ALSUntangled #73: Lion's Mane

Lion's Mane (Hericium erinaceus) has historically been used as traditional medicine in Asia and Europe for its potential benefits in fighting infection and cancer. It has gained interest in the neurodegenerative disease field because of its mechanisms of action; these include anti-inflammation, neuroprotection, and promoting neurite growth demonstrated in various cell and animal models. A very small, double-blind, placebo-controlled trial in patients with mild cognitive impairment showed a temporary improvement in cognitive function; this finding has yet to be replicated. However, there have been no studies in ALS cell or animal models or in humans with ALS. Lion's Mane appears safe and inexpensive when consumed in powder or capsule, but one anaphylactic case was reported after a patient consumed fresh Lion's Mane mushroom. Currently, we do not have enough information to support the use of Lion's Mane for treating ALS. We support further research in ALS disease models and clinical trials to study its efficacy.

Prevalence of silent atrial fibrillation in high-risk patients - preliminary results from a European three-country handheld ECG-screening study

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Helsefonden Lilly and Herbert Hansens Foundation

Introduction

Patients with atrial fibrillation (AF) should in most cases be offered prophylactic anticoagulation treatment to prevent a stroke. However, the arrhythmia can appear without symptoms, so-called silent AF. Even without symptoms AF constitutes a risk for stroke.

Purpose

To screen high-risk patients with diabetes type 2 (DMII) or heart failure (CHF) for silent AF.

Methods

We included patients > 64 years with either DMII or CHF from out-patient clinics and local health centers. Exclusion criteria were known AF, anticoagulation treatment, recent stroke, or an implanted pacemaker or ICD. Patients were recruited from a total of eleven study centers in three countries. All underwent 14-days of intermittent ECG screening with a handheld ECG recording four times each day; the recordings were digitally stored. AF was diagnosed in cases of irregular heart rhythm and absence of P waves on at least one recording (thirty seconds) or on at least two recordings for a minimum of ten seconds.

Results

In total, 813 patients were included, 541 of these with DMII. The mean age was 73,4 years ± 5,8 SD, 40,7% of the patients were female.

In the DMII group thirteen patients (2.4%) were diagnosed with silent AF and offered anticoagulation. In the CHF group six (2.2%) patients had diagnosed silent AF on the handheld ECG. The prevalence of AF increased with increasing age, see Table 1. Thus, in the youngest group AF was diagnosed in 1.3% of the patients compared to 3.9 % in the age group 75 years or older.

Conclusions

Screening for silent AF in high-risk patients with DMII or CHF seems worthwhile, especially in patients 75 years or older. Abstract Figure. ECG with atrial fibrillation

SAT0632-HPR PATIENTS VIEW ON CONSULTATION IN OUTPATIENT CLINIC – FROM SATISFACTION TO DEMAND OF GUIDANCE INTO MORE SELF-MANAGEMENT

Background:

Patients with rheumatic diseases, routinely consult the outpatient clinic 1-2 times a year to see their rheumatologist. Many of the patients also attend nurse-led consultations to receive instructions, regarding treatment in association to their intravenous treatment, or DMARD dispensing in the clinic. As clinicians we have an assumption of what the ”good practice” is in relation to the patients, but we have little insight, into the patients’ own experience and satisfaction.

Objectives:

To investigate the patients views on the level of information, and their experience and satisfaction with the doctor and nurse-led consultations in the outpatient clinic.

Methods:

The approach of the survey was both quantitative and qualitative. A questionnaire was designed with four questions on a matrix scale concerningtheir information level on their disease/symptoms;their treatment;if they had received written material and if so, it’s value; andtheir possibility to talk about subjects that matters for them during consultations. To gain a qualitative approach with focus on the patients’ experiences and comments, every question was constructed with space for comments. Comments were transcribed, indexed, analysed, and thematically divided. The inclusion of patients were all patients visiting the clinic within a specific week in January 2019.

Results:

The results from the four questions, are shown in the figures below, measured in percentage. In total, 283 participated (response rate 60%).

Four themes covered from the analysis of patients’ comments.“Seeking own answers”, “Own coping – effort”, “Conversation with doctor/nurse”and“Treatment/medication”.Comments revealed many descriptions and stories of patients, showered with all types of suggestions of taking control or managing the disease by them self, from their family or media. It also revealed their interest in discussing, these subjects and matters with the doctor/nurse, without being rejected. The feeling of rejection resulted in some patients trying other treatments or introducing changes in their lifestyle, without involving the doctor. The patients also called for more knowledge about physical training, and not only medical treatment.

Conclusion:

In general, the patients had a very positive perception towards the consultations, and the information from the outpatient clinic. Despite that, the themes indicated a pattern, that needs to be considered, so clinicians acknowledge the patients wish for guidance, besides the medical treatment. To support the patient, without leaving them with a feeling of being rejected, we need to consider how to articulate the subjects the patients are exposed to outside our clinic, so the patients feel free to inform or involve the clinic instead of being silent, in risk of counteracting the medical treatment.

Acknowledgments:

We are grateful to the participants who shared their experiences. We also thank an internal research group taking part of the investigation.

Disclosure of Interests:

Ida Lund: None declared, Annette Hansen Consultant of: AbbVie, Speakers bureau: Eli Lily, Betina Stampe: None declared, René Cordtz: None declared, Lene Dreyer: None declared

Determinants of trabecular bone score and prevalent vertebral fractures in women with fragility fractures: a cross-sectional sub-study of NoFRACT

Determinants of trabecular bone score (TBS) and vertebral fractures assessed semiquantitatively (SQ1-SQ3) were studied in 496 women with fragility fractures. TBS was associated with age, parental hip fracture, alcohol intake and BMD, not SQ1-SQ3 fractures. SQ1-SQ3 fractures were associated with age, prior fractures, and lumbar spine BMD, but not TBS.

INTRODUCTION

Trabecular bone score (TBS) and vertebral fractures assessed by semiquantitative method (SQ1-SQ3) seem to reflect different aspects of bone strength. We therefore sought to explore the determinants of and the associations between TBS and SQ1-SQ3 fractures.

METHODS

This cross-sectional sub-study of the Norwegian Capture the Fracture Initiative included 496 women aged ≥ 50 years with fragility fractures. All responded to a questionnaire about risk factors for fracture, had bone mineral density (BMD) of femoral neck and/or lumbar spine assessed, TBS calculated, and 423 had SQ1-SQ3 fracture assessed.

RESULTS

Mean (SD) age was 65.6 years (8.6), mean TBS 1.27 (0.10), and 33.3% exhibited SQ1-SQ3 fractures. In multiple variable analysis, higher age (β_{per SD} = - 0.26, 95% CI: - 0.36,- 0.15), parental hip fracture (β = - 0.29, 95% CI: - 0.54,- 0.05), and daily alcohol intake (β = - 0.43, 95% CI - 0.79, - 0.08) were associated with lower TBS. Higher BMD of femoral neck (β_{per SD} = 0.34, 95% CI 0.25-0.43) and lumbar spine (β_{per SD} = 0.40, 95% CI 0.31-0.48) were associated with higher TBS. In multivariable logistic regression analyses, age (OR_{per SD} = 1.94, 95% CI 1.51-2.46) and prior fragility fractures (OR = 1.71, 95% CI 1.09-2.71) were positively associated with SQ1-SQ3 fractures, while lumbar spine BMD (OR_{per SD} = 0.75 95% CI 0.60-0.95) was negatively associated with SQ1-SQ3 fractures. No association between TBS and SQ1-SQ3 fractures was found.

CONCLUSION

Since TBS and SQ1-SQ3 fractures were not associated, they may act as independent risk factors, justifying the use of both in post-fracture risk assessment.

Ratings of pain and activity limitation on the visual analogue scale and global impression of change in multimodal rehabilitation of back pain - analyses at group and individual level

PURPOSE

To evaluate changes in pain intensity and activity limitation, at group and individual levels, and their associations with the global impression of change after multimodal rehabilitation in patients with back pain.

METHOD

Patients with long-term back pain (n = 282) participated in a 4-week programme with a follow-up after 6 months. Visual analogue scales (VAS) were used to rate pain intensity and activity limitation. Global impression of change (GIC) was rated on a 7-category scale. The sign test, the Svensson method and the Spearman rank correlation were used for analyses.

RESULTS

Significantly lower ratings in pain and activity limitation at follow-up were found at group level. However, a large individual variability was found by the Svensson method. The correlations between GIC and changes in pain and activity limitation were rs  =  0.49 and rs  =  0.50, respectively. A rated GIC of at least "much better" on group level showed changes of  ≥20 mm on the VAS.

CONCLUSIONS

At group level, lower VAS ratings were found in patients with back pain. However, a large individual variability in pain and activity limitation was also found resulting in low to moderate associations between GIC and the change in VAS ratings. The large individual variability might be due to the impreciseness in the ratings on the VAS. We have presented a critical discussion of statistical methods in connection with the VAS. Implications for Rehabilitation The use of VAS as a rating instrument may be questioned, especially for perceived pain intensity which is a too complex experience to be rated on a line without any visible categories. Single ratings of pain intensity should preferably be complemented with the ratings of activity limitation in patients with long-term back pain. Global impression of change is a suggested inclusive rating after rehabilitation. The improvement desired by the patient should preferably be determined before rehabilitation.

Gender related differences in pain in spinal cord injured individuals

STUDY DESIGN

Out of a population of 456 patients with spinal cord injuries (SCI), 130 having pain were selected after matching, based on gender, age, American Spinal Injury Association (ASIA) impairment grade and level of lesion.

OBJECTIVE

To investigate whether gender differences with regard to pain perception and prevalence exist in a population of patients following spinal cord injury.

SETTING

Spinalis SCI Unit (out-patient clinic), Stockholm, Sweden.

METHOD

130 patients suffering from pain were assessed over a 12-month period in a yearly health control.

RESULTS

SCI women had a higher prevalence of nociceptive pain than men and their use of analgesics was greater. However, no differences between the sexes could be seen regarding pain and localization, onset, distribution, factors affecting pain, number of painful body regions, pain descriptors, ratings of pain intensities or in pain and life satisfaction.

CONCLUSION

This study showed that SCI men and women describe their pain very similarly. However, SCI women had a higher prevalence of nociceptive pain than men and their use of opiates and non-steroid anti-inflammatory drugs (NSAIDs) was greater.

Reliability and responsiveness of three different pain assessments

The visual analogue scale (VAS) and ordered categorical scales, i.e. numeric rating scales (NRS), are commonly used in the assessment of pain. However, these scales are bounded by fixed endpoints and thus the range of measurement is limited. The disparity in repeated assessments of perceived pain intensity with the VAS, NRS, and electrical stimulation applied as a matching stimulus was studied in 69 patients (48 women and 21 men, 19-72 years) with chronic nociceptive or neurogenic pain. Responsiveness with transcutaneous electrical nerve stimulation (TENS) using the same measurement procedures was evaluated in the same patients. Comparison of results from the three pain assessments showed that the painmatcher is at least as reliable and responsive as VAS and NRS. None of the three measurements showed evidence for systematic disagreement and had only significant random individual disagreement. They also showed evidence for responsiveness.

[Gerontopsychiatric treatment in comparison between integrated management at a university and separated management at a district hospital. 1: Patient characteristics]

OBJECTIVE

We wanted to study differences between geriatric psychiatric patients and their management in an integrated (with other adult age groups) care in the University Psychiatric Hospital (PUK) compared to those in a separated (only according to age) care in the Psychiatric State Hospital (LKH), which together treat all psychiatric inpatients in Goettingen, Germany.

METHOD

We performed standardized chart reviews of randomly selected groups of patients, who had been treated in the PUK (n = 151) and the LKH (n = 145) in the years 1991 and 1992.

RESULTS

The LKH patients were significantly older (74.8 +/- 8.7 y versus 70.3 +/- 8.3 y), more often living alone and/or without children. 31.9% of them were living in a nursing home compared to 6.5% of the PUK patients. Psychic disorders had not shown up before old age in 55.7% of all cases. 50.4% of the patients were in a psychiatric hospital for the first time. The majority of the patients (65.6%) had not been investigated by a psychiatrist before admission.

CONCLUSIONS

More socially handicapped patients were treated in the LKH. For most cases, the hospital treatment had been the first psychiatric treatment at all.

[Gerontopsychiatric treatment in comparison between integrated management at a university and separated management at a district hospital. 2: Diagnoses and treatment]

OBJECTIVE

We wanted to study differences between geriatric psychiatric patients and their management in an integrated (with other adult age groups) care in the University Psychiatric Hospital (PUK) compared to those in a separated (only according to age) care in the Psychiatric State Hospital (LKH), which together treat all psychiatric inpatients in Goettingen, Germany.

METHOD

We performed standardized chart reviews of randomly selected groups of patients, who had been treated in the PUK (n = 151) and the LKH (n = 145) in the years 1991 and 1992.

RESULTS

Most patients of the LKH suffered from organic brain diseases/dementia (63.4%; PUK: 29.1%). In the PUK, depression was the most frequent diagnosis (57.6%; LKH: 21.1%). A part of about 25% of the patients showed neurological deficits. Specialised diagnostics were performed mostly in the PUK. Both institutions treated the wide majority of patients with CNS drugs. Antidementia drugs were given significantly more often in the LKH. About one third of the patients were released into changed living environments.

CONCLUSIONS

Patients with further progressed dementias were treated mainly in the LKH. This has consequences for diagnostics, treatment duration and side effect rate.

Sensory stimulation (massage) reduces blood pressure in unanaesthetized rats

The objective of this study was to investigate how sensory stimulation by massage-like stroking influences blood pressure and heart rate in conscious rats. Also, the influence of different locations and durations of the stimulation were assessed. For this purpose, the ventral side of the abdomen or the dorsal side of the back was manually stroked at a speed of approximately 20 cm/s, with a frequency of 0.67 Hz and at an estimated pressure of 100 mm H2O. During the treatment, the rats were held across the scapula and the neck region. Blood pressure and heart rate were measured with the cuff technique before treatment and repeatedly during the post-stimulatory period. Massage-like stroking for 5 min of the abdominal area produced a maximum decrease of approximately 20 mm Hg in blood pressure and 60 beats/min in heart rate. This reduction remained significant at 3 and 4 h after stimulation, respectively. Stimulation of the abdominal area for 2 min produced a less pronounced decrease in blood pressure as compared to the 5-min stroking. Stroking of the back resulted in a short-lasting blood pressure increase that gradually returned to the baseline level within the post-stimulatory observation time. Control animals that were handled in the same way as the experimental animals except for the stroking showed an increase of approximately 20 mm Hg in blood pressure and 60 beats/min for about 1 h after the cessation of the handling. The responses of the blood pressure and heart rate to both abdominal and back massage were significantly inhibited as compared to the control animals. These results suggest that massage-like stroking of the skin produces an inhibitory effect on the cardiovascular excitatory responses in rats. Especially, the results of the present study demonstrate that massage-like stroking of the abdomen reduces both blood pressure and heart rate below the pre-stimulus baseline levels.

Stroking of the abdomen causes decreased locomotor activity in conscious male rats

The specific aim of the present study was to determine if stroking in conscious rats can influence spontaneous locomotor behavior in an open-field arena. For this purpose, conscious rats were held across the scapula and the ventral side of the abdomen was stroked at a pressure of 100-150 mm H2O and at a speed of approximately 20 cm/s. The stimulation frequency was approximately 40 strokes/min and the duration 2, 5, and 10 min. Animals held for 10 min served as controls. There was a significant decrease in rearing and locomotion and a significant increase in peripheral activity in the open-field arena after the treatment. Maximal effects were obtained after 5 min of stroking. These effects were consistent with a stroking-induced sedative effect similar to that seen in this open-field arena model following neuroleptics or large doses of oxytocin.

Massage-like stroking of the abdomen lowers blood pressure in anesthetized rats: influence of oxytocin

The aim of this study was to determine how massage-like stroking of the abdomen in rats influences arterial blood pressure. The participation of oxytocinergic mechanisms in this effect was also investigated. The ventral and/or lateral sides of the abdomen were stroked at a speed of 20 cm/s with a frequency of 0.017-0.67 Hz in pentobarbital anesthetized, artificially ventilated rats. Arterial blood pressure was recorded with a pressure transducer via a catheter in the carotid artery. Stroking of the ventral, or both ventral and lateral sides of the abdomen for 1 min with a frequency of 0.67 Hz caused a marked decrease in arterial blood pressure (approx. 50 mmHg). After cessation of the stimulation blood pressure returned to the control level within 1 min. The maximum decrease in blood pressure was achieved at frequencies of 0.083 Hz or more. Stroking only the lateral sides of the abdomen elicited a significantly smaller decrease in blood pressure (approx. 30 mmHg decrease) than stroking the ventral side. The decrease in blood pressure caused by stroking was not altered by s.c. administration of an oxytocin antagonist (1-deamino-2-D-Tyr-(Oet)-4-Thr-8-Orn-oxytocin, 1 mg/kg) directed against the uterine receptor. In contrast, the administration of 0.1 mg/kg of oxytocin diminished the effect, which was antagonized by a simultaneous injection of the oxytocin antagonist. These results indicate that the massage-like stroking of the abdomen decreases blood pressure in anesthetized rats. This effect does not involve intrinsic oxytocinergic transmission. However, since exogenously applied oxytocin was found to diminish the effect of stroking, oxytocin may exert an inhibitory modulatory effect on this reflex arc.

Acro-osteolysis (Hajdu-Cheney) syndrome: report of a case with abnormal tooth structure

The acro-osteolysis (Hajdu-Cheney) syndrome is a rare disorder of bone metabolism characterized by progressive dissolution of a number of bones. Although previous reports have detailed several dental abnormalities associated with this syndrome, this is the first report describing structural changes in the dentin and cementum of teeth.

[Periorbital and orbital cellulitis in children]

During a six-year period 28 febrile children with acute periorbital swelling were identified. Median age was 1.8 years (range, two weeks-nine years). When possible, the children were classified as having preseptal cellulitis (infectious focus in the subcutaneous tissue in front of the orbital septum) or postseptal cellulitis (focus in the paranasal sinuses). In six children a diagnosis of preseptal subcutaneous cellulitis was based upon the clinical presentation and positive culture results. Five children were additionally classified as having preseptal cellulitis due to severe conjunctivitis. Fifteen children were classified as having postseptal cellulitis due to infection in the paranasal sinuses (ethmoiditis). In seven of the latter cases the diagnosis was based upon the results of CT/MR-scans or operation. Two children could not be classified. All children were given antibiotic treatment and four had an operation. There were no recurrences or sequelae. In our study a presumed diagnosis could be made in retrospect in most cases, but at the time of presentation the clinical picture was often confusing. We found a CT- or MR-scan to be most helpful, especially in identifying the children requiring surgical treatment.

Myocardial and microvascular injury following coronary surgery and its attenuation by mode of reperfusion

In 14 patients undergoing coronary surgery, repeated atrial biopsies were obtained before and at the end of ischemia, and at 20 and 60 min of reperfusion. In half of the patients reperfusion was initiated with an abrupt rise in blood temperature and pressure, in the other half with a gradual rise. The biopsies were prepared for transmission electron microscopy and analyzed by stereological technique. In all biopsies, myocytic injury, as revealed by mitochondrial changes and intracellular edema, occurred following ischemia (P = 0.0003 and 0.007, respectively). The intracellular edema regressed following 20 min of reperfusion (P = 0.008). The myocytic mitochondrial changes persisted during reperfusion towards the end of the observation period (P = 0.0001). Interstitial edema increased following ischemia (P = 0.007) and persisted following 60 min of reperfusion (P = 0.009). The capillary part was significantly reduced after 20 min of reperfusion (P = 0.003), probably reflecting interstitial edema. Most changes were reversible in nature, although foci of irreversible changes were shown. In patients with a gradual start of reperfusion there was a significant regression of interstitial edema (P = 0.005) at 60 min reperfusion compared to the patients with an abrupt start, where the same changes seemed to persist or even increase. The study demonstrates that "reperfusion injury" occurs in human myocardium. It can be discerned from "ischemic" injury, and it may be reduced by a gentle mode of reperfusion.

[Muscle tissue for diagnosis of neuromuscular diseases. Procedures of specimen taking, transport and preparation]

In this review we describe surgical methods for open muscle biopsy. In order to obtain optimal tissue quality, correct handling of the muscle specimens at all stages of the procedure is essential. A technologist who is familiar with the procedure should be present in the operating room. This is important to ensure that specimens for histochemical or biochemical studies are frozen immediately and specimens for electron microscopy are fixed without delay. We describe procedures for processing the specimens for cryostat sections, paraffin sections and electron microscopy, and a simple method for handling muscle specimens in local hospitals before transfer to a hospital with a neuropathological service.

Mitochondrial diseases and myopathies: a series of muscle biopsy specimens with ultrastructural changes in the mitochondria

From 1986 to 1991, 472 muscle biopsy specimens from patients from different hospitals in Norway were examined. Of these, 364 were embedded for electron microscopy, and 194 were examined with electron microscopy. Ultrastructural alterations in the mitochondria were detected in 49 of these specimens. Characteristic electron microscopic findings included subsarcolemmal accumulation of abnormal mitochondria of various shapes and sizes, often containing electron-dense granules and sometimes lipid vacuoles in the mitochondria and diffusely electron-lucent matrix space. Paracrystalline inclusion bodies were seldom seen in specimens from young patients, but in some cases mitochondrial electron-dense granules at the cristae were found. These amorphous densities are consistent with lipoproteins, suggesting that they may represent an early stage of paracrystalline inclusions. Biochemical and genetic exploration of the patients with biopsy specimens suggesting mitochondrial disease indicated maternally genetic inheritance and an enzyme defect in the respiratory chain in 21 patients in two families. Three patients had MELAS syndrome, 7 Marinesco-Sjögren syndrome, and 2 Kearns-Sayre syndrome. Five family members had ptosis, cardiomyopathy, mild myopathy, and increased lactate in cerebrospinal fluid and serum. In addition to the diseases mentioned above, changes in the mitochondria were detected in other conditions such as Rett's syndrome (n = 1), ornithine transcarbamylase deficiency (n = 2), and hypothyroidism (n = 2) as well as in 3 patients with clinical and laboratory results indicative of inflammatory myopathy and 3 patients with clinical and laboratory findings consistent with peripheral neuropathy. It is concluded that, although ultrastructural changes in the mitochondria may represent unspecific findings, electron microscopic examination of muscle biopsy specimens is a useful screening method to select specimens for further biochemical analysis and to obtain an early and more precise diagnosis of the disease.

[Mitochondrial diseases. Diagnostic light and electron microscopic changes in muscle biopsies from patients with mitochondrial myopathy]

Mitochondrial myopathy can be caused by several metabolic defects in the mitochondria. Cells with high levels of oxidative metabolism, such as skeletal muscle, myocardium and brain cells, are particularly vulnerable to these defects. We describe the structural changes in muscle biopsies from 49 patients with mitochondrial myopathy. The younger patients were often symptom-free, but the possibility of a genetic defect was suggested by the family history. "Ragged-red fibres" were found in 10% of the biopsies. Typical paracrystalline inclusions were seen in the mitochondria of the oldest patients. Electron-lucent matrix and increased thickness of the inner membranes of the mitochondria in particular were found in the younger patients. Disorganization of cristae, with cristolysis and unfolding of the cristae was also found. We suggest that structural mitochondrial changes in mitochondrial myopathy constitute a stepwise process and that the mitochondrial alterations of the cristae may represent an early stage in the morphogenesis of mitochondrial disease.

Ultrastructural changes in rat hearts following cold cardioplegic ischemia of differing duration and differing modes of reperfusion

Morphologic consequences of prolonged global hypothermic (15 degrees C), cardioplegic ischemia and two reperfusion techniques were studied in Langendorff-perfused rat hearts. A 'gentle' reperfusion technique, with gradual rise in perfusate temperature and pressure to physiologic levels over 30 min, was used for 12 hearts following 2-hour or 3 1/2-hour (6 in each group) ischemia. Abrupt reperfusion, with perfusate at 37 degrees C and 70 mmHg, was performed on 13 hearts (6 ischemic for 2 hours and 7 for 3 1/2 hours). Six nonischemic, perfused hearts served as controls. Randomly selected specimens from the left ventricle after 45-60 min reperfusion were prepared for transmission electron microscopy. Volume fractions of myocardial structural components were calculated from stereologic point-counting on the electron micrographs. Two-way analysis of variance revealed that interstitial edema developed with increasing ischemic time and was not influenced by reperfusion technique. The degree of endothelial damage was independent of ischemic time, but was lessened by 'gentle' reperfusion. Both mitochondrial injury and myocyte edema were less when perfusate temperature and pressure were slowly raised after 3 1/2-hour ischemia.

On the technique of external cardiac compression

ECG, arterial flow and pressure were recorded during external cardiac compression (ECC) in a patient whose heart had ceased beating. The patient was a 68-year-old female who remained comatose for 2 weeks after an emergency laparotomy for perforated diverticulitis of the colon. She developed sepsis, renal failure, and cardiopulmonary failure. During ECC, the pressure on the sternum was maintained for about 0.5 sec (sustained pressure technique), flow and mean arterial pressure were improved by 32 and 20%, respectively, as compared with flow and pressure obtained with a quick and more jerky compression. During spontaneous heart activity with a low blood pressure, a superimposed ECC improved both flow and mean arterial pressure. Calcium chloride and adrenaline injected into the right atrium increased the tone and contractile power of the heart and greatly improved flow and pressure when the heart was subsequently compressed during asystole.

[Expiratory air diversion during general anesthesia (author's transl)]

A system for disposing of expiratory air containing volatile anaesthetic gases during anaesthesia is described. It consists of a reservoir bag and an adjustable suction connected to the outlet port of the anaesthesia machine or the nonbreathing valvel. A valve is incorporated which opens to the atmosphere if the reservoir bag should collaps completely, thus creating a slight vacumn in the system. Another valve, opens if the bag should become fully expanded and a slifht positive pressure develop in the system. Halothane concentrations in the "anaesthetists breathing zone" were negligible when this system was being used.