Adherence to Standard Operating Procedures is Crucial for Intensive Care Unit Survival of Elderly Patients

Elderly patients account for 42–52% of intensive care unit (ICU) admissions and for almost 60% of all ICU days in the USA and up to 50% receive inappropriate antibiotic treatment. The aim of this study was to evaluate whether adherence to Standard Operating Procedures (SOPs) reduced ICU mortality in an elderly population. The study included consecutive patients ( n = 228) aged ≤ 60 years with an ICU stay of > 72 h. SOPs were based on evidence-based medicine guidelines for diagnosis and treatment of infections, and on local resistance rates. According to preset indicators of quality management standards and assessment of different degrees of adherence, an implementation rate > 70% was considered adherent (high adherence group [HAG]) and ≤ 70% was considered non-adherent (low adherence group [LAG]). Patients in the HAG ( n = 137) had significantly reduced mortality compared with LAG patients ( n = 91): 5.8% versus 19.8%, respectively. It was concluded that adherence to SOPs based on evidence-based medicine that consider local resistance rates for antibiotic treatment in elderly ICU patients is associated with a lower mortality rate.

Tyramine in the assessment of regional adrenergic function

Regional adrenergic function is difficult to assess in humans. Tyramine given through a microdialysis probe may be a useful tool in this regard. However, tyramine data is hard to interpret given the drug's complex mode of action. We characterized the response to tyramine, isoproterenol, and dopamine in adipose tissue with microdialysis probes in normal subjects. We measured glycerol concentrations to follow changes in lipolysis and monitored tissue perfusion with ethanol dilution. During perfusion with tyramine, dialysate glycerol concentration increased dose-dependently from 83+/-8 microM at baseline to 181+/-18 microM at 3.5 mM tyramine (p<0.001) followed by a fall down to 121+/-9 microM at 35 mM tyramine (p<0.001). Propranolol almost completely blocked this response. A similar lipolytic response was not observed in isolated human adipocytes. Dopamine <35 microM did not replicate the tyramine-induced lipolysis; however, dopamine >35 microM potently inhibited lipolysis. We conclude that tyramine-induced lipolysis is explained by a pre-synaptic mechanism. Tyramine applied through a microdialysis probe in concentrations up to 3.5 mM can be used to assess pre- and post-synaptic mechanisms regulating lipid mobilization.

Rauchfreie Gaststätten

BACKGROUND AND OBJECTIVE

Every year over 3,300 non-smokers in Germany die from diseases caused by passive smoking. It was the aim of this study to obtain country-wide representative opinions about a smoking ban in restaurants.

MATERIAL AND METHODS

Data were obtained from a cross-sectional sample of the population, 2,008 men and women aged 16 years or over. Opinions on smoking ban in restaurants were analysed by bivariate and multivariate methods with regard to potential influencing factors such as smoking status and socio-demographic status.

RESULTS

The majority of those questioned, namely 50% (95% confidence interval 57-61), wished for a smoking ban in restaurants. This represents an increase of 6% compared with the preceding year. While over 82% of never-smokers and 71% of previous smokers were in favor of a smoking ban, agreement for a ban among smokers averaged 25%, depending on the amount smoked. Agreement was especially common among women, the elderly and married persons. Three of four Germans said that they would continue to go to restaurants as frequently after smoking had been banned there.

CONCLUSION

This is the first scientific study of opinions among the population on the smoking ban in restaurants of Germany. The current average approval rate for a ban was comparable to that among other nations. An overwhelming majority of the population would welcome a smoking ban and would, after its introduction, visit restaurants as often as previously.

Blood flow in subcutaneous adipose tissue depends on skin-fold thickness

Blood flow in subcutaneous adipose tissue is reduced in obese compared to lean subjects. Limitations in vascular supply might interfere with adipose tissue function as a metabolic and endocrine organ. We tested the hypothesis that nutritive blood flow and tissue metabolism depends on subcutaneous adipose tissue thickness even in normal-weight subjects. Sixteen young, healthy, normal-weight subjects (8 men, 8 women) were included in the study. Abdominal subcutaneous adipose thickness was assessed by skin-fold measurements. The microdialysis technique was applied for monitoring basal adipose tissue blood flow (ethanol dilution technique) and metabolism. An increase in skin-fold thickness from 15 to 45 mm and from 8 to 37 mm was associated with a linear increase in basal ethanol ratio from 0.19 to 0.63 and 0.25 to 0.75 and linear decreases in dialysate glucose concentrations from 1.95 to 0.24 mM and 1.68 to 0.29 mM, and 152 to 42 microM and 172 to 49 microM for glycerol concentrations in men and women, respectively (p < 0.05). Isoproterenol-stimulated blood flow also inversely correlated to skin-fold thickness (p < 0.05). We conclude that increased adipose tissue thickness is associated with reduced tissue perfusion and metabolism, even in lean subjects. Skin-fold thickness is an important confounding variable in metabolic studies, particularly in microdialysis experiments.

Increased training load and the beta-adrenergic-receptor system on human lymphocytes

The influence of increased training on the sympathoadrenergic system was investigated. Moderately trained male subjects (n = 15) increased their training within 10 wk by 60%; eight of the subjects increased their training volume, and seven increased their training intensity. Before and after the training, an exhaustive treadmill exercise was carried out. Acute treadmill exercise increased beta-adrenergic receptor number on mononuclear lymphocytes, isoproternol-stimulated cAMP production, and plasma catecholamine concentration. The increase of receptor number can at least partially be explained by a changed lymphocyte composition at rest and after exercise. After training, the exercise-induced increase of beta-adrenergic receptor number was significantly blunted, and the exercise-induced increase of the isoproternol-stimulated cAMP production per beta-receptor was enhanced. Subjects who experienced increased symptoms of physical discomfort and/or mood changes showed an enhanced cAMP production after training. These findings point to an altered regulation of the receptor and postreceptor mechanisms as an effect of a 10-wk period of hard training.

A microspectrophotometric study of the shielding properties of eyespot and cell body in Chlamydomonas

The eyespot apparatus of the unicellular alga Chlamydomonas exhibits a clear directivity, i.e., it perceives light from different directions with different sensitivity. Using a newly constructed confocal microscope we have studied how absorption and reflection of eyespot and cell body shape this directivity. In agreement with previous results the eyespot was found to be highly reflectant, owing to its interference reflector design, but only for yellow light. Light of 490 nm, the maximum of absorption of the photoreceptor, was hardly reflected at all, even when the reflector was "tuned" to lower wavelengths by tilting it relative to the incoming light. The absorption of the carotenoids in the interference reflector also contributed little to the shielding properties of the cell, leaving the major contribution to the cell body. Thus most of the attenuation of light reaching the eyespot from the rear is due to chlorophyll and other pigments within the cell. In its peak around 490 nm the "contrast-ratio" reached a value of 8-10.

How Chlamydomonas keeps track of the light once it has reached the right phototactic orientation

By using a real-time assay that allows measurement of the phototactic orientation of the unicellular alga Chlamydomonas with millisecond time resolution, it can be shown that single photons not only induce transient direction changes but that fluence rates as low as 1 photon cell(-1) s(-1) can already lead to a persistent orientation. Orientation is a binary variable, i.e., in a partially oriented population some organisms are fully oriented while the rest are still at random. Action spectra reveal that the response to a pulsed stimulus follows the Dartnall-nomogram for a rhodopsin while the response to a persistent stimulus falls off more rapidly toward the red end of the spectrum. Thus light of 540 nm, for which chlamy-rhodopsin is equally sensitive as for 440-nm light, induces no measurable persistent orientation while 440-nm light does. A model is presented which explains not only this behavior, but also how Chlamydomonas can track the light direction and switches between a positive and negative phototaxis. According to the model the ability to detect the direction of light, to make the right turn and to stay oriented, is a direct consequence of the helical path of the organism, the orientation of its eyespot relative to the helix-axis, and the special shielding properties of eyespot and cell body. The model places particular emphasis on the fact that prolonged swimming into the correct direction not only requires making a correct turn initially, but also avoiding further turns once the right direction has been reached.

Pool cue chalk: a source of environmental lead

Lead compounds are used as coloring agents for numerous products. Two cases of children with elevated blood lead concentrations encountered by the authors suggested that pool cue chalk may serve as a source of environmental lead. The objective of this study was to determine lead content of various brands and colors of pool cue chalk. Atomic absorption analyses were conducted of 23 different types of pool cue chalk for lead content. Three of 23 types of pool cue chalk contained more than 7000 ppm (mg/kg) lead: one manufacturer's green and tangerine chalk and another manufacturer's green chalk. It was concluded that some brands of pool cue chalk contain relatively large amounts of lead and could contribute to childhood lead poisoning.

The C-reactive protein for detection of early infections after lumbar microdiscectomy

The tendency for short hospitalization after lumbar microdiscectomy implies the need for early confirmation or disapproval of serious postoperative infections such as spondylodiscitis or deep wound infections. The C-reactive protein (CRP) is a well-known screening parameter for monitoring postoperative infectious complications in other fields. Our objective was to establish the diagnostic significance of CRP-in comparison with ESR and WBC-for monitoring infectious complications after lumbar microdiscectomy. Over a 15 months period we studied prospectively a homogeneous group of N = 400 patients with lumbar disc herniations who were operated on a single level for the first time. CRP, ESR and WBC values were determined in all patients pre-operatively, and on postoperative days 1 and 5. Clinical and laboratory findings were correlated and the diagnostic significance of CRP, ESR and WBC calculated. N = 385 (96%) patients had an uneventful postoperative course. N = 15 (4%) patients developed infectious complications, of which N = 6 (1.5%) were unrelated and N = 9 (2.5%) related to surgery. Evaluation of the laboratory values showed: The CRP baseline is a very individual value of no prognostic relevance. A high postaggression peak is typical and essential as a reference value for only the future time course will disclose any infection. We found 0% false negative and 4% false positive results on day 5. The sensitivity for serial CRP testing was calculated as 100% and specificity as 95.8%. ESR (sensitivity: 78.1%/specificity: 38.1%) and WBC (sensitivity: 21.4%/specificity: 76.8%) both failed to reach such distinct diagnostic significance on day 5. The C-reactive protein has thus proved to be a reliable, simple and economical screening test for infectious complications after lumbar microdiscectomy, superior to classical laboratory parameters.

The combined pterional and orbitocygomatic approach to extensive tumours of the lateral and latero-basal orbit and orbital apex

Using standardized transcranial (pterional, subfrontal, fronto-orbital) approaches, complete removal of tumours located in the latero-basal aspect of the orbit and the lateral orbital apex with or without extension to the temporal fossa is not possible or can only be achieved if excessive traction is applied to the contents of the orbit and the brain. In contrast, the combined pterional and orbitocygomatic approach provides unhindered access to the superior, lateral and latero-basal orbit, superior and inferior orbital fissure and, if required, to the temporal fossa including the foramina ovale and rotundum. Six patients with extensive orbital lesions underwent surgery using this technique with good operative results.

Catecholamines, lymphocyte subsets, and cyclic adenosine monophosphate production in mononuclear cells and CD4+ cells in response to submaximal resistance exercise

We examined the effect of 30 min of submaximal resistance exercise on free and sulphoconjugated plasma catecholamine concentrations determined by high performance (-pressure) liquid chromatography separation, the distribution of circulating lymphocytes quantified by flow cytometry, and isoproterenol induced cyclic adenosine monophosphate (cAMP) production in mononuclear cells (MNL) and CD4+ cells. Venous blood samples were taken before, immediately after and 45 min after exercise. Resistance exercise increased free plasma adrenaline (A) and noradrenaline (NA) concentrations, whereas sulphoconjugated catecholamine concentrations remained unchanged. Exercise induced leucocytosis and lymphocytosis was predominantly manifested by an increase in the number of total lymphocytes, monocytes, CD3+, CD8+ cells and CD3- CD16/CD56+ cells. Redistribution resulted in a decrease in the CD4+:CD8+ ratio. The total number and distribution of lymphocytes returned to baseline after 45-min rest. An exercise-induced increase in the number of CD3- CD16/CD56+ cells was significantly correlated with the increase in plasma NA (r = 0.66; P = 0.035), indicating a NA dependent process of redistribution. The cAMP-production in MNL was significantly elevated after resistance exercise, when cells were stimulated with 1 mumol.1(-1) isoproterenol [pre-exercise 16.5 (SD 3.3); postexercise 21.6 (SD 9.8); 45 min postexercise 10.7 (SD 2.8)]. The cAMP production in CD4+ cells was not affected by exercise. Therefore, it is discussed whether redistribution is responsible for the exercise induced increase in cAMP production in MNL.

Percutaneous needle trephination. Experience in 200 cases

For many years percutaneous needle and classic burr-hole trephination with insertion of plastic catheters for external ventricular drainage are in use. The shortcomings of the conventional puncture needles were compensated for by the development of a modified instrument in recent years. In this prospective study we tried to define advantages and disadvantages of percutaneous ventriculostomy with this modified needle in a large number of patients. We treated and followed a total number of 200 patients with external ventricular drainage for various reasons (42% obstructive hydrocephalus, 27% haematocephalus, 11% malresorptive hydrocephalus, 11% elevated ICP and 9% infections). The ventriculostomy is performed--after percutaneous trephination with a 1.5 mm drill and 1.2 mm needle under local anaesthesia as a bedside procedure. The modified blunt needle is provided with markings and a set screw which allows insertion to a prefixed depth and a sharp guide which is withdrawn after penetration of the dura. It is then bent rostrally and fixed by a plaster cast. The mean duration of drainage was 9 days (1-30 days). Mean operating time for the whole procedure including fixation and connection to the drainage system was 20 minutes. Overall complication rate was 13% (N = 26). Two intracerebral haemorrhages (1%) occurred, of which one was caused by overdrainage. Five (3%) infections in primarily not infectious cases (N = 182) were seen. Only one case of infection occurred without loosening of the needle on day 17. In 19 patients (10%) the needles had loosened. Fifteen times this complication was repaired in time and no infection occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

Isolation of avirulent clones of Candida albicans with reduced ability to recognize the CR2 ligand C3d

Four clones of the yeast Candida albicans, isolated on the basis of their tolerance to clotrimazole, were compared with their parental strains in terms of growth, morphology, virulence, and cell surface complement receptor activity. In a newly described synthetic medium, these clones, designated C1, C2, N, and P, produced germ tubes or pseudohyphae, but no true hyphae, in a pattern which was specific for each strain. The growth of each clone at 37 degrees C, under conditions which favor the filamentous growth form of the organism, was equal to that of the parental strain (H12). The pathogenicity of each clone was tested in an intravenous mouse model. None of the mice infected with the tolerant clones but all of the mice infected with H12 developed severe renal candidiasis after infection with 1.4 x 10(6) to 2.0 x 10(6) CFU/ml. The number of CFU of each clone from the mouse kidney was reduced about 3 or 4 orders of magnitude in comparison with the wild type. As a correlate, we measured the complement receptor activity (CR2 and CR3) of each clone. The C3 ligands, iC3b and C3d, were conjugated to sheep erythrocytes (E) sensitized with antibody (A) to the erythrocytes (EA). We found that all tolerant clones showed reduced recognition of C3d-bearing sheep erythrocytes (EAC3d) in rosetting assays. Clone P showed more than an 80% reduction in rosetting of EAC3d in comparison with H12 cells. In contrast, recognition of iC3b (EAiC3b) by each of the clones was similar to that by H12 cells. When dithiothreitol extracts of clone P and H12 were compared by immunoblot, both quantitative and qualitative differences in reactivities were observed with antibodies specific for the Candida C3d receptor and with antiserum from a patient with chronic mucocutaneous candidiasis.

Positive interaction of nikkomycins and azoles against Candida albicans in vitro and in vivo

Nikkomycins X and Z (NZ), competitive inhibitors of fungal chitin synthetase, were combined with azoles in a series of in vitro checkerboard assays to test for synergism against Candida spp. All combinations of nikkomycins and azoles tested resulted in marked synergistic activity against an isolate of Candida albicans, with fractional inhibitory concentration indices ranging from 0.016 to 0.28. No synergistic effect was demonstrable with isolates of C. tropicalis, C. parapsilosis, or C. krusei, though results for the latter two were suggestive of an additive effect. In survival models of mice infected intravenously with C. albicans, NZ administered singly in doses ranging from 5 to 50 mg/kg of body weight twice a day was able to delay the onset of mortality but showed no dose-response effect. The combination of NZ and the azole R 3783 administered orally in a ratio of 8:1 to 40:1 or greater (wt/wt) enhanced survival better than did the drugs given individually, but this effect was less evident for combinations involving fluconazole. In short-term organ load assays with outbred mice infected intravenously with C. albicans, high ratios of NZ to R 3783 reduced the CFU per gram in kidneys more significantly than did the drugs individually. Statistically significant reductions were not seen for short-term fungal burden assays using combinations of NZ and fluconazole in outbred mice or in inbred mice more susceptible to candidiasis. In a model of rat vaginal candidiasis, the combination of NZ and R 3783 administered either orally or vaginally was more effective than the drugs used singly. Thus, under certain conditions, combination therapy with nikkomycin and select azoles may offer promise for an increased therapeutic effect in candidiasis.

Segregation of Na(+)-channel gene expression during neuronal-glial branching of a rat PNS-derived stem cell line, RT4-AC

RT4 is a family of cell lines isolated from an ethylnitrosourea-induced rat peripheral neurotumor. RT4-AC cells express both excitable membrane and glial cell properties. In a process called cell-type conversion, RT4-AC cells segregate these properties to generate three distinct derivative cell types which have been classified as either neuronal (RT4-E and RT4-B) or glial (RT4-D). In this report we demonstrate that: (1) upon cell-type conversion, Na(+)-channel mRNA expression segregates primarily with the RT4 neuronal derivatives, (2) the SkM2 Na(+)-channel gene, which was originally isolated from rat muscle cDNA libraries, is the predominant gene expressed by the RT4 neuronal derivatives, (3) the three rat brain Na(+)-channel genes I, II, and III and the muscle-derived SkM1 gene are not the principal Na(+)-channel genes involved in the segregation, although very low levels of message of these genes are detected, and (4) the RT4 glial derivative expresses slightly higher levels of message from rat brain genes I and II than the neuronal derivatives. Since the RT4 cell lines were derived from a peripheral neurotumor these results present the possibility that the SkM2 gene may be important in vivo in the rat peripheral nervous system.

[Two cases of laryngeal sac suppuration in orangutans in the Münster Zoological Park (all weather zoo)]

It is reported on two cases of pyosis of the laryngeal pouch in two Orang-outangs. In one case the disorder led to the death of the animal within three months, while the other was treated surgically and the pus drained. The discussion is based on available literature. The masked feature of the disorder and its insidious progress is pointed out. The cause is attributed to hereditary disposition and faulty zoo-keeping.

[The value of occlusion plethysmography and stress venous pressure in functional diagnosis following leg vein thrombosis]

In 52 patients with condition after thrombosis of the deep leg veins before discharge from hospital the venous capacity and the venous outflow were measured on the two legs by means of occlusion plethysmography of the veins as well as the percental decrease of the venous pressure during action of the leg muscles by means of phlebodynamometry. The results have been compared with the phlebography. 10 patients again had a venous system without pathologic findings, in 12 patients unchangedly was a complete and in 30 ones in incomplete occlusion. By means of the measuring of the venous pressure still existing obstacles of the outflow of the pelvic and femoral region could be separated from the lower leg and their degree of severity, too, could be quantified. The venous capacity and the venous outflow allowed with sufficient security to delimit the values of the healthy leg from those of the postthrombotic one, whereas a localization of the height and a further quantification of the postthrombotic condition failed. Improved technology of the devices as well as the establishment of venous capacity and venous outflow in one measuring process increase the value of the venous occlusion plethysmography clearly as a non-invasive method which can be carried out by a function-assistant.

[Problems in intramural and ambulatory drug therapy of heart insufficiency following myocardial infarct]

In 105 patients with acute myocardial infarction the intake of glycosides and diuretics according to indication was controlled in the period from the end of the acute phase up to the first year. Despite lacking clinical signs of a cardiac insufficiency the treatment established in the clinic was performed in an unchanged way up to the first year. It is the common task of the family doctors and cardiologists to take part in a scientific prescription of glycosides and diuretics after infarction.

[Effect of long-term therapy with prazosin/propranolol on blood pressure and cardiopulmonary function in essential hypertension]

In 25 hypertensives (42 +/- years), predominantly at stage I according to WHO-criteria, by the application of daily 5 +/- 4 mg prazosine and as combination of 9 +/- 6 mg with 73 +/- 31 mg propranolol the blood pressure normalized itself from on an average 183 to 148 mgHg systolically and 113 to 93 mgHg diastolically. In a long-term experiment confirmable also echocardiographically prazosine alone decreased the afterload of the heart in an unchanged high energy requirement at rest, and in a submaximal ergostasis the aerobic metabolic situation deteriorated. This could again be balanced by the combination with propranolol, whereby oxygen pulse, product of the pressure frequency and PWC 130 even improved. Function and size of the left ventricle remained echocardiographically uninfluenced in the two forms of therapy.

[Relation of elevated ST segment in the electrocardiogram to echocardiography determined wall kinetics in patients after myocardial infarct]

The connection of ECG findings and disturbances of the kinetics after myocardial infarction was controlled on 104 patients in correlation to the echocardiography. The investigations were performed at discharge from hospital and in the 3rd month after infarction by means of ECG at rest and exercise electrocardiogramme as well as echocardiography. In this case was shown that the elevation of the ST-segment after anterior-wall infarction was above all the expression of an ischaemia and was in most cases accompanied by an akinesia of the anterior wall. Only patients with a precordial ST-elevation over 2 mm at rest with increase to more than 4 mm under exercise or patients with a smaller ST-elevation, but a symptom-limited performance to 50 Watt, connected with ST-elevation, ventricular extrasystoles or pathological diastolic pressure of the pulmonary arteries as withdrawal criterion belonged to the group with dyskinesias and aneurysms, respectively.

[Effective use of study procedures using instruments in infarct patients before discharge from the clinic]

81 males and 23 females after myocardial infarction at the age of 61 +/- 12 and 69 +/- years, respectively, were examined at the end of the stay in the clinic and after one year by means of ergometry and echocardiography. While at the discharge from the clinic the females reached maximally only 50 Watt, 34.7% of the males transgressed this achievement. Also in the watt pulse and in the product of the pressure frequency these patients reached high values, less frequently showed pathological ST segments under exercise and echocardiographical revealed a smaller left ventricle, a greater shortening fraction as well as more insignificant disturbances of the kinetics. This group-typical behaviour remained up to the first year. In patients with pathological diastolic pressure of the pulmonary artery at rest in 8% the latent left heart insufficiency could clinical not be recognized and in those patients with pathological pressure under exercise 54% finished the ergometry without any other recognizable reasons of discontinuation. Finally, the patients who died up to the first year belonged to the group with complications in the intensive care unit, with high resting pulse rate, pathological diastolic pressure of the pulmonary artery, large left ventricle as well as left atrium and low shortening fraction at rest and low watt-number, when discharged from hospital.

[Long-term ergometry and echocardiography results in patients following acute myocardial infarct with the best possible completion of rehabilitation phase I in accordance with the indications]

55 patients (43 males at the age of 60.3 +/- 10.8 years and 12 females at the age of 71.6 +/- 8.4 years) with earliest possible end of the rehabilitation phase I after acute myocardial infarction beginning with the end of the second week were as to their ergometric and echocardiographic parameters compared with an identical control group with usual duration of mobilisation. When discharged from hospital and one year after infarction they obtained with 50 to 23 and 72-26 watt respectively, the same numbers of watt as the patients of the control group. In the two groups the increase in vitality after the first year was obtained exclusively by men. In a short duration of phase I of two weeks they obtained the most favourable values with regard to number of watt, product of pressure rate, diastolic pulmonary pressure, diameter of left ventricle and atrium as well as to the shortening fraction at discharge from hospital and one year after infarction. The values were identical to those in the control group with usual duration of the rehabilitation phase I.