Use of abciximab-modified thrombelastography in patients undergoing cardiac surgery

Thrombelastography (TEG) is a reliable coagulation monitoring system that can guide blood product transfusion in cardiac surgery. The maximum amplitude (MA) of TEG measures clot strength, which is dependent on both fibrinogen level and platelet function. Inhibition of platelet function with abciximab-fab is suggested to permit quantitative assessment of the contribution of fibrinogen to clot strength. We hypothesized that abciximab-modified TEG permits prediction of plasma fibrinogen levels and that the difference of standard MA and abciximab-modified MA (deltaMA) is a correlate for platelet function. We correlated abciximab-modified MA with plasma fibrinogen levels and deltaMA with platelet count in patients undergoing coronary revascularization. Correlation between plasma fibrinogen levels and abciximab-modified MA was significant (adjusted r2: 0.8; P < 0.0001). Correlation of deltaMA with platelet count was not significant when calculated in millimeters (adjusted r2: 0.04; P = 0.73). However, when deltaMA was calculated in dynes per square centimeter (deltaGMA), it correlated significantly with platelet count (adjusted r2: 0.51; P < 0.0001). We conclude that abciximab-modified TEG may therefore help to discriminate between hypofibrinogenemia and platelet dysfunction as a cause of decreased MA.

IMPLICATIONS

We examined the use of abciximab-modified thrombelastography in patients undergoing cardiac surgery. Modification of thrombelastography with abciximab-fab allows prediction of fibrinogen levels, despite coagulation altered by cardiac surgery. The difference of standard maximum amplitude and abciximab-modified maximum amplitude correlates with platelet function when expressed in dynes per square centimeter.

Ultrasonographic examination of the stifle region in cattle--normal appearance

The stifle region of 18 healthy cattle (14 cows, four bull calves) and the stifles of five bovine cadavers were examined using 7.5 MHz linear or convex and 5 MHz sector transducers. The normal ultrasonographic appearance of soft tissues and bony structures was studied.The homogeneously echogenic patellar and collateral ligaments, the combined tendon of the long digital extensor and peroneus tertius muscles, the popliteus tendon, the anechoic articular cartilage of the femoral trochlea, the echogenic menisci and the hyperechoic bone surfaces were imaged successfully in all cattle and cadavers. The boundaries of the joint pouches only became partially identifiable, when small amounts of anechoic fluid were present in the medial and lateral femorotibial joint pouches. After experimental filling in cadavers, the distended synovial cavities were imaged as clearly demarcated, anechoic areas. Measurement values of cross-sectional diameters of the ligaments, tendons and the popliteal lymph node, the width of normal joint pouches, where visible, and articular cartilage thickness are presented. The established results should serve as reference data for ultrasonography of bovine stifle disorders.

Activation of endothelium by immunotherapy with interleukin-2 in patients with malignant disorders

Treatment with intravenous recombinant human interleukin-2 (rh IL-2) is frequently accompanied by the capillary leak syndrome and disturbances of the coagulation system. Although the exact mechanisms are still not fully understood, the involvement of the endothelium is proven. This investigation aimed to elucidate more precisely the role of the endothelium in the generation of IL-2-based side-effects. In nine tumour patients receiving intravenous rh IL-2, parameters characterizing endothelial cell activation as well as activation of the coagulation system were evaluated. A significant increase of the circulating endothelial leucocyte adhesion molecule-1 (cELAM-1) and the vasoconstrictor peptide endothelin-1 (ET-1) was observed (P<0.05), indicating activation of endothelial cells. The simultaneous increase of tissue-plasminogen activator and plasminogen activator inhibitor type-1 during therapy (P<0.05) corroborated this observation. A decrease in platelet count parallelled by an increase of fibrin degradation products, the prolongation of partial thromboplastin time, and the decrease of fibrinogen (P<0.05) suggested the development of disseminated intravascular coagulation (DIC), induced by activated endothelium and intensified by transient hepatic failure. We concluded that activation of the endothelium mediated by IL-2 was accompanied by a loss of endothelial integrity and capillary leak. The activated endothelium can trigger DIC via activation of the coagulation cascade. The increased ET-1 might act as an endogenous counter-regulator of the disadvantageous haemodynamic side-effects induced by IL-2.

Ultrasonographic imaging and thickness measurement of the sole horn and the underlying soft tissue layer in bovine claws

Ultrasonographic imaging and thickness measurements of sole horn and underlying soft tissue layer were evaluated in 100 bovine claw specimens. The claws were trimmed and examined in longitudinal planes using a 7.5 MHz linear transducer. The sole horn, underlying soft tissue layer and distal surface of the distal phalanx of all claws were clearly visualized. The sole horn had a heterogeneous hypoechoic appearance; the underlying soft tissue layer was predominantly anechoic. Corium and subcutis could be differentiated. The best imaging of these structures was achieved in claws with less than 10 mm sole horn thickness and soft sole horn. Imaging of the dorsal wall structures was more difficult. In each claw, B- and A-mode measurements of horn thickness of sole and dorsal wall and distance from outer claw surface to distal phalanx surface were made at three marked points on the weightbearing surface and at one point on the dorsal wall. In 10 claws, CT-images were taken and the horn density was determined. All claws were then frozen, transected and anatomical reference measurements were made after thawing. Statistical correlation coefficients of 0.88 and higher were found for B-mode ultrasonographic and anatomical measurements of sole horn thickness. A-mode proved not to be useful for the sole horn thickness measurement. B-mode ultrasonography was carried out successfully in the claws of five living cattle.

The assessment of four different methods to verify tracheal tube placement in the critical care setting

One of the most serious complications of conventional endotracheal intubation is unidentified placement of the tube in the esophagus. The aim of our study was to evaluate four different methods for immediate detection of the tube position: auscultation, capnographic determination of ETCO2, esophageal detection method (EDM) using a self-inflating bulb, and the transillumination method using a lighted stylet (Trachlight; Laerdal, Armonk, NY). Thirty-eight endotracheally intubated patients admitted to our medical intensive care unit were enrolled in the study. A second identical tube was inserted into the esophagus under laryngoscopic control. The endotracheal tube was then disconnected from the ventilator. Two blinded examiners, one experienced, the other inexperienced, determined the tube position within 30 s using one of the four methods. The order of the tubes tested and the methods used were randomized. In 130 of 152 examinations, both examiners correctly diagnosed the position of the tube. The wrong result was obtained by both examiners 4 times; only the experienced examiner was wrong 4 times, and only the inexperienced examiner was wrong 14 times. Using ETCO2, both examiners were correct in all cases. Auscultation showed an obvious relation to the examiner's experience: the experienced examiner was correct in all cases, the inexperienced examiner was correct in only 68% of cases. Using the self-inflating bulb, there were two wrong results of the experienced examiner and one wrong result of the inexperienced examiner. The transillumination technique was associated with a high error rate by both examiners (16% and 13%, respectively). Comparing all four methods showed that capnography is superior to auscultation (P = 0.0005) and to the Trachlight detection method (P = 0.0078). EDM was not statistically superior to auscultation and transillumination. Capnography was the most reliable method for rapid evaluation of tube position, followed by EDM, whereas auscultation and Trachlight did not seem to be of comparable value. Experience was a determining factor for auscultation.

IMPLICATIONS

To prevent unidentified esophageal intubation, a serious complication in the critical care setting, four methods for detecting tube position were tested by two examiners (one experienced, the other inexperienced) in endotracheally intubated patients after insertion of a second tube into the esophagus.

Clinical study of toe ulcer and necrosis of the apex of the distal phalanx in 53 cattle

Clinical signs, causative factors, radiographic findings, type and duration of treatment or reason for killing were evaluated in 53 cattle (mean age: 5.3 years) suffering from toe ulcer and/or apical pedal bone necrosis. A total of 78 claws were affected. Four cattle suffered from a toe ulcer in one claw, 35 cattle showed osteolysis of the apex of the distal phalanx in a single claw and 14 cattle in two or three claws per cow. Overtrimming by means of a grinding disc and/or perforation of the sole was diagnosed as the major cause in 27 cattle (49%), laminitis in 30.2% and traumatic injuries in 11.3%. Radiography revealed a varying degree of osteolysis involving up to two-thirds of the pedal bone. Twenty-one cattle (39.6%) showing multiple toe disorders or involvement of one single claw with concurrent internal diseases were destroyed. In 23 cattle, the osteolytic bone was resected using a bone curette or hammer and chisel. Of these, the treatment was successful in 20 animals. The healing period ranged from 16-60 days when one claw was affected and from 43-53 days when two claws were affected. In five cattle, the digit was amputated.

Placement of a pulmonary artery catheter via a previously unrecognized persistent left superior vena cava

This case report describes a patient with persistent left superior vena cava (LSVC) as discovered by difficult placement of a pulmonary artery catheter via the left subclavian vein. After positioning in wedge position, chest x-ray showed a catheter route suggestive of persistent LSVC. Since this abnormality may yield potential clinical complications, this possibility should be considered in every difficult central venous access.

[Use of sodium ceftiofur in the combined therapy of complicated septic diseases in cattle]

The use of Sodium-Ceftiofur (Excenel) with a dosage regimen of 1 mg/kg body mass intramuscularly was evaluated in the therapy of complicated claw diseases, like septic arthritis of the distal interphalangeal joint, septic tenosynovitis of the digital flexor tendon sheath or complicated interdigital necrosis. Sodium-Ceftiofur was applied in 34 dairy cattle in addition to surgical intervention. 14 cattle of the control group perceived only surgical intervention without additional antibiotic therapy. Application of the cephalosporin proved to be necessary, with the untreated animals exhibiting far more disturbance of the reconvalescence course in the postoperative phase. Treated animals had a decreasing duration of the postoperative stay at the clinic. Sodium-Ceftiofur was found to be an effective antibiotic in the therapy, an application over a five- to 10-day-period is recommended in complicated digital diseases. As a side effect five cows exhibited slight diarrhea, which disappeared without additional treatment.

[Limitations of life support in patients with anoxic encephalopathy after CPR. Results of a questionnaire to Austrian intensive care units]

A questionnaire was sent to 97 Austrian intensive care units to define the current practises of predicting neurologic outcome in patients with anoxic encephalopathy after cardio-pulmonary resuscitation. All relevant prognostic predictors, such as clinical scales, electrophysiological techniques and laboratory tests were included to examine if these procedures influence the decision to withdraw life support. The answers of 68 (70%) units were collected and analysed. The results show that tests such as somatosensory evoked potential of the determination of brain cell-specific cytosolic enzymes are without any practical importance in Austria. In addition, the methods of reducing life support were evaluated. According to the controversial discussion in the literature, there is no common approach to this problem, especially in the question of withdrawing controlled mechanical ventilation. The result of our survey show, that there is a need for general guidelines to determine the prognosis and the methods of withdrawing life support which could be used in all intensive care units regardless of their size and technical infrastructure.

Successful automatic external defibrillator operation by people trained only in basic life support in a simulated cardiac arrest situation

OBJECTIVE

To show whether in an in-hospital cardiac arrest, early defibrillation can also be performed by hospital staff trained only in basic life support.

BACKGROUND

The International Liaison Committee on Resuscitation (ILCOR) endorses the concept that in many settings non-medical individuals should be allowed and encouraged to use defibrillators.

METHODS

Five different groups of hospital staff were evaluated whether they were able to correctly operate an automatic external defibrillator in a simulated sudden cardiac arrest situation without any prior instruction. The participants were assigned either to the 'basic life support-trained' group (BLS, n = 40, or to the 'advanced life support-trained' group (ALS, n = 40).

RESULTS

All persons of the 'only BLS-trained' group delivered the three sequential ('stacked') shocks with the automatic external defibrillator when persistent ventricular fibrillation was simulated. The 'ALS-trained' persons successfully delivered the three shocks with the automatic external defibrillator in 98% of the cases. When this group used a conventional defibrillator, only 88% were able to deliver the three shocks, however they were able to do it significantly more quickly.

CONCLUSION

Using an automatic defibrillator without any prior instruction, even persons trained only in BLS were able to deliver three sequential shocks in a simulated persistent ventricular fibrillation cardiac arrest.

Time course of immunological markers in patients with the systemic inflammatory response syndrome: evaluation of sCD14, sVCAM-1, sELAM-1, MIP-1 alpha and TGF-beta 2

BACKGROUND

The systemic inflammatory response syndrome (SIRS) is viewed as a system-wide inflammatory response. Up until now, no parameter has been available for predicting the development of septic shock. In the present study, we evaluated the usefulness of serum levels of CD14, vascular cells adhesion molecule-1 (VCAM-1), endothelial leucocyte adhesion molecule-1 (ELAM-1), macrophage inflammatory protein (MIP) 1 alpha and transforming growth factor beta 2 (TGF-beta 2) as early markers of outcome in patients with SIRS.

METHODS

A group of 28 SIRS patients (13 survivors/15 non-survivors) was compared with a healthy control group and with patients with local inflammation. Blood samples were analysed on days 0, 4 and 7. Proinflammatory parameters such as sCD14, sVCAM-1, sELAM-1, MIP-1 alpha and anti-inflammatory parameters such as TGF-beta 2 were determined using enzyme-linked immunosorbent assay (ELISA).

RESULTS

At the beginning, all evaluated proinflammatory immunological parameters with the exception of sVCAM-1 were significantly increased in patients with SIRS compared with the healthy control group. However, no significant difference could be observed for all immunological parameters comparing survivors and non-survivors, with the exception of interleukin (IL) 6 at day 7.

CONCLUSION

All evaluated proinflammatory parameters were increased in patients with SIRS during the course of the disease. However, the parameters have no correlation with outcome and prognosis of SIRS patients.

[Experiences with inhalative nitric oxide in internal medicine intensive care patients with adult respiratory distress syndrome]

Inhalative nitric oxide (NO) has recently been included in the therapeutic armament for the treatment of ARDS. We evaluated the effect of inhalative NO on hemodynamic and oxygen transport parameters in 30 internal intensive care patients suffering from ARDS. All patients received a pulmonary artery catheter. Hemodynamics were assessed prior to NO therapy and after 1, 6, 12, and 24 h. 80% (n = 24) of the patients were classified as therapy responders. The median NO dose was 15 ppm (range 5 to 40 ppm). The PaO2/FiO2--ratio increased significantly after initiation of NO (p = 0.0002) while the pulmonary shunt fraction (Qs/Qt) decreased significantly (p = 0.0019). All other measured or calculated parameters including arterial and pulmonary arterial blood pressure remained unchanged. No negative effects of the therapy could be observed. Inhalative NO improves oxygenation in most intensive care patients with ARDS and thus offers the possibility to reduce invasiveness of mechanical ventilation.

Ultrasonographic appearance of normal superficial cervical and subiliac lymph nodes in cattle

The superficial cervical and the subiliac lymph nodes of 18 healthy, non-pregnant Simmental cows with a mean (sd) age of 5-6 (1.6) years were examined ultrasonographically in transverse and longitudinal planes with a real-time B-mode unit equipped with a 7.5 MHz linear-transducer. The position, demarcation and echogenicity of the lymph nodes were examined, and the craniocaudal and lateromedial diameters of each lymph node were measured three times within a period of six weeks. The pole to pole length of the lymph nodes was determined with a tape measure on the surface of the skin because the whole length could not be imaged in a single scan field. The gross anatomical and histological results showed that the lymph nodes were normal. Ultrasonographically, they were well demarcated from the adjoining muscular and subcutaneous tissue. Their internal structure was characterised by an anechoic to hypoechoic cortical zone corresponding to the lymphoid tissue, and an echogenic medullary zone, where the lymphatic sinuses converge towards the hilus and produce numerous acoustic interfaces. In all the lymph nodes, the hilar area had an echoic to hyperechoic appearance. The mean (sd) pole to pole length of the superficial cervical lymph nodes was 15.5 (3.2) cm and of the subiliac lymph nodes 13.5 (2.4) cm. The mean craniocaudal and lateromedial diameters of the superficial cervical lymph nodes were 2.8 (0.3) cm and 1.6 (0.3) cm, and those of the subiliac lymph nodes were 2.4 (0.4) cm and 1.1 (0.3) cm. The ultrasonographic morphology of these normal lymph nodes was consistent and provides basic reference data for the investigation of lymphadenopathies in cattle.

[Squamous cell carcinoma of the claw matrix in a cow]

Clinical, radiographic, gross-pathological and histological findings in a squamous cell carcinoma of the claw matrix in a three-year-old Simmental cow are described. The cow showed severe lameness of the right foreleg. Radiological examination revealed a large osteolytic focus in the medial distal phalanx. The tentative clinical diagnosis of apical pedal bone necrosis was followed by amputation and pathological examination of the claw. The horn capsule showed no lesions. Pathological examination revealed soft consistency of pedal bone and the cut surface showed a yellowish crumbling material, which had replaced most of the pedal bone. Histologically, infiltration and osteolysis of distal pedal bone by a squamous cell carcinoma was ascertained. This claw tumor has not been reported until now. Clinically, it resembles apical pedal bone necrosis and therefore should be included in the differential diagnosis.

Cutaneous, multilocular T-cell lymphosarcoma in a horse--clinical, ultrasonographic and pathological findings

Clinical, ultrasonographic and pathological findings of a cutaneous, multilocular T-cell lymphosarcoma (malignant lymphoma) in a 13-year-old, brown Austrian warmblood mare are reported. The horse was under clinical observation, and the tumours were sonographically monitored over an 8 month period, revealing worsening of body condition, weight loss, lameness of the left hindlimb and a slight increase in the tumours size. Most of the tumours were covered by normal skin, one showed ulceration. Ultrasonography of the tumours allowed accurate anatomical localization in relation to the adjoining tissue, assessment of their internal structure, of involvement of adjacent muscles and of a regional lymph node, and it facilitated the percutaneous fine-needle aspiration. Necropsy confirmed muscular infiltration in three locations. Light microscopy and immunohistology led to the diagnosis of a T-cell lymphosarcoma.

[A protocol for the assessment of patients with coma of unknown origin]

OBJECTIVE

Evaluation of the applicability of a protocol designed for the quick and efficient management of patients with coma of unknown origin (CUO).

METHODS

Every patient admitted to our Emergency Department with the diagnosis of CUO was evaluated with our diagnostic protocol. The first diagnostic steps included evaluation of the hemodynamic and respiratory situation, Glasgow Coma Scale, basic neurologic and clinical examination, as well as blood withdrawal, for analysis of metabolic and toxicologic parameters. If indicated, cranial computer tomography (CCT) and/or lumbar puncture were performed.

RESULTS

Within the study period from 1. 1. 1995 until 30. 9. 1996, 122 patients (65 males, median age 50 years, 25 and 75 percentile: 33; 69) were included. Blood analysis and the toxicological screening were diagnostic effective in 66 patients, clinical examination and body temperature in one case each, CCT in 50 patients and lumbar puncture in 2 patients. By the use of this diagnostic protocol 51 neurologic, 38 toxicologic, 28 metabolic and 2 infectious causes of coma were diagnosed (98%). Etiology of 2 of the comas remained unclear.

CONCLUSION

By using our protocol, 98% of the causes of CUO were clarified. The main causes of coma were of neurological, toxicological and metabolic origin. CCT and the blood analysis were the most important procedures leading to a final diagnosis.

Renal tolerability of four different once-daily dose regimen of netilmicin in critical care patients

A prospective, randomized trial was conducted in a medical intensive care unit to assess safety and tolerability of four different dose regimens of intravenous netilmicin given once daily in the treatment of febrile episodes in critically ill patients. Eighty patients with febrile episodes during their stay in the intensive care unit were included in the study. The patients were randomized into four groups: Group 1 received a single daily dose of netilmicin based upon weight, age and renal function according to a dosage nomogram [13] (mean dose 298 +/- 29 mg, median 300 mg, range 250-350 mg), group 2 received 150% of this standard dose (mean 418 +/- 45 mg, median 400 mg, range 350-500 mg), group 3 200% (mean 525 +/- 41 mg, median 500 mg, range 400-550 mg) and group 4 250% (mean 710 +/- 39 mg, median 650 mg, range 600-750 mg). Duration of treatment was six days. Positive cultures were obtained in 29 patients. Serum creatinine and creatinine clearance, as well as netilmicin trough levels and levels of alpha 1-microglobulin showed no significant difference between the groups before, during, and after therapy. Our results indicate that with once daily dosing even high doses of netilmicin are well tolerated in patients with a creatinine clearance of > 70 ml/min before therapy. Necessary precautions include monitoring of drug trough levels (< 1 mg/L) and maintenance of adequate volume status.

Long-term ultrasonographic and venographic study of the development of tarsal vein thrombosis in a cow

The development of thrombosis of three tarsal veins in a cow was studied by repeated ultrasonographic and venographic examinations for nine months. The venous diameter, the echogenicity of the thrombi and the sequential venographic findings were evaluated. Initially, the thrombosed parts of the ramus cranialis and caudalis of the vena saphena lateralis and the ramus caudalis of the vena saphena medialis had greatly increased diameters and were not compressible. The thrombi appeared as poorly echogenic masses. Within five months, the diameters of the occluded veins had decreased to almost normal dimensions. The echogenicity of the thrombi diminished at their distal and proximal ends. The length of the thrombi was decreased by up to 6.5 cm. However, the thrombosed veins did not re-open. One year after diagnosis, the cow was culled and the persistence of the venous thromboses was confirmed.

Arthrosonography--the use of diagnostic ultrasound in septic and traumatic arthritis in cattle--a retrospective study of 25 patients

The case records, clinical, radiographic, ultrasonographic and arthrocentesis findings from 25 cattle with septic or traumatic arthritis were reviewed. The total of 30 joints involved were: articulatio cubiti (elbow joint)-1, articulatio carpi (carpal joint)-10; articulatio genus (stifle joint)-4, articulatio tarsocruralis (tarsocrural joint)-8; articulatio metacarpo-/metatarsophalangea (metacarpo-/metatarsophalangeal joint -7. Ultrasonographic investigation was performed using 7.5 MHz linear and 5 MHz sector transducers. In eight cattle, a concurrent infection of periarticular tendon sheaths or hygroma was diagnosed. The distension of the joint cavities could be imaged in all cases. Assessing echogenicity, acoustic enhancement, ultrasonographic character of the exudate (liquid or clotted) and findings revealed by aspiration, arthrotomy or at necropsy, the synovial effusion was classified as: serous, fibrinous or fibrino-purulent. Diagnostic ultrasound provided a comprehensive preoperative diagnosis in septic and traumatic arthritis by imaging the accurate localization of soft-tissue swelling and the extent and consistency of joint effusion.

Ultrasonographic imaging of pathology of the digital flexor tendon sheath in cattle

The clinical, radiographic, ultrasonographic and exploratory centesis findings in 33 cattle suffering from a septic tenosynovitis of the digital flexor tendon sheath are described. Forty-one digital flexor tendon sheaths were affected: 13 of the cattle had a unilateral and eight had a bilateral septic tenosynovitis, and in the other 12 cattle with unilateral tenosynovitis one or more of the digital joints were also involved. The distended compartments of the digital flexor tendon sheath and the affected digital joint recesses could be determined accurately by ultrasonography. Depending on the type of inflammation (serous, fibrinous or purulent) the compartments and recesses were filled with anechoic, heterogeneous hypoechoic or echogenic inflammatory content. Flow-phenomena could be observed when there were effusions of liquid into the synovial cavities. Ultrasonography provided accurate preoperative details of the pathological changes to the affected tendon sheaths and the adjoining digital joints. The characteristic ultrasonographic features of septic tenosynovitis of the digital flexor tendon sheath are described.

Application of real-time ultrasonography for the detection of tarsal vein thrombosis in cattle

The clinical and ultrasonographic features of the thrombosis of three tarsal veins in a six-year-old dairy cow are described. Thrombosis and metastatic abscessation developed on the left tarsus six days after the amputation of the lateral claw of the left hindlimb. Originally, the cow suffered from a severe purulent arthritis of the distal interphalangeal joint and a retroarticular abscess, caused by interdigital necrobacillosis. By means of real-time ultrasonography, using a 7.5 MHz transducer, a marked subcutaneous oedema, a subcutaneous abscess, and a thrombosis of the ramus cranialis and ramus caudalis of the vena saphena lateralis reaching the confluence into the vena saphena lateralis and a thrombosis of the ramus caudalis of the vena saphena medialis could be identified. The thrombosed veins were not compressible, were oval and had an increased diameter of up to 9 x 12 mm. Intraluminal masses were visualised as hypoechoic structures and the veins distal to the thrombosis were distended up to 10 x 13 mm. The differential diagnosis and pathogenesis of the thrombosis and the abscessation are discussed, and the clinical course and the sonographic observations of the thrombosis during a six week period are described.

[Results of critical care management of patients after bone marrow transplantation]

In a retrospective study we investigated the clinical course of patients who required intensive care support after bone marrow transplantation. Out of 25 patients only 5 (20%) survived treatment in the intensive care unit (ICU) and this group showed a significantly lower age, lower APACHE III and organ-failure scores and higher serum albumin values, as well as a longer interval between bone marrow transplantation and admission to intensive care. However, no patient requiring mechanical ventilation primarily for pneumonia or other infections arising as a complication of bone marrow transplantation survived intensive care. All patients requiring ventilation for more than 24 hours died in hospital. Of the 5 patients surviving ICU treatment only 3 were eventually discharged from hospital and only one single patient was alive after 6 months. Hence, current intensive care management appears to be indicated in only a small group of patients after bone marrow transplantation.

Angular limb deformity in a calf treated by periosteotomy and wedge osteotomy

A carpus valgus deformity was diagnosed in a five-week-old Brown Swiss calf. The 45 degrees deformity was caused by the malaligned healing of a fracture of the left metacarpus after birth trauma. The deviation improved to 25 degrees after being treated with a semicircular lateral periosteotomy above the distal physis of the radius. A complete correction was made by means of a wedge osteotomy five months after the first treatment. A 20 degrees wedge of bone was removed. The metacarpus was stabilised with a seven-hole dynamic compression plate which was removed 12 weeks later. Thirty months later the calf was sold as a pregnant heifer at an auction of breeding cattle.