[Patient education--support--help with decisions: ethical aspects in treatment of amyotrophic lateral sclerosis]

Patients with amyotrophic lateral sclerosis (ALS) develop progressive, degenerative loss of muscle function while retaining mental capacity. This implies special problems of patient information, which should be phase-adapted and patient centered. The difficult task of the physicians requires to provide sufficient information, to enable shared decision-making, without leaving the patient alone. Respiratory failure due to loss of muscle function is often the limiting problem. However, the possible option of ventilatory support opens the question when to stop treatment. It is most important to differentiate between intended mercy-killing and foregoing treatment due to the patient's wish. Discontinuation of treatment is morally justifiable, even required, if the patient refuses further treatment. Advance directives may be helpful to make decisions according to patients' preferences in time.

Prostate-specific antigen corrected for prostate volume improves differentiation of benign prostatic hyperplasia and organ-confined prostatic cancer

OBJECTIVE

To determine whether the ratio of PSA and prostate volume provides additional useful information for the discrimination of benign prostatic hyperplasia from prostatic carcinoma.

PATIENTS AND METHODS

Since 1989, a prospective study has been in progress involving 229 patients (49 with locally confined prostatic carcinoma, 180 with benign prostatic hyperplasia) to establish whether the ratio of prostate-specific antigen (PSA) and prostate volume, determined by transrectal ultrasound (longitudinal x anterior-posterior x transverse diameter x 0.52), allows a better differentiation than the absolute PSA values.

RESULTS

In this population of patients with prostatic disease, the positive predictive value for diagnosis of a prostatic carcinoma was 26% with an absolute PSA threshold value of 4.0 ng/ml, and 36% at a threshold value of 10 ng/ml. With a threshold value of the PSA/prostate volume ratio of 0.25 ng/(ml x cm3), the positive predictive value was 56% compared with 93% for a threshold value of 0.4 ng/(ml x cm3).

CONCLUSION

The ratio PSA/prostate volume is a superior method for the diagnosis of prostatic carcinoma both with regard to its sensitivity and its specificity in patients with absolute PSA values in excess of 4 ng/ml.

Prediction of tumor recurrence after radical prostatectomy using elimination kinetics of prostate-specific antigen

The serum half-life of prostate-specific antigen (PSA) calculated subsequent to radical prostatectomy can serve to predict which patients are at high risk of bearing residual prostatic carcinoma despite their initial attainment of undetectable PSA serum levels. This report updates previous results to a mean follow-up period of 37 months. The initial results are essentially confirmed in that a mean PSA elimination half-life of 1.6 days in patients considered to be cured at least 24 months after prostatectomy provides additional useful information for predicting outcome in patients with potentially curable prostate cancer.

[Eosinophilic fasciitis (Shulman syndrome) as a rare differential diagnosis of sclerodermiform skin changes]

For 3 months, a 70-year-old woman had been affected by painless, symmetrical swellings in the limbs, spreading proximally, causing hardening of the skin and impaired joint movements, but no fever. Her general condition and findings on physical examination were according to age. ESR was 22/42 mm and there was a thrombocytosis (533,000/microliters) and eosinophilia (16%, absolute 2,140/microliters). Radiological and ultrasound examinations were normal. Skin biopsy revealed marked oedema of the connective tissue septa and perivascular lymphohistiocytic infiltrations, which--together with the other findings--suggested eosinophilic fasciitis. She was treated with prednisone, 100 mg daily, reduced gradually to 8 mg daily, as well as cimetidine, 800 mg daily, as immunomodulator, and intensive physiotherapy. The swellings and eosinophilia regressed within 8 weeks, but the hardening and impaired mobility persisted. Maintenance glucocorticoids are being continued.

[The quotient of prostate-specific antigen and prostate volume. Improved differentiation between benign prostatic hyperplasia and locally circumscribed prostate cancer]

Absolute serum prostate-specific antigen (PSA) values are of little help in the identification of locally confined prostatic cancer (PCA), because of a considerable overlap with the PSA values found in benign prostatic hyperplasia (BPH). Prostate gland volumes were estimated sonographically in 112 patients using the product of the three maximal diameters (longitudinal, anterior-posterior, transverse) and the factor 0.52. PSA was determined with a monoclonal immunoenzymetric assay (Tandem-E, Hybritech). The prostates were removed by either transvesical prostatectomy (for BPH) or radical retropubic prostatovesiculectomy (for PCA). In each case the diagnosis was verified by systematic histological examination. The ratio of serum PSA to estimated prostate volume did not exceed 0.4 ng/(ml x ml) in any of the 74 patients with BPH, whereas 23 of the 38 patients with PCA had a ratio above 0.4 ng/(ml x ml). The information provided by the PSA-prostate volume ratio is superior to absolute PSA values in preoperative differentiation between BPH and PCA. With a PSA-prostate volume ratio over 0.4 ng/(ml x ml) patients are at high risk for PCA and should be evaluated by prostate biopsy.

Preoperative corticosteroids. A contraindication to lung transplantation?

Regular preoperative application of corticosteroids has been considered as a contraindication to lung transplantation for fear of an increased risk of postoperative morbidity and mortality. Recently, however, we have accepted patients for transplantation in whom treatment with steroid medication could not be terminated preoperatively. Up to February 1991, 27 unilateral and bilateral transplantations in 26 patients were analyzed. Corticosteroid therapy was discontinued at least three months prior to transplantation in 13 patients (group 1), whereas in 14 cases, the patients continued their daily corticosteroid therapy to the time of transplantation (prednisolone, 0.1 to 0.3 mg/kg/day; group 2). There were no significant differences between the groups with respect to sex, age, diagnosis, or type of transplantation. One limited bronchial dehiscence occurred; the incidence of postoperative bronchial stenosis was identical in both cohorts; one patient died in each group. In conclusion, no increased morbidity or mortality could be found following lung transplantation with regular preoperative administration of prednisolone up to 0.3 mg/kg/day. Thus, patients who cannot be weaned from their steroid medication but who otherwise are acceptable candidates should not be excluded from lung transplantation.

Imaging of pulmonary artery and vein anastomoses by transesophageal echocardiography after lung transplantation

BACKGROUND

In patients after isolated lung transplantation, the postoperative course may be complicated by dysfunction of the pulmonary artery and vein anastomoses.

METHODS AND RESULTS

Pulmonary artery and vein anastomoses in 11 transplanted lungs (four left, four right, and three bilateral lungs) in 10 patients were studied 1 day to 11 months after operation by transesophageal echocardiography (TEE). All 14 pulmonary vein anastomoses, all seven right (100%) and five of seven (71%) left pulmonary artery anastomoses could be visualized by TEE. Thrombosis of a left pulmonary vein anastomosis could be identified by TEE and successfully treated by thrombolysis. TEE detected a significant stenosis in one right and one left pulmonary artery anastomosis; anastomoses dysfunction were confirmed by cardiac catheterization and pulmonary angiography and successfully treated by surgical correction in both cases.

CONCLUSIONS

Function and morphology of pulmonary artery and vein anastomoses in patients after isolated lung transplantation can reliably be assessed by TEE. In patients with suspected dysfunction of an anastomosis, TEE may be considered the diagnostic technique of choice.

Evaluation of lung function during pulmonary rejection and infection in heart-lung transplant patients. Hannover Lung Transplant Group

Pulmonary rejection and infection are the most important complications after lung transplantation. To evaluate the diagnostic value of pulmonary function testing for early detection and discrimination of these complications, seven heart-lung recipients were examined. The diagnosis of each complication was confirmed by clinical and laboratory findings including transbronchial biopsies and bronchoalveolar lavage. Eight episodes of rejection, ten episodes of viral infection and six episodes of bacterial pneumonia were analyzed. Pulmonary rejection was associated with a significant fall in the FEV1/IVC% and the FEF50%. In viral infection, the most impressive finding was a reduction in the DCO, whereas no obstructive or restrictive airway dynamics were observed. During bacterial pneumonia, pulmonary function measurement revealed a decrease in IVC without signs of obstructive airway dynamics. Adequate treatment resulted in reconstitution of pretreatment values. Assessment of lung function provides valuable information for the diagnosis of pulmonary complications following HLTx.

Chronic ethanol treatment of rats and the myocardial β-adrenoceptors

We examined the effect of chronic treatment with ethanol on the dynamics of beta-adrenoceptor binding in left ventricular myocardium of rats. After treatment with BAAM (20 mg/kg i.p.), an irreversible inhibitor of beta-adrenoceptors, the inhibition of beta-adrenoceptor binding was less, and the recovery of receptor binding was faster in chronically ethanol-treated rats compared to the control animals given equicaloric dextrin maltose treatment. When intracellular beta-adrenoceptor recycling was inhibited with colchicine, cytoplasmic left ventricular beta-adrenoceptor binding was greater in ethanol-treated compared to dextrin maltose-treated animals. We conclude that the previously reported decreased functional activity of the beta-adrenoceptor-mediated system probably reflects the contribution of ethanol-mediated effects not entirely restricted to the receptor-binding mechanisms.

3D-surface reconstruction of intravascular ultrasound images using personal computer hardware and a motorized catheter control

A system for three-dimensional (3D) presentation of intravascular ultrasound (US) images was designed. A standard hardware configuration based on personal computer equipment was used for acquisition and processing of image data. Pullback imaging with the US catheter was controlled by a specially designed motor assembly and performed either in equidistant 1-10 mm steps or at a constant retraction speed. Curvature of the vessel was documented on biplane digital subtraction angiograms and the US images were arranged according to the vessel shape in the angiograms. 3D reconstruction appears essential for spatial orientation of intravascular US and may be helpful in the planning of vascular interventions for a better appreciation of the extent and morphology of vascular lesions.

Half-life of prostate-specific antigen after radical prostatectomy: the decisive predictor of curative treatment?

Prostate-specific antigen (PSA) half-life calculated in 51 patients subsequent to radical prostatectomy was found to identify patients with residual disease earlier and more reliably than the criterion of not achieving undetectable PSA levels postoperatively. It is proposed that residual tumor affects the half-life by contributing to the serum level of PSA. When PSA half-life was calculated solely in potentially cured patients, we found a half-life of 1.5 days being considerably shorter than in the previous reports based on patient populations regardless of the outcome of disease in the follow-up.

[Unilateral lung transplantation in terminal pulmonary emphysema]

Early attempts of single lung transplantation for end-stage chronic obstructive pulmonary disease mostly failed due to a ventilation-perfusion mismatch between the allograft and the contralateral native lung. We performed unilateral lung transplantation in a 39-year-old female with severe pulmonary emphysema and could demonstrate in a one year follow-up that the transplanted lung will be given preference for both--ventilation and perfusion in approximately the same ratio (80%/90%). With improvement of pulmonary preservation, individual adjustment of immunosuppression and detailed monitoring of the transplanted lung unilateral lung transplantation becomes a therapeutical option in patients with severe emphysema.

[Meat as component of a balanced diet]

From the point of view of the nutritionist, meat has an important role to play in supplying the body with proteins (essential amino acids, vitamins and minerals). There is no doubt that meat is the most valuable source of dietary iron. These facts make meat an important constituent of a balanced diet in a range of age and performance groups, including children and adolescents, pregnant women and nursing mothers, senior citizens and athletes. In the discussion about the nutritional/physiological quality of meat and meat products, total fat, cholesterol and purines must also be considered. About 80 g of lean meat per day, or a portion of about 150 g three times a week in patients with disorders of fat metabolism or elevated uric acid levels complies with the recommendations for low-fat and low-cholesterol alimentation, and helps ensure a balanced diet.

[Unilateral lung transplantation]

For patients with terminal pulmonary fibrosis unilateral lung transplantation offers a new therapeutic option. At the Hannover Medical School 5 patients have been successfully treated by single lung transplantation. In 3 patients a left, and in 2 patients a right lung transplant was performed. One patient required intraoperative support by cardiopulmonary bypass. Bronchial omentopexy was used in all instances. Currently all patients are alive. A marked improvement of pulmonary function parameters was seen in all cases. The patients are all able to lead a normal life.

The QA program evaluation: a powerful punch

Even the best quality assurance program requires periodic review in order to attain or regain maximum efficiency and effectiveness. The JCAHO standard for annual QA program evaluation adds impetus to this obligation. Riverside Methodist Hospitals' QA program evaluation is constructed in a three year cycle. Internal evaluation in year one and external expert evaluation in year three are balanced in year two with a combined internal/external program review. The year one internal evaluation discussed in the article outlines a framework for evaluation which includes positioning the evaluation for maximum influence, identifying key QA program components and designing meaningful, comprehensive evaluation inputs. The informed judgments of professionals, as well as traditional documentation review, provide powerful evaluative insights. Evaluation outputs include a program rating, an identification of program strengths and weaknesses, and targeted recommendations for QA program improvements.

[A computerized processing unit for ambulatory diagnosis of sleep apnea and nocturnal hypoxemia]

A new mobile device for the evaluation of the sleep-apnoea-syndrome in outpatients prior to conventional polysomnography, processes and stores the oronasal airflow detected by a thermistor, and the heart rate and oxygen saturation in a microprocessor unit. The major problem in on-line data processing of these variables is the interpretation of the thermistor signal for correct apnoea detection. This preliminary study investigates the reliability of the computer algorithm by control of the automatic airflow assessment. With a sensitivity of 97.3% the algorithm proved to be extreme reliable. Combined with the detection of heart rate and oxygen saturation it provides the capacity for comprehensive analysis of cardiorespiratory events and appears to be suitable for application in an outpatient setting.

[A modified unit for detecting sleep apnea]

A comprehensive diagnostic work-up of patients with a suspected sleep apnea syndrome must include conventional polysomnographic monitoring during the night. On account of the considerable staff and technical requirement, however, this definitive diagnostic measure is not suitable for use as a screening programme. For this reason we undertook to develop a device for the computer-aided recording of sleep apnea. The heart of the unit is a 65816 microprocessor with an address capacity of 16 Mbytes. The oro-nasal airflow is recorded with the aid of thermistors, and, after digital filtering, the respiratory rate is continuously recorded on the basis of this signal. Continuous recording of the heart rate and oxygen saturation, is also effected, the recorded data being stored in the microprocessor. On conclusion of the data acquisition phase, evaluation and a compressed display is shown on any conventional personal computer. Our preliminary experience reveals that the algorithm employed is extremely reliable for the detection of respiration rate and apnea, even in the presence of unfavourable signal forms. Clinically relevant deviations from manual evaluation do not occur. As was to be expected, processing of the signals for heart rate and oxygen saturation presented no problems.

[Protective effect of ketotifen and disodium cromoglycate in bronchial challenge tests with allergens (author's transl)]

The protective effect of ketotifen and disodium cromoglycate (DSCG) was evaluated by a randomised double blind cross-over study in 15 children with allergic bronchial asthma. 13 children were allergic to house dust mite (Dermatophagoides pteronyssinus), two to grass pollen. After a positive bronchial challenge test ketotifen or DSCG was given for 4 days followed by bronchial challenge with increasing allergen concentrations. Seven patients showed better allergen tolerance after ketotifen, 5 after DSCG. Protective action against late reactions was found only in 2 children after ketotifen and one child after DSCG.

[Mercury concentrations in the air, in the blood and urine of dentists in dental clinics and free practice]

The concentration of mercury in the air was measured for 12 assistants and students, 27 dentists, and 42 dental assistants. The total concentration of mercury in the blood and the urine was also determined and compared with a control group. The results were as follows: 1. The highest concentration of mercury in the air (3--12 microgram Hg/m3) appeared only briefly. 2. The mercury concentration in the spontaneous urine of the dentists and dental assistants (6 microgram/l) was only slightly higher than that for the nonexposed control group (4 microgram/l). 3. The mercury concentration in the whole blood of the students (22 microgram/l) was the highest; that of the dentists and dental assistants (with several years exposure to mercury vapor, 7.0 and/or 6.5 microgram/l) was only slightly higher than that of the nonexposed control group (5 microgram Hg/l).