumour development a 5-year survival rate of 17.7% could be obtained. This rate increased to 27.2% after subtotal or total gastrectomies. The choice of surgical procedures for gastric cancer does not show any principal differences between young and old persons; thus, the use of individual and liberal criteria for total gastrectomy can be justified even in the aged.

After breaking through thin ice, a 4-year-old boy drowned in a lake. A quickly alerted rescue helicopter found and recovered the child, drifting underneath the clear, thin ice. Primary resuscitation by the helicopter crew was unsuccessful. Upon arrival in the hospital the child had fixed, dilated pupils and asystole. Core temperature was 19.8 degrees C. Rewarming was conducted slowly while cardiopulmonary resuscitation was continued. Twenty minutes after arrival at the hospital, ventricular complexes appeared in the ECG (temperature 22.1 degrees C); after another 10 min this converted to sinus rhythm. At short intervals, blood gas analyses and electrolyte determinations were carried out and corrected adequately. For cerebral protection methohexital was given and the child was hyperventilated. Seventy minutes after arrival at the hospital the child was brought to the pediatric ICU with stable circulation. There, further rewarming (centrally/peripherally combined) was carried out, aiming at 1 degree C rewarming per hour until a normal temperature was reached. The patient had to be kept on the ventilator for 10 days and after another 2 weeks was discharged home. He had recovered completely without any cerebral damage. One of the reasons why 88 min of cardiac arrest were tolerated by this patient without sequelae may have been rapid and deep hypothermia.

In a case of epidural application of buprenorphinehydrochloride a reduction of arterial pO2 was seen 4-6 hours after the injection. This cannot be explained as a respiratory depression due to buprenorphine, because immediately after a repeat epidural application of the drug the pO2 rose again. Reduced pO2 a long time after buprenorphine is a a result of hypoventilation caused by increased pain.

A method is described for fixing a central-vein-catheter, during insertion when the envelope is withdrawn, so as to render the procedure more sterile.

The report concerns initial experience with local anesthesia in the treatment of urolithiasis by extracorporeal shock wave lithotripsy. This form of anesthesia is well tolerated for stones of limited size and hardness, though the patients must be carefully selected.

Animal experiments have shown bicarbone to be a suitable material for alloplastic tracheal replacement. So far survival rates have been limited by connective tissue stenoses and by loosening prostheses. Although the transplants are not lined by bronchial mucosa, the movement of secretions is not seriously impaired due to the smooth surface. It is still a matter of speculation as to whether modifying the suture technique with a more elastic transistion from the trachea to the prosthesis would produce better results.

In previous study it was demonstrated that the clinical use of bupivacaine 0.75% for peridural anesthesia appears to be without risk. There was seen no toxicity (bradycardia, convulsion, respiratory depression etc) at the measured plasma levels. Very important is the early onset of action of this drug contrary to the other used concentrations. It is useful for a major surgery. Hypotension can be avoided by applying volume transfusion.

In two patient groups undergoing coronary surgery (n = 10) hemodynamic side effects of mexiletine and lidocaine were investigated. Changes of clinical importance were seen in cardiac-output, stroke volume, total peripheral resistance, triple- and cardiac index. There are significant differences 10, 15, and 30 min after application (p less than 0.05; p less than 0.025) in cardiac-index.

Ten urological patients with spinal anesthesia were sedated with midazolam 0.03 mg/kg i.v. A similar group (n = 10) was given placebo instead of midazolam (2 ml 0.9% NaCl). Patients who received midazolam slept lightly but were rousable. During the operation 2 l/min oxygen was administered via a nasal cannula; pO2 and pCO2 remained within normal limits throughout the procedure. No cardiovascular side effects such as hypotension or other reaction such as vomiting, nausea, or confusion were observed after midazolam. At the end of the operation all patients were fully awake and cooperative.

In some critically ill patients respiratory can be maintained by high frequency jet ventilation. Gas exchange and transport by this method cannot be explained exactly up to date. Therefore it is impossible to compare this method with classical IPPV. Statistics and nomograms must be prepared for common clinical use.