Notfallbehandlung instabiler Beckenfrakturen - Stellenwert der „Beckenzwinge”

It was the objective of this investigation to describe the results after stabilisation of pelvic fractures with the pelvic clamp in polytraumatized patients with unstable pelvic ring fractures.

PATIENTS

Between 1999 and 2001 11 polytraumatized patients with an average age of 38 years with unstable fractures of the pelvic ring were treated with the "pelvic clamp" (PC).

METHOD

The patient's data were analysed retrospectively from the moment they were admitted to our department until 48 hours after the treatment with the pelvic clamp. The following data were observed: -- The time period until the pelvic clamp was placed. -- The mean blood pressure. -- The oxygenation level (PaO (2)/FiO (2) coefficient). -- The number of requested blood units. -- The time period until hemodynamic stabilisation took place.

RESULTS

8 patients survived their injuries. 5 of them were admitted primarily to our department (ISS 39.8, PTS 35), the other 3 were secondarily admitted to our department (ISS 48.3, PTS 39). 3 of 11 patients (27 %) died averaged within the first 45 minutes after admittance. They also were treated in other units before admittance to our department. 8 surviving patients showed -- a hemodynamic stabilisation 6 hours after the treatment with the PC. -- an increase of the mean blood pressure about 25 % 20 minutes after the treatment with the PC. -- a stabilisation of the oxygenation level 6 hours after the treatment with the PC. -- a decrease of the number of requested blood units 6 hours after treatment with the PC.

CONCLUSION

Even if the number of patients who were treated is small, the study shows a positive trend in terms of stabilisation of the vital parameters after stabilisation of the pelvic fracture with the pelvic clamp.

Inhibition of adenovirus infection by the bronchoalveolar lavage supernatant in vitro

BACKGROUND

Gene transfer using the adenovirus has been discouraging, since the level of recombinant gene expression was always low. Non-specific and specific immune responses prevent infection or kill infected cells. Most of the specific immune responses against the adenovirus are well known and can be eluded at least in animal models. The non-specific immune response is not so well investigated. We have previously demonstrated a strong anti-adenoviral effect of bronchoalveolar lavage (BAL) supernatants of different patients independent of their content of specific anti-adenoviral immunoglobulins of the subclasses IgA, IgG, and IgM. In this paper we examine the influence of defensins and immunoglobulins within the epithelial lining fluid of the lung on the infection of adenovirus type 5.

METHODS

Pooled BAL supernatants were separated by gelchromatography; IgA and IgG, respectively were removed from the BAL supernatants by anti-IgA- and anti-IgG affinity chromatography.

RESULTS

The anti-adenoviral capacity could be assigned to the high molecular weight portion including the immunoglobulin- and at a much lower degree the albumin-fractions. All fractions from affinity chromatography; the IgA fraction, the resulting BAL depleted from IgA, the IgG fraction, and the resulting BAL depleted from IgG were highly inhibitory on adenoviral infectivity.

CONCLUSION

The main anti-adenoviral component in BAL is part of a high molecular weight complex, either being a large protein itself, or being a small peptide bound unspecifically to different bigger proteins. Defensins are not important factors of anti-adenoviral infectivity in the epithelial linig fluid of our patients.

Addition of the Oral NK1 Antagonist Aprepitant to Standard Antiemetics Provides Protection Against Nausea and Vomiting During Multiple Cycles of Cisplatin-Based Chemotherapy

Purpose: This analysis evaluated whether the antiemetic efficacy of the NK1 receptor antagonist aprepitant (EMEND™, Merck, Whitehouse Station, NJ) plus standard antiemetics could be sustained for up to six cycles of cisplatin-based chemotherapy.

Patients and Methods: Patients receiving cisplatin ≥ 70 mg/m2 were blindly assigned to receive one of the following three regimens: (1) aprepitant 375 mg 1 hour before cisplatin on day 1 and aprepitant 250 mg on days 2 to 5 (n = 35); (2) aprepitant 125 mg before cisplatin and aprepitant 80 mg on days 2 to 5 (n = 81); or (3) placebo before cisplatin on days 2 to 5 (n = 86). All groups received ondansetron 32 mg and dexamethasone 20 mg before cisplatin, and dexamethasone 8 mg on days 2 to 5. The primary end point was complete response (no emesis and no rescue therapy) over 5 days following cisplatin in up to six cycles. A cumulative probability analysis using a model for transitional probabilities was used to analyze the data. The aprepitant 375/250-mg regimen was discontinued early in light of new pharmacokinetic data.

Results: In the first cycle, 64% of patients in the aprepitant group and 49% in the standard therapy group had a complete response. Thereafter, complete response rates for the aprepitant group were still 59% by cycle 6, but decreased to 34% by cycle 6 for the standard therapy group. Reasons for discontinuation were similar across treatment groups.

Conclusion: Compared with patients who received standard therapy, those who received only the aprepitant regimen had better and more sustained protection against chemotherapy-induced nausea and vomiting over multiple cycles.

Pregnancy-induced changes in substance P and neurokinin 1 receptor (NK1-R) expression in the rat uterus

Adrenergic nerve fibres of the mammalian uterus degenerate during pregnancy. The behaviour of peptidergic fibres, such as substance P-positive fibres and of its preferred neurokinin 1 receptor (NK1-R), is poorly studied in the pregnant rat uterus. The present study analysed the changes in substance P immunoreactivity and in the expression of NK1-R protein in the uterus of non-pregnant, pregnant (days 7, 14 and 21) and postpartum rats (days 1, 8 and 22) by immunohistology, dot blot analysis and western blot analysis. In non-pregnant rats, substance P-positive fibres were localized to the myometrium; these fibres progressively disappeared during gestation and were almost absent at term (day 21). At day 22 post partum, substance P-positive fibres had recovered to numbers comparable with those in the non-pregnant uterus. Dot blot analysis revealed a significant decrease in the immunoreactivity of substance P in the uterus at mid-pregnancy (day 14) and especially at term. Expression of the NK1-R protein showed a progressive increase throughout pregnancy reaching a peak on day 1 post partum; downregulation of NK1-R protein occurred on day 8 post partum. The low and high expressions of NK1-R protein were coincident with a large number of eosinophils and almost no eosinophils in the uterus at oestrus and at term, respectively. It was concluded that substance P immunoreactivity is inversely correlated with NK1-R protein expression in the pregnant and postpartum uterus. The marked upregulation of NK1-R protein at term and after birth indicates that the NK1-R may be involved in the complex regulation of labour and postpartum physiology. However, it is likely that the NK1-protein is not involved in the recruitment of eosinophils into the uterus at oestrus.

IL-6 and PGE2 release by human osteoblasts on implant materials

Regarding orthopaedic implant loosening it has been hypothesized that particle-activated macrophages release interleukin-1 (IL-1) and tumor necrosis factor-alpha (TNF-alpha). This in turn stimulates osteoblasts to release interleukin-6 (IL-6) and prostaglandin E(2) (PGE(2)). These mediators recruit and activate osteoclasts and may therefore lead to bone resorption and loss of implant fixation. In this study we compared the ability of different materials to induce the release of IL-6 and PGE(2) from primary isolated, human osteoblasts without preceding activation by macrophages. We tested stainless steel, cobalt-chromium alloy (CoCrMo), commercially pure titanium (cpTi), Ti-6Al-7Nb and Ti-6Al-4V processed in the same manner as corresponding clinical implants. After 12 and 24h the cells had actively secreted IL-6 and PGE(2). There were no clear differences among the implant materials or with the plastic control. The amount of factors the cells released in our study compare well with the findings of other authors who investigated osteoblasts on plastic. In comparison with the literature these amounts are lower than secretion levels of osteoblasts stimulated with implant particles, IL-1 or TNF-alpha. Moreover, other authors found that osteoclasts require higher concentrations of PGE(2) to become activated than the concentrations measured in our experiments. Therefore, the amount of PGE(2) released from the osteoblasts in our study is probably not sufficient to induce osteolytic activity. Because of contradictory statements in the literature it is unclear if the measured IL-6 concentrations promote osteolytic activity. Differences in material composition does not significantly influence the release of these factors if the materials have similar surface roughnesses.

[Radiology in managed care environment: opportunities for cost savings in an HMO]

PURPOSE

A large regional health plan in the Northeastern United States noted that its radiology costs were increasing more than it anticipated in its pricing, and noted further that other similar health plans in markets with high managed care penetration had significantly lower expenses for radiology services. This study describes the potential areas of improvement and managed care techniques that were implemented to reduce costs and reform processes.

MATERIALS AND METHODS

We performed an in-depth analysis of financial data, claims logic, contracting with provider units and conducted interviews with employees, to identify potential areas of improvement and cost reduction. A detailed market analysis of the environment, competitors and vendors was accompanied by extensive literature, Internet and Medline search for comparable projects. All data were docu-mented in Microsoft Excel(R) and analyzed by non-parametric tests using SPSS(R) 8.0 (Statistical Package for the Social Sciences) for Windows(R).

RESULTS

The main factors driving the cost increases in radiology were divided into those internal or external to the HMO. Among the internal factors, the claims logic was allowing overpayment due to limitations of the IT system. Risk arrangements between insurer and provider units (PU) as well as the extent of provider unit management and administration showed a significant correlation with financial performance in terms of variance from budget. Among the external factors, shared risk arrangements between HMO and provider unit were associated with more efficient radiology utilization and overall improvement in financial performance. PU with full-time management had significantly less variance from their budget than those without. Finally, physicians with imaging equipment in their offices ordered up to 4 to 5 times more imaging procedures than physicians who did not perform imaging studies themselves.

CONCLUSION

We identified initiatives with estimated potential savings of approximately $ 5.5 million. Some of these initiatives are similar to the reforms to reduce cost and improve quality that are already implemented or proposed within the German healthcare system.

[How are interstitial lung diseases diagnosed in Germany? Results of the scientific registry for the exploration of interstitial lung diseases ("Fibrosis registry") of the WATL]

From 1995 to 1999 we evaluated questionnaires sent by pulmonologists and departments of pulmonology in order to register interstitial lung diseases. On the whole 1142 patients (579 males, 563 females, mean age 51.1 +/- 15.3 years, sarcoidosis, n = 511, extrinsic allergic alveolitis, n = 145, idiopathic pulmonary fibrosis, n = 308, bronchiolitis obliterans organizing pneumonia (BOOP), n = 93, others, n = 85) were recorded in the registry. With reference to the mean age sarcoidosis occurred most frequently in the fourth decade and idiopathic pulmonary fibrosis in the sixth decade. In all these diseases bronchoscopy with bronchoalveolar lavage and transbronchial biopsy was predominantly used for further diagnosis. It was striking that high-resolution computed tomography of the thorax was still rarely used when diagnosing these diseases. Apart from the group with BOOP the number of non-smokers in men and women was decisively higher than the average of the population of Germany.

Functional relevance of antiemetic control. Experience using the FLIE questionnaire in a randomised study of the NK-1 antagonist aprepitant

Little information exists on the functional impact of effective antiemetic protection. In the present study, the Functional Living Index-Emesis (FLIE), was used to assess patient-reported impact of chemotherapy-induced nausea and vomiting (CINV) after administration of a new NK-1 receptor antagonist (aprepitant). Cisplatin-treated patients in a double-blind randomised trial received either aprepitant+dexamethasone+ondansetron on day 1 and aprepitant+dexamethasone on days 2-5 or standard antiemetic therapy (dexamethasone and ondansetron on day 1 and dexamethasone on days 2-5). Emetic events, nausea ratings and rescue medications were recorded in a 5-day diary and the FLIE was completed on day 6. Compared with standard therapy, significantly more patients treated with the high dose aprepitant regimen achieved a Complete Response (71 vs 44%, P<0.001) and also reported no impact on daily life as indicated by the FLIE total score (84 vs 66%, P<0.01). Use of the FLIE demonstrated that improved control of emesis was highly effective in reducing the impact of CINV on patients' daily lives.

[Acute myocardial infarction in premenopausal women]

Prospective, systematic studies of the pathophysiology and prognosis of premenopausal women vs young men who suffer an acute myocardial infarction (MI) and are treated with direct angioplasty are scarce.

METHODS AND RESULTS

A total of 782 consecutive and unselected patients who presented with an acute ST-elevation MI within 12 h of symptom onset underwent immediate angiography to guide direct angioplasty. Using this therapeutic approach clinical characteristics, angiographic observations, and short- and long-term prognosis were analyzed in a sub-group of 31 premenopausal women and compared to 192 young men with acute MI. Premenopausal women account for 4% of individuals with acute MI and for 15% (31/205) of all women. Men of the same age range make up 25% (192/782) of all MI patients (p<0.001). Three or more classic risk factors were present in 20/31 women. Young women presented later than men. Angiography demonstrated a coronary occlusion in 27/31 women (88%) but in 98% of young men (p<0.02). Direct PTCA was successful in all premenopausal women and in 179/185 men (97%, p=ns). Predischarge EF was 57% in women and 54% in men (p=ns). After 4 years of follow-up, all women had survived as compared to a 95% survival in young men. Major cardiac events had occurred in 50% of persons of either gender.

CONCLUSION

Premenopausal women account for 4% of individuals and for 1/6 of all female patients who presented with acute MI within 12 h of onset. Hospital admittance is delayed in young women. MI was caused by (atherosclerotic) coronary occlusion in most young women and in virtually all young men. Short- and long-term survival of premenopausal women is favorable after direct PTCA for acute MI and not different than men from the same age group.

[Quality management in surgery--an overview of methods and possibilities]

Numerous methods of assessing quality in health care have been presented over the last years. Since the German health care reform of 2000 introduced a legal obligation to quality assurance, hospitals have to meet that condition. However, no specific system of quality assurance was implicated. Therefore, many potential users search for systems suiting their own needs. However, German hospitals can benefit from international experience in quality management. Accreditation, visitation, excellence schemes, and certification seem to be the dominant methods. Every method is worthy of hospital evaluation. Certifications illustrate the quality system view without regard to profession, while excellence schemes evaluate the development of quality management in hospitals. Accreditation portrays a specific hospital as a whole, while visitations follow the professional perspective of quality assurance. Depending on the perspective and aims, there are advantages and disadvantages in each method. Finally, a combination of two may also be helpful. Indeed, no "role model" exists yet for assessing quality in health care. These methods of quality management are applicable especially in surgery, because a variety of standard outcome parameters such as length of stay, duration of procedure, and complication and relapse rates are already available.

Genetic variations of the SLC7A9 gene: allele distribution of 13 polymorphic sites in German cystinuria patients and controls

Cystinuria is a hereditary disorder of cystine and dibasic amino acid transport across the luminal membrane of renal tubules and intestine, resulting in recurrent nephrolithiasis. While mutations in the SLC3A1 gene cause type I cystinuria, patients with non-type I cystinuria carry mutations in the SLC7A9 gene. Both gene products form the renal amino acid transporter rBAT/b0,+AT affected in cystinuria. In the present study a total of 59 patients with different ethnic background were screened for sequence variations in SLC7A9, out of these 32 were of German origin. For determination of allele frequencies of detected polymorphisms, 58 healthy German controls were investigated. Molecular-genetic analysis was performed using single-strand conformation polymorphism analysis, restriction assays and sequencing. Allele frequencies were analyzed statistically for the detected polymorphisms. In addition to the 6 already known variants we identified 7 new polymorphisms. Statistical analyses showed a significantly different distribution of alleles between German patients and German controls in case of the polymorphisms c. 147C>T (exon 2), c.386C>T (exon 3), IVS3+22T>G, c.584C>T (exon 4), c.610T>C (exon 4), c.692C>T (exon 5), c.852C>A (exon 6) and c.872C>T (exon 6). In summary, our results show that cystinuria is a complex disease which is not only caused by mutations in SLC7A9 and SLC3A1, but also influenced by other modifying factors such as variants in SLC7A9.

[Intratesticular cysts in infancy - case report and review of the literature]

INTRODUCTION

Intratesticular cysts in neonates and infants are rare findings compared to other cystic lesions of the testes and can be diagnosed by high-power ultrasonography. In contrast to simple epithelial cysts seen in adults, which are usually small and incidental findings, intratesticular cysts in infants are often diagnosed because of an increase in scrotal size.

CASE REPORT

We report the case of a 6-month-old child with painless swelling of the right scrotum and the ultrasonographic finding of an intratesticular cyst. Together with surgical enucleation of the cyst, biopsy of the macroscopically normal testicular parenchyma was performed and showed tubular atrophy in the vicinity of the cyst.

CONCLUSIONS

In view of possible increase in size with resulting atrophy of testicular parenchyma, intratesticular cysts in neonates and infants should be treated surgically by simple cyst resection.

Ex situ resection of primary cardiac tumors

The prognosis of malignant heart tumors is pessimistic; 50% of patients die within 6 months. No optimal therapy has been established, and standardized therapeutic concepts have not been developed due to the low incidence of this disease. In most cases, chemotherapy and radiotherapy have not shown any survival benefit compared to surgical treatment. Obviously, radical resection of the tumor is the most important determinant for long-term survival. Here, we report on two patients in whom radical resection of heart tumors could be accomplished only after explantation of the heart.

Multiple risk factor intervention reduces cardiovascular risk in hypertensive patients with echolucent plaques in the carotid artery

OBJECTIVE

In a previously published randomized 6-year study we observed that multiple risk factor intervention reduced cardiovascular risk in high-risk hypertensive men, and that this effect was confined to patients with carotid artery plaques. Hypothetically, the underlying mechanism might have been a stabilization of echolucent, instable, rupture-prone plaques. The aim of the present study was to examine plaque characteristics by B-mode ultrasound in the previous intervention study, and also to investigate the relationship between plaque characteristics at baseline and cardiovascular events during the 6-year follow-up in the two randomization groups.

METHODS

High resolution B-mode ultrasound was used to characterize plaque echogenicity in four subgroups - dominantly echolucent, substantially echolucent, dominantly echogenic, and uniformly echogenic.

RESULTS

In the usual care group 17 of 32 (53%) patients with echolucent plaques at baseline suffered from a combined end-point (any death or nonfatal myocardial infarction or nonfatal stroke) during follow-up compared with seven of 28 (25%) patients in the intervention group (P = 0.036). The corresponding numbers in patients with echogenic plaques were n = 4/13 (31%) and n = 4/17 (24%), respectively (NS). In the usual care group 11 of 33 (33%) patients with no plaques suffered from a combined end-point during follow-up compared with 11 of 30 (37%) in the intervention group.

CONCLUSION

Our data indicate that the beneficial effect of the multiple risk intervention programme was confined to those patients with echolucent plaques. The data have to be confirmed with a large-scale trial.