Helen Askitopoulou

Effects of Weight Loss on QT Interval in Morbidly Obese Patients

Background: Obesity causes structural changes to the heart that may influence its function. Furthermore, morbid obesity is associated with an acquired prolongation of the QTc interval that may lead to potentially hazardous arrhythmias. The present study investigated the effect of body weight loss following vertical banded gastroplasty (VBG) on the QTc interval. Methods: 17 morbidly obese patients, scheduled for elective VBG, were studied before the operation and 8-10 months postoperatively, when each patient had achieved a weight loss of ≥ 25% of the preoperative body weight. Results: 15 patients achieved significant body weight loss of ≥ 25% within the first 8-10 postoperative months (P <0.001).This weight loss, corresponding to an excess weight loss of 48.7% and a mean body mass index (BMI) reduction from 49.7 kg/m2 to 36.6 kg/m2, was followed by significant shortening of the QTc interval from 428 msec to 393 msec (P <0.001). Conclusions: The significant postoperative weight loss following VBG was accompanied by shortening of the QTc interval. This effect is expected to reduce the incidence of fatal conditions associated with the long QT syndrome, such as malignant ventricular arrhythmias and sudden death, and therefore improve morbidity and mortality.

Ethik der Reanimation und Entscheidungen am Lebensende

Der unerwartete Kreislaufstillstand stellt ein Ereignis dar, das haufig verheerende Folgen fur die betroffene Person, Fami-lie und Freunde mit sich bringt. Wahrend einige Wiederbelebungsversuche erfolg-reich mit einem guten Langzeit-Outcome einhergehen, trifft dies fur die Mehrzahl der Falle trotz groser Anstrengungen und einiger Verbesserungen in der Versorgung von Herz-Kreislauf-Patienten wahrend des letzten Jahrzehnts nicht zu.Professionelle Helfer sind verpflichtet, alles Notige zu tun, um Leben zu schut-zen und zu bewahren. Die Gesellschaft als Ganzes, besonders aber Rettungsdienst-personal, Krankenhauser und andere Ein-richtungen des Gesundheitswesens mus-sen fur den Fall des plotzlichen Kreislauf-stillstands geeignete Masnahmen planen, organisieren und anwenden. Damit sind meist der Einsatz vieler Ressourcen und hohe Kosten verbunden, v. a. in den wohl-habenderen Landern. Technische Neue-rungen, medizinische Evidenz und stei-gende Erwartungen der Offentlichkeit haben ethische Uberlegungen zu einem wichtigen Bestandteil jeglicher Interven-tion oder Entscheidung am Lebensende werden lassen. Dazu gehort, durch geeig-nete Allokation der verfugbaren Ressour-cen das bestmogliche Ergebnis fur den einzelnen Patienten, die Angehorigen und die gesamte Gesellschaft zu erzielen.Um sicherzustellen, dass Entschei-dungen, mit Wiederbelebungsversuchen zu beginnen oder nicht, angemessen sind und dass Patienten mit Wurde behandelt werden, bedarf es einiger Erwagungen. Derartige Entscheidungen sind komplex und konnen durch individuelle, internati-onal und lokal kulturelle, rechtliche, traditi-onelle, religiose, soziale und okonomische Faktoren beeinflusst werden [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]. Zuweilen konnen die Ent-schlusse im Voraus getroffen werden, aber haufig mussen diese schwierigen Entschei-dungen zum Zeitpunkt des Notfalls in-nerhalb von Sekunden oder Minuten fal-len, insbesondere im auserklinischen Be-reich aufgrund von begrenzten Informati-onen. Daher ist es wichtig, dass professio-nelle Helfer sich mit den zugrunde liegen-den Prinzipien vertraut machen, bevor sie in eine Situation geraten, in der eine Re-animationsentscheidung getroffen wer-den muss. Entscheidungen zum Lebens-ende und ethische Erwagungen sollen von professionellen Helfern also im Vorhinein und im jeweiligen gesellschaftlichen Kon-text erfolgen. Obwohl es nur wenige wis-senschaftliche Grundlagen gibt, die Anlei-tungen fur Entscheidungen am Lebensen-de bieten konnten, handelt es sich um ein wichtiges Thema. Daher wurden Informa-tionen fur professionelle Helfer in diese Re-animationsleitlinien aufgenommen.Diese Sektion der Leitlinien beschaf-tigt sich mit einigen wiederkehrenden ethischen Aspekten und Entscheidungen am Lebensende:F Ethische Grundprinzipien,F plotzlicher Kreislaufstillstand aus glo-baler Sicht,F Outcome und Prognosestellung,F wann Wiederbelebungsversuche be-ginnen und wann beenden,F Patientenverfugungen und Anwei-sungen zum „do not attempt resusci-tation“ (DNAR, d. h. kein Reanimati-onsversuch),F Anwesenheit von Familienangehori-gen wahrend der Reanimation,F Organbeschaffung,F Reanimationsforschung und infor-mierte Einwilligung sowieF Forschung und Ausbildung an gerade Verstorbenen.

Analgesia and anesthesia: etymology and literary history of related Greek words.

G reek is a particularly cultivated language and has been used to express and refine philosophical and scientific concepts for more than 30 centuries. It is not by chance that international scientific language has formed, and continues to form, many of its terms by borrowing Greek roots, words, or word parts (1). The ancient Greeks were preoccupied with what we now call the “theory of language.” Plato, in his dialogue Kratylus, examined the history of names and claimed that words, as names of things, were directly connected with the objects they indicated (2). If we learned the names of things, therefore, we could easily understand the things themselves, because the study of the language then formed the only method of scientific research and discovery (2). Today, the original meaning and use of current medical terms in ancient Greece is not widely known. In this article, the etymological, linguistic, and literary aspects of words of Greek origin, used in current anesthetic practice, are examined. The described words of Greek origin are presented in Table 1 with their Greek spelling, meaning, and etymology.

References to anesthesia, pain, and analgesia in the Hippocratic Collection.

The Hippocratic Collection, containing 60 medical texts by Hippocrates and his pupils, was searched using the electronic database Thesaurus Lingua Graeca to identify the words “anaesthesia” and “analgesia,” their derivatives and also words related to pain. Our purpose was to investigate the special use and meaning of these words and their significance in medical terms. The word “anaesthesia” appears 12 times in five Hippocratic texts to describe loss of sensation by a disease process. This observation reveals Hippocrates as the first Greek writer to use the word in a medical rather than a philosophical context. Hippocrates was also the first Greek physician to keep an airway open by bypassing a pharyngeal obstruction with the insertion of narrow tubes into the swollen throat of a patient with quinsy, thus facilitating the airflow into the lungs. In the Hippocratic texts, “analgesia” is related to “anaesthesia” for the first time, when it is pointed out that an unconscious patient is insensitive to pain. Hippocrates and his followers rationalized pain as a clinical variable and as a valuable diagnostic and prognostic tool. They used expressive and precise adjectives and well-defined characteristics of pain, such as location, duration, or relation to other symptoms, to elucidate a disease process. They also had a wide terminology for the various types of pain, still in use today. Many cures were described for the treatment of pain, including incisions, effusions, venesection, purges, cauterization and, most interestingly, the use of many plants, such as opium or the application of soporific substances. In particular, Hippocrates refers to opium poppy as “sleep inducing.”

Pain relief and sedation in Roman Byzantine texts: Mandragoras officinarum, Hyoscyamos niger and Atropa belladonna

Abstract Evidence on pain relief and sedation for surgical and medical purposes was traced in literary medical treatises from the Roman and Byzantine times (2nd century BC to 7th AD). Roman and Byzantine scientists, such as Dioscorides Pedanios, Gaius Plinius Secundus, Galen, Orivasios from Pergamum, Themistios, Aetios of Amida, Ioannes Damascenos and others, referred to Mandragoras officinarum, Hyoscyamos niger and Atropa belladonna as the most important herbs, besides the opium poppy, to be used for producing pain relief and sedation. From Galens time and until the Byzantine period, mandragoras was used in various mixtures with other herbs, but mostly with opium, as a sedative for surgical purposes. It was also prescribed, as an analgesic and emetic against miscellaneous diseases or ailments and as an antidote for snakebites. However, its frequent use was not recommended. The sedative properties of hyoscyamos and belladonna were also well known, these substances being among the main herbs used for sedation. The evolution of medicine noticed the lethal properties of these substances and allowed their use in more standardised doses in the form of poultices, decoctions, drops or inhalations either unadulterated or in mixtures.

Cranial trauma in ancient Greece: From Homer to classical authors

This article presents literary evidence on traumatic cranio-cerebral injuries in ancient Greece from about 900 B.C. to 100 B.C. The main sources of information are epic and classic Greek texts of that period. Homer provides the first literary source of head trauma, which he portrayed in his epic poems The Iliad and The Odyssey. He describes 41 injuries of the head, face and cervical spine, of which all but two were fatal. Subsequently, other classical authors like Plato, Plutarch and others illustrate cases of cranial trauma that occurred mainly in the battlefields, during athletic games or in unusual accidents. They describe some interesting cases of head trauma in prominent men, such as the poet Aeschylos, the kings Pyrrhos and Kyros and Alexander the Great. Most of these descriptions show that the ancient Greeks possessed very good knowledge of the anatomy of the head and neck region and also of the pathophysiological consequences of trauma in the region.

Ethik der Reanimation und Entscheidungen am Lebensende. Kapitel 11 der Leitlinien zur Reanimation 2015 des European Resuscitation Council

Der traditionelle medizinorientierte Ansatz mit seiner Betonung auf „Tue Gutes“ („beneficence“) hat sich verschoben in Richtung eines ausgewogenen patientenzentrierten Ansatzes mit größerem Gewicht auf der Autonomie des Patienten. Dies hat zu vermehrter Verständnisbereitschaft und Interaktion zwischen Patient und professionellem Helfer geführt. Zukünftige Leitlinien können aus der Beteiligung aller Interessengruppen Nutzen ziehen: Vertreter der Öffentlichkeit, Patienten, Überlebende und die Gesellschaft als aktive Partner beim Verständnis und der Umsetzung der ethischen Prinzipien. Inhalt und Umsetzung der traditionellen ethischen Prinzipien stehen im Kontext eines patientenbezogenen Ansatzes hinsichtlich der Reanimation: 5 Autonomie, einschließlich der Respektierung persönlicher Präferenzen, die in Patientenverfügungen ausgedrückt werden; dies impliziert eine korrekte Information und Kommunikation. 5 Fürsorge (Gutes tun – „beneficence“), einschließlich Prognosestellung, wann begonnen werden soll, Aussichtslosigkeit, Fortführung der CPR („cardiopulmonary resuscitation“ – kardiopulmonale Reanimation) während des Transports, besondere Situationen – mit klarer Unterscheidung zwischen plötzlichem Kreislaufstillstand und zu erwartendem Stillstand von kardialer Funktion und Atmung in terminalen Situationen. 5 Schadensvermeidung („non-maleficence“), einschließlich DNAR/ DNACPR-Anweisungen, wann beendet oder nicht begonnen werden soll, sowie Beteiligung des Patienten oder seines Vertreters. 5 Gerechtigkeit und gleicher Zugang, einschließlich der Vermeidung von Ungleichheiten.

Effect of the physical properties of isoflurane, sevoflurane, and desflurane on pulmonary resistance in a laboratory lung model.

Background:Airway resistance depends not only on an airway’s geometry but also on flow rate, and gas density and viscosity. A recent study showed that at clinically relevant concentrations, the mixtures of volatile agents with air and oxygen and oxygen–nitrogen affected the density of the mixture. The goal of the current study was to investigate the effect of different minimum alveolar concentrations (MACs) of three commonly used volatile agents, isoflurane, sevoflurane, and desflurane, on the measurements of airway resistance. Methods:A two-chamber fixed-resistance test lung was connected to an anesthesia machine using the volume control mode of ventilation. Pulmonary resistance was calculated at baseline (25% oxygen in air); at 1.0, 1.5, and 2.0 MAC; and also at the same concentrations, 1.2% and 4%, of isoflurane, sevoflurane, and desflurane mixtures with 25% oxygen in air. The analysis of variance test for repeated measures and probabilities for post hoc Tukey and least significant difference tests were used. Results:Isoflurane affected pulmonary resistance only at 2 MAC. Sevoflurane caused a significant increase of pulmonary resistance at 1.5 and 2 MAC, whereas desflurane caused the greatest increase in pulmonary resistance at all MAC values used. At 1.2% concentration, no difference from the baseline resistance was observed, whereas at 4%, the three agents produced similar increases of pulmonary resistance. Conclusion:High concentrations of volatile agents in 25% oxygen in air increased the density of the gas mixture and the calculated resistance of a test lung model with fixed resistance.

Archaeological evidence on the use of opium in the Minoan world

Abstract A wealth of prehistoric archaeological findings unearthed by archaeologists has brought forward a rich harvest of information about the use of opium poppy in the Minoan civilization. They reveal the widespread use of opium for cult rituals or healing purposes in the east Mediterranean and Crete at least since 5th century BC, when no written references existed. Poppy capsules ornamenting figurines, bas-reliefs, vases, pins and jewelry imply the multiple symbolic meanings of opium—healing, fertility, wealth and immortality. The Minoan “goddess of poppies, patronage of healing,” dated from 1300 BC, wearing in her head three hairpins of poppy capsules, is a distinct example of the knowledge in the Minoan world of the healing and soporific properties of opium and also of the methods of extracting it from the poppy capsule. The presence of opium poppy in different objects of everyday life like lekythia, rings, pyxis from Crete and Mycenae also suggests a long tradition of the use of opium byproducts in the ancient East Mediterranean.

Airway management in cervical spinal cord injured patients: a survey of European emergency physiciansʼ clinical practice

No European airway management guidelines are currently specific to patients with cervical spinal cord injury (CSCI). The objectives of this study were to determine the clinical practice of European emergency physicians and anaesthesiologists regarding airway management in patients with CSCI. A questionnaire survey was completed by the participants of the fourth European Congress on Emergency Medicine regarding the preferred intubation techniques and the relevant skills, as well as airway management manoeuvres that, in the physicians opinion, caused the least and the greatest cervical spine movement. A total of 115 questionnaires from physicians from 15 European countries were returned. The most preferred techniques for tracheal intubation in patients with CSCI were the use of direct laryngoscopy, awake nasal intubation with a fibreoptic bronchoscope, and the use of the intubating and standard laryngeal mask airway, in descending order. Not all emergency physicians were skilled in an alternative intubation technique to direct laryngoscopy, in contrast to the anaesthesiologists, who were all familiar with at least the standard laryngeal mask airway. More than half of the physicians considered that the fibreoptic bronchoscope provided the least cervical spine movement. However, most of the physicians who indicated the use of the fibreoptic bronchoscope as their preferred technique, were not skilled in its use. Furthermore, two-thirds of the respondents did not recognise that mask ventilation causes considerable cervical spine movement. Emergency physicians need better training in airway management to anticipate problems in patients with CSCI.