The comorbidity profiles and medication issues of patients with multiple system atrophy: a systematic cross-sectional analysis

BACKGROUND

Multiple system atrophy (MSA) is a complex and fatal neurodegenerative movement disorder. Understanding the comorbidities and drug therapy is crucial for MSA patients' safety and management.

OBJECTIVES

To investigate the pattern of comorbidities and aspects of drug therapy in MSA patients.

METHODS

Cross-sectional data of MSA patients according to Gilman et al. (2008) diagnostic criteria and control patients without neurodegenerative diseases (non-ND) were collected from German, multicenter cohorts. The prevalence of comorbidities according to WHO ICD-10 classification and drugs administered according to WHO ATC system were analyzed. Potential drug-drug interactions were identified using AiDKlinik®.

RESULTS

The analysis included 254 MSA and 363 age- and sex-matched non-ND control patients. MSA patients exhibited a significantly higher burden of comorbidities, in particular diseases of the genitourinary system. Also, more medications were prescribed MSA patients, resulting in a higher prevalence of polypharmacy. Importantly, the risk of potential drug-drug interactions, including severe interactions and contraindicated combinations, was elevated in MSA patients. When comparing MSA-P and MSA-C subtypes, MSA-P patients suffered more frequently from diseases of the genitourinary system and diseases of the musculoskeletal system and connective tissue.

CONCLUSIONS

MSA patients face a substantial burden of comorbidities, notably in the genitourinary system. This, coupled with increased polypharmacy and potential drug interactions, highlights the complexity of managing MSA patients. Clinicians should carefully consider these factors when devising treatment strategies for MSA patients.

The comorbidity and co-medication profile of patients with progressive supranuclear palsy

BACKGROUND

Progressive supranuclear palsy (PSP) is usually diagnosed in elderly. Currently, little is known about comorbidities and the co-medication in these patients.

OBJECTIVES

To explore the pattern of comorbidities and co-medication in PSP patients according to the known different phenotypes and in comparison with patients without neurodegenerative disease.

METHODS

Cross-sectional data of PSP and patients without neurodegenerative diseases (non-ND) were collected from three German multicenter observational studies (DescribePSP, ProPSP and DANCER). The prevalence of comorbidities according to WHO ICD-10 classification and the prevalence of drugs administered according to WHO ATC system were analyzed. Potential drug-drug interactions were evaluated using AiDKlinik®.

RESULTS

In total, 335 PSP and 275 non-ND patients were included in this analysis. The prevalence of diseases of the circulatory and the nervous system was higher in PSP at first level of ICD-10. Dorsopathies, diabetes mellitus, other nutritional deficiencies and polyneuropathies were more frequent in PSP at second level of ICD-10. In particular, the summed prevalence of cardiovascular and cerebrovascular diseases was higher in PSP patients. More drugs were administered in the PSP group leading to a greater percentage of patients with polypharmacy. Accordingly, the prevalence of potential drug-drug interactions was higher in PSP patients, especially severe and moderate interactions.

CONCLUSIONS

PSP patients possess a characteristic profile of comorbidities, particularly diabetes and cardiovascular diseases. The eminent burden of comorbidities and resulting polypharmacy should be carefully considered when treating PSP patients.

Functional and Molecular Properties of DYT-SGCE Myoclonus-Dystonia Patient-Derived Striatal Medium Spiny Neurons

Myoclonus-dystonia (DYT-SGCE, formerly DYT11) is characterized by alcohol-sensitive, myoclonic-like appearance of fast dystonic movements. It is caused by mutations in the SGCE gene encoding ε-sarcoglycan leading to a dysfunction of this transmembrane protein, alterations in the cerebello-thalamic pathway and impaired striatal plasticity. To elucidate underlying pathogenic mechanisms, we investigated induced pluripotent stem cell (iPSC)-derived striatal medium spiny neurons (MSNs) from two myoclonus-dystonia patients carrying a heterozygous mutation in the SGCE gene (c.298T>G and c.304C>T with protein changes W100G and R102X) in comparison to two matched healthy control lines. Calcium imaging showed significantly elevated basal intracellular Ca2+ content and lower frequency of spontaneous Ca2+ signals in SGCE MSNs. Blocking of voltage-gated Ca2+ channels by verapamil was less efficient in suppressing KCl-induced Ca2+ peaks of SGCE MSNs. Ca2+ amplitudes upon glycine and acetylcholine applications were increased in SGCE MSNs, but not after GABA or glutamate applications. Expression of voltage-gated Ca2+ channels and most ionotropic receptor subunits was not altered. SGCE MSNs showed significantly reduced GABAergic synaptic density. Whole-cell patch-clamp recordings displayed elevated amplitudes of miniature postsynaptic currents and action potentials in SGCE MSNs. Our data contribute to a better understanding of the pathophysiology and the development of novel therapeutic strategies for myoclonus-dystonia.

PD-1-inhibitor pembrolizumab for treatment of progressive multifocal leukoencephalopathy

The reactivation of human JC polyoma virus (JCPyV) results in lytic infection of oligodendrocytes and neuronal cells. The corresponding clinical picture is called progressive multifocal leukoencephalopathy (PML) and results mostly from a disease-related or drug-induced immunosuppression. The opportunistic brain infection leads to a progressive demyelination of multiple areas of the central nervous system. Patients can present with various neurological deficits ranging from slight motoric symptoms to marked aphasia or reduced vigilance. Currently, there is no effective causal therapy for PML. Survival depends on the ability to achieve timely immune reconstitution. If the immune system cannot be restored, PML progresses rapidly and often ends fatally within months. Recently, some evidence for positive response has been reported in patients treated with immune checkpoint inhibitor therapy. Here, we provide a case series of three PML patients with underlying hematological malignancies who were treated with anti-PD-1-antibody pembrolizumab at Hannover Medical School. All patients received an extensive diagnostic follow-up including cerebrospinal fluid analysis, brain imaging, and lymphocyte-phenotyping via flow cytometry. Our patients had very different outcomes, with the only patient showing a specific anti-JCPyV immune response in the sense of an increased JCPyV antibody index clearly benefiting most from the treatment. Our results partly support the hypothesis that anti-PD-1 therapy may represent a promising treatment option for patients with PML. However, there is a current lack of pre-therapeutic stratification regarding the therapeutic response rates. Before larger studies can be initiated to further evaluate the efficacy of anti-PD-1 antibodies in PML, it is imperative to develop a reliable strategy for selecting suitable patients.

Iron overload is accompanied by mitochondrial and lysosomal dysfunction in WDR45 mutant cells

Beta-propeller protein-associated neurodegeneration is a subtype of monogenic neurodegeneration with brain iron accumulation caused by de novo mutations in WDR45. The WDR45 protein functions as a beta-propeller scaffold and plays a putative role in autophagy through its interaction with phospholipids and autophagy-related proteins. Loss of WDR45 function due to disease-causing mutations has been linked to defects in autophagic flux in patient and animal cells. However, the role of WDR45 in iron homeostasis remains elusive. Here we studied patient-specific WDR45 mutant fibroblasts and induced pluripotent stem cell-derived midbrain neurons. Our data demonstrated that loss of WDR45 increased cellular iron levels and oxidative stress, accompanied by mitochondrial abnormalities, autophagic defects, and diminished lysosomal function. Restoring WDR45 levels partially rescued oxidative stress and the susceptibility to iron treatment, and activation of autophagy reduced the observed iron overload in WDR45 mutant cells. Our data suggest that iron-containing macromolecules and organelles cannot effectively be degraded through the lysosomal pathway due to loss of WDR45 function.

Towards the liquid phase exfoliation of bismuth iodide

Liquid phase exfoliation (LPE) of layered compounds towards few- or monolayers has been established as one of the prime methods in the growing field of 2D material research. Here, we present first steps towards an effective LPE of bismuth(iii) iodide, a semiconductor with potential as a photovoltaic absorber material. We highlight guidelines in the choice of exfoliating solvent, which differ significantly from those used with transition metal dichalcogenides or graphene. We also present first evidence of successful few-layer formation from spectroscopic, electron microscopy and electron diffraction investigations.

[Home care treatment of cancer pain patients with patient-controlled analgesia (PCA)]

BACKGROUND

Only limited data and experience with patient-controlled analgesia (PCA) in outpatients for palliative home care, related to organization, effectiveness and costs are available.

PATIENTS AND METHODS

In our retrospective study we analyzed the effectiveness, care intensity and pain reduction of 108 palliative cancer pain patients with PCA, included in a palliative home care system.

RESULTS

After equivalent conversion of the opioid doses from oral/transcutaneus to parenteral administration a dose increase was necessary in 12.9% of the patients. The pain therapy was effective until death for an average of 38.9 days (median 21 days). During 3,889 days of PCA therapy there were 76 unscheduled visits based on technical problems.

CONCLUSION

In cases of cancer pain patients with failed oral or transcutaneous opioid medication, sufficient pain reduction can be achieved with parenteral drug administration by PCA. Domestic PCA requires a lot of human and financial resources, with trained nursing services and regular house visits by physicians experienced in palliative medicine but this method is sufficient and safe to use.

Larvicidal effect of imidacloprid/moxidectin spot-on solution in dogs experimentally inoculated with Angiostrongylus vasorum

A controlled, randomized, blinded dose confirmation study was conducted to evaluate the larvicidal efficacy and safety of imidacloprid 10 mg/kg/moxidectin 2.5 mg/kg body weight spot-on solution in dogs experimentally inoculated with 200 infective third stage larvae (L3) of Angiostrongylus vasorum. Twenty-four adult dogs were randomly allocated to three study groups of 8 dogs each. Animals in group 1 were treated 4 days post-inoculation (dpi), those in group 2 at 32 dpi, and the dogs in group 3 were left untreated. All dogs were euthanized and necropsied 56-59 dpi. In order to determine the worm burdens in the arterial lung vessels a method of reverse lung perfusion with phosphate buffered solution after inhibition of coagulation with heparin was applied. In the control group, excretion of first stage larvae (L1) of A. vasorum started 47-55 dpi and all dogs excreted L1 at least on one sample day before euthanasia (0.1-32.5 larvae per gram of faeces). A mean of 99 (SD 42.8) adult parasites were recovered in the post-mortem examinations in these eight control dogs. In contrast, no L1 at all were found in the faeces of dogs of groups 1 and 2, nor were any adult parasites detected at necropsy. Respiratory symptoms were observed in dogs of groups 2 and 3. Pathological findings in the lungs correlated with the treatment groups: in the animals of group 1, no or minimal lesions were found, while in all those of group 2 dispersed patterns of pale pink, slightly raised and consolidated foci were present in all lung lobes. In contrast, the lungs of the dogs from group 3 were severely affected: large confluent areas were hardened, raised and discoloured, with frequent haemorrhagic patches. Pneumonia, thrombi and parasites were histologically confirmed. The lung lymph nodes were regularly enlarged. Hence, imidacloprid/moxidectin spot-on effectively eliminated fourth stage larvae (L4) and immature adult A. vasorum in experimentally infected dogs and prevented patent infections. The earlier an infected dog was treated, the less severe were the pathological lesions observed in the lungs.

Evaluation of the efficacy and safety of imidacloprid 10% plus moxidectin 2.5% spot-on in the treatment of generalized demodicosis in dogs: results of a European field study

Efficacy and safety of the test product imidacloprid 10%+moxidectin 2.5% spot on (Advocate, Advantage multi) in the treatment of canine generalized demodicosis were evaluated in a multi-centre, controlled, randomized, blinded field study in Albania, France, and Germany. The study was conducted according to a non-inferiority design to demonstrate that the efficacy of the test product is not inferior to that of a control product containing milbemycin oxime (Interceptor, tablets for oral application). Of the 72 dogs enrolled, all of which expressed clinical signs of generalized demodicosis, 63 completed the study. Of these, 30 dogs were treated 2-4 times, at 4-week intervals, with the test product at the recommended dose of at least 0.1 ml/kg body weight. Thirty-three dogs were treated daily for two to four periods of 4 weeks with the control product according to label instructions (0.5-1 or 1-2 mg/kg body weight). Presence of mites in deep skin scrapings and clinical improvement were assessed 3-6 times at each inspection at 4-week intervals. Treatment was discontinued in dogs negative for mites on two subsequent examinations 4 weeks apart or at the last examination on day 84. At the end of the trial, dogs in both groups showed a similar clinical improvement. No Demodex mites were detected in 26 of 30 dogs treated with imidacloprid/moxidectin and in 29 of 33 dogs treated with milbemycin oxime. Statistical evaluation confirmed that the efficacy of the test product in the treatment of generalized canine demodicosis was not inferior to that of milbemycin oxime.

Efficacy and safety of imidacloprid/moxidectin spot-on solution and fenbendazole in the treatment of dogs naturally infected with Angiostrongylus vasorum (Baillet, 1866)

A randomized, blinded, controlled multicentre field trial study was conducted to evaluate the efficacy and safety of imidacloprid 10%/moxidectin 2.5% spot-on solution and fenbendazole in treating dogs naturally infected with Angiostrongylus vasorum. Dogs were randomly treated either with a single dose of 0.1 ml/kg bodyweight of imidacloprid 10%/moxidectin 2.5% spot-on solution or with 25 mg/kg bodyweight fenbendazole per os for 20 days. The study period was 42 days with dogs being examined on days 0, 7 and 42. The primary efficacy parameter was the presence of L1 larvae in faecal samples evaluated by a Baermann test from three consecutive days. Thoracic radiographs performed on each visit were being taken as a paraclinical parameter to support the results of the Baermann test. Twenty-seven dogs in the imidacloprid/moxidectin group and 23 dogs in the fenbendazole group completed the study according to protocol. The efficacies of the two treatment protocols were 85.2% (imidacloprid/moxidectin) and 91.3% (fenbendazole) with no significant difference between treatment groups. On radiographic evaluation pulmonary parenchyma showed similar improvement in each group. No serious adverse effects to treatment were recorded: most of the minor adverse effects were gastrointestinal such as diarrhea (nine dogs), vomitus (eight dogs) and salivation (three dogs). In general, these adverse effects were of short duration (1-2 days) within the first few days after treatment start and required little or no treatment. This prospective study demonstrates that both treatment protocols used are efficacious under field conditions, that treatment of mildly to moderately infected dogs with either of these protocols is safe and yields an excellent prognosis for recovering from the infection.

[Evaluation of blood and breath alcohol measurement in patients with hepatocellular carcinoma during procedures in intubated patients with percutaneous ethanol instillation]

The accuracy of breath alcohol measurements in intubated patients with assisted ventilation was evaluated. The breath alcohol concentration was measured in 24 patients undergoing percutaneous alcohol injection therapy for hepatocellular carcinoma with Alcotest 7410 med, from Dräger, Germany. The blood ethanol concentrations (BACs) were determined in each blood serum applying the German forensic criteria standard, namely, two alcohol dehydrogenase (ADH) and two gas chromatography (GC) measurements. The blood alcohol concentrations were between 0.07 and 1.51 per thousand in the central venous samples and 0.02-1.66 per thousand in the arterial samples. An excellent correlation between both the venous and arterial blood alcohol concentrations (r2=0.94), as well as between the breath alcohol concentrations and the venous (r2=0.84) or arterial alcohol concentration (r2=0.89), p<0.01 for both parameters was revealed. Determination of breath alcohol concentration using the Alcotest in intubated patients is reliable and reflects the blood alcohol values.

The efficacy of an imidacloprid/moxidectin combination against naturally acquired Sarcoptes scabiei infestations on dogs

The study was undertaken to evaluate and compare the efficacy of an imidacloprid (10% w/v)/moxidectin (2.5% w/v) combination (Advocate Bayer HealthCare, Animal Health) with that of selamectin for the treatment of Sarcoptes scabiei on dogs. Thirty naturally infested dogs, of which one was later withdrawn because of distemper, were allocated to two equal groups and individually housed. The dogs in each group were treated twice, four weeks apart, with either the combination product (0.1 mL/kg body weight) or with selamectin (0.05 mL/kg body weight) administered topically. Skin scrapings were made every 14 days over a period of 50 to 64 days after the first treatment to quantify mite numbers. Clinical signs and the extent of sarcoptic lesions were assessed on each dog when skin scrapings were made. Efficacy was based on the presence or absence of mites, supported by clinical signs associated with canine sarcoptic mange. From Day 22 and onwards no Sarcoptes mites were found in the skin scrapings of any of the treated dogs. Treatment with the imidacloprid/moxidectin formulation or with selamectin was highly effective against Sarcoptes scabiei and resulted in an almost complete resolution of clinical signs within 50 to 64 days after the initial treatment.

Korrelation degenerativer Bandscheibenveränderungen im MRT mit dem Befund der Diskographie bei Rückenschmerzpatienten

BACKGROUND

MRI can be too sensitive for detecting degenerative changes and commonly displays pathology that is not necessarily responsible for the patient's symptoms.

METHODS

Retrospectively, we investigated MRI findings and results of discography in 23 patients with lower back pain. MRI investigations were performed with a 1.0 and 1.5 Tesla device using T1-weighted and T2-weighted sagittal plane imaging and T2-weighted transverse plane imaging.

RESULTS

Of the 35 degenerated discs, 16 were detected on MRI as having a high intensity zone (HIZ). Eleven of the 35 segments had previous lumbar disc surgery with a HIZ rate of 81.8%, whereas the HIZ rate for unoperated segments was only 29.2%.

CONCLUSIONS

HIZ is known to be a common lesion found using MRI in lower back pain patients. In operated segments, we found an incidence of 81.8% and in unoperated segments of 28.2%. Discography can discriminate between painful and non-painful discs. With the help of additional parameters such as contrast mean volume and pain characteristics during puncture, the number of false positive discograms can be reduced.

Efficacy and safety of imidacloprid 10% plus moxidectin 2.5% spot-on in the treatment of sarcoptic mange and otoacariosis in dogs: results af a European field study

Efficacy and safety of treatment with imidacloprid 10%+moxidectin 2.5% spot-on (Advocate, Advantage multi; Bayer AG, Leverkusen, Germany) were tested in dogs naturally infested with Sarcoptes scabiei or Otodectes cynotis in a multi-centre, controlled, randomized, blinded field study conducted in France, Germany, Albania and the UK. The study was performed according to a non-inferiority design to demonstrate that the efficacy of imidacloprid/moxidectin spot-on was not inferior to that of a control product containing selamectin (Stronghold spot-on; Pfizer). All Sarcoptes-infested dogs were topically treated twice (days 0 and 28) with the dosage recommended by the respective manufacturer (27 dogs with imidacloprid/moxidectin, 26 with selamectin). All Otodectes-infested dogs were treated on day 0 (35 dogs with imidacloprid/moxidectin, 34 with selamectin), and only those still positive on day 28 received a second treatment. Parasitological cure rate in Sarcoptes-infested dogs was 100% for both treatments, while parasitological cures rates in the Otodectes-infested dogs at day 28 and day 56 were 68.6 and 85.7% with imidacloprid/moxidectin, and 64.7 and 88.2% with Stronghold. Non-inferiority of Advocate was confirmed statistically. Clinical assessment of skin lesion scores at day 56 showed that with either product >96% of the dogs treated against sarcoptic mange were improved or cured, the difference between the groups being non-significant. On the basis of a final clinical assessment of lesion scores, 80% of the dogs treated with imidacloprid/moxidectin against otoacariosis and 85.3% of those treated with selamectin were rated cured or improved. Only three mild, possibly drug-related adverse reactions were observed among alI treated animals (two in the imidacloprid/moxidectin group, one in the selamectin group). It is concluded that imidacloprid/moxidectin spot-on is an effective and safe treatment for sarcoptic mange and otoacariosis in the dog.

The laryngeal tube for difficult airway management

BACKGROUND AND OBJECTIVE

Since the introduction of the laryngeal mask into clinical practice, various additional supraglottic ventilatory devices have been developed. Although it has been demonstrated that the laryngeal tube is an effective airway device during positive pressure ventilation no clinical study has been performed thus far regarding its use in patients with predicted ventilation and intubation difficulties.

METHODS

The aim of this study was to prospectively evaluate the use of the laryngeal tube for temporary oxygenation and ventilation in adult patients with supraglottic airway tumours scheduled to undergo a pharyngeal-laryngeal oesophagoscopy and bronchoscopy under general anaesthesia. In addition to our standard airway management with face mask ventilation and rigid bronchoscopy, all patients were temporarily ventilated with an laryngeal tube. Also, in patients requiring laryngeal biopsies, endotracheal intubation was performed with a 6.0 mm microlaryngeal tracheal tube. Minute ventilation volumes, tidal volumes, ventilation pressures, end-expiratory CO2 concentration, oxygen saturation and arterial blood gas samples were measured.

RESULTS

From 54 enrolled patients only patients with relevant tumour masses were evaluated (n = 23). Mask ventilation was performed without difficulty in 15 of 23 patients. Mechanical ventilation with the laryngeal tube was possible in 22 of 23 patients with an audible leak present in three. Conventional endotracheal intubation was successfully performed in 19 of 23 patients. During face mask ventilation, minute volume, tidal volume, ventilation pressure, end-tidal CO2, oxygen saturation and arterial PO2 were significantly lower and PCO2 significantly higher (P < 0.05, paired t-test). No statistically significant differences were noted between the laryngeal tube and the microlaryngeal tracheal tube.

CONCLUSIONS

The possibility of difficult ventilation and intubation must always be considered, in patients with supraglottic airway tumours. In these cases, the laryngeal tube can be considered for routine airway management and may be useful in the 'cannot-intubate' situation although difficulties should be anticipated in patients with previous irradiation, specifically of the throat area.

Katecholaminrefraktäre Hypotension - aktuelle Entwicklungen

Vasoplegia as catecholamine resistent hypotension occurs in severe hemorrhagic or septic shock and post cardiopulmonary bypass. The entire rational behind this phenomenon is still unclear. An ATP-shortage in the vascular musculature, disregulation of vasopressin release, and the activation of ATP-dependent potassium-channels are discussed. In the last years, attention is drawn towards the activation of ATP-dependent potassium-channels and the possible therapeutic inhibition by glibenclamid. However, inhibition of potassium-channels does not normalize blood pressure under all circumstances. In particular in septic shock other mechanisms have to be involved. Overall, the sometimes desperate clinical situation has led to a large number of case reports und uncontrolled series of retrospectively analysed cases, where vasopressin or methylenblue were discribed as successfully reversing catecholamine resistent hypotension. Nevertheless, in hemorrhagic and septic shock scientific evidence of the clinical effects and the right dose as well as placebo controlled studies comparing the agents and possible combinations of agents are desirable but hardly available yet. In the case of severe hypotension following surgery under cardiopulmonary bypass results of the first randomized and placebo controlled studies describe successful restoration of blood pressure and even a decrease in perioperative mortality. Concerning the side effects, vasopressin and methylenblue, like most vasopressors, can cause gastrointestinal ischemia, but with the small number of patients enrolled so far, further major side effects can not be ruled out. Accordingly, the identification of risk factors for the development of vasoplegia and the prediction of the extent of the response or the rate of non-responders to these treatments are widely unknown. However, although the administration of vasopressin and methylenblue can not be recommended as a standard treatment it provides an additional option in individual cases of life threatening vasoplegia.

Lagerungsschäden aus der Sicht des Anästhesisten

Anaesthetist and surgeon cooperate in positioning the patient for surgery according to interdisciplinary agreements. The legal demands on documentation for standard positioning procedures are met with a symbol or short notice on the anaesthesia protocol. In the case of damage to the patient, however, the doctor has to furnish evidence that the patient has been positioned correctly. Complications associated with perioperative patient positioning are reported to be 1 to 1000. Peripheral nerves are at highest risk, but soft tissue, joint, vascular and ocular damages are also reported. The problems and adequate care of different positioning modes, such as recumbent, lateral, prone, seated and lithotomy position, are discussed in detail.

[Analysis of acetabular changes in Morbus Perthes disease with radiomorphometry]

AIM

Decreases in depth and irregularity are typical changes of the acetabulum in patients with Perthes disease and develop secondary to the femoral head involvement. Optimal timing of therapy plays an important role to prevent these secondary changes. The present study investigates the influence of the amount of femoral head involvement and the patients' age on the acetabulum and the outcome.

METHODS

66 patients with 76 affected hip joints were included in the study. 20 hips had a conservative therapy, 22 an operative therapy (IVO). 34 hip joints underwent a conservative therapy at first, followed by an operative intervention. The radiomorphometric analyses at the time of diagnosis, pre- and postoperatively and at follow-up were performed with epiphyseal ratio, acetabular ratio and acetabulum-head ratio. At the time of diagnosis the patients were classified with the Catterall classification, at follow-up with Mose classification.

RESULTS

Independent from therapy there was a correlation of the parameters with Catterall classification over the whole course, i.e., the higher the Catterall group the worse the parameter at the time of diagnosis as well as at follow-up. Operatively treated patients with Catterall IV tended towards a worse result of the epiphyseal ratio whereas they achieved better results in the other parameters compared to conservatively treated patients. Catteral I and II patients achieved good results.

CONCLUSION

Operative treatment of the higher Catterall groups seems to be more effective than conservative therapy. Secondary changes of the acetabulum develop in proportion to the amount of femoral head involvement.

["Highlights" in emergency medicine -- severe head trauma, polytrauma and cardiac arrest]

According to scientific publications focusing on emergency medicine and published in international journals in the past few months, new and clinically important results can be identified. In patients with severe head trauma (SHT), application of hypertonic solutions is possible; long term outcome, however, is not improved by this measure. Prehospital capnometry is important, because otherwise up to 40 % of all mechanically ventilated patients are hypoventilated. In a study in 200 patients with prehospital cardiac arrest and ventricular fibrillation as initial cardiac rhythm, subgroup analysis (alarm-response time > 5 min) showed an increase in survival rate (14 % vs. 2 %), if defibrillation was proceeded by 3 min of conventional cardiopulmonary resuscitation (CPR) for reperfusion. If ACD ("active compression decompression")-CPR is combined with a specific ventilatory valve ("inspiratory impedance threshold device", ITD) which does not allow passive inspiration, survival rate after cardiac arrest is increased for up to 24 h. Such a device facilitates an increase in venous return to the heart during decompression of the thorax. High-dose adrenalin for intrahospital CPR in children is not associated with better survival but with worse outcome. Comparison of an emergency medical service (EMS) system from U.K. with paramedics and a physician-staffed German EMS system demonstrated that survival rate following prehospital cardiac arrest is markedly increased with doctors on board. The European multicentre trial comparing vasopressin vs. adrenalin as first vasopressor during CPR in 1219 patients did not reveal any differences between both groups. In subgroup analyses of patients with asystoly and prolonged CPR, vasopressin was superior without being associated with a benefit on neurological outcome. Further subgroup analyses revealed beneficial effects of amiodarone and thrombolysis during CPR. Thrombolysis during CPR apears to be associated with an increased rate of haemodynamic stabilisation without increased risk of bleeding complications. In a very clear advisory statement, the "International Liaison Committee on Resuscitation" (ILCOR) has recommended mild therapeutic hypothermia (i. e., cooling of cardiac arrest victims to 32 - 34 degrees C central body temperature for 12 - 24 h following cardiac arrest of cardiac etiology) not only for unconciuous patients with ventricular fibrillation as initial prehospital rhythm, but also for all other adult patients (other rhythms, intrahospital CPR) following cardiac arrest. In randomised controlled clinical trials, this therapy has markedly improved survival rate and neurological outcome. Such therapeutic cooling can be initiated nearly everywhere and with simple methods - like the infusion of ice-cold cristalloid solutions.

Reduction of catheter-related infections in neutropenic patients: a prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter

Antiseptic coating of intravascular catheters may be an effective means of decreasing catheter-related colonization and subsequent infection. The purpose of this study was to assess the efficacy of chlorhexidine and silver sulfadiazine (CH-SS)-impregnated central venous catheters (CVCs) to prevent catheter-related colonization and infection in patients with hematological malignancies who were subjected to intensive chemotherapy and suffered from severe and sustained neutropenia. Proven CVC-related bloodstream infection (BSI) was defined as the isolation of the same species from peripheral blood culture and CVC tip (Maki technique). This randomized, prospective clinical trial was carried out in 106 patients and compared catheter-related colonization and BSI using a CH-SS-impregnated CVC (n=51) to a control arm using a standard uncoated triple-lumen CVC (n=55). Patients were treated for acute leukemia (n=89), non-Hodgkin's lymphoma (n=10), and multiple myeloma (n=7). Study groups were balanced regarding to age, sex, underlying diseases, insertion site, and duration of neutropenia. The CVCs were in situ a mean of 14.3+/-8.2 days (mean+/-SD) in the study group versus 16.6+/-9.7 days in the control arm. Catheter-related colonization was observed less frequently in the study group (five vs nine patients; p=0.035). CVC-related BSI were significantly less frequent in the study group (one vs eight patients; p=0.02). In summary, in patients with severe neutropenia, CH-SS-impregnated CVCs yield a significant antibacterial effect resulting in a significantly lower rate of catheter-related colonization as well as CVC-related BSI.

Differential platelet receptor expression following hydroxyethyl starch infusion in thrombocytopaenic orthotopic liver transplantation recipients

BACKGROUND AND OBJECTIVE

Platelet function abnormalities influence the haemostatic defect in patients with liver failure. Patients after orthotopic liver transplantation present thrombocytopaenia associated with bleeding problems, which may be aggravated by the interaction of hydroxyethyl starches with platelets.

METHODS

From 12 patients after liver transplantation venous blood samples (3 mL) were taken before, 20 and 120 min after infusion of hydroxyethyl starch of medium molecular weight (200 kDa/0.5) 6% 10 mL kg(-1) over a period of 30 min. Surface expression of glycoprotein IIb/IIIa and P-selectin were quantified by flow cytometry as well as the percentage of platelet-leucocyte complexes.

RESULTS

A significant decrease of P-selectin expression following administration of hydroxyethyl starch after 120 min (89.1 +/- 4.2%, P = 0.029) and a corresponding significant reduction in the formation of platelet-monocyte complexes (81.1 +/- 7.8%, P = 0.001) were observed. There was no alteration in the glycoprotein IIb/IIIa expression after hydroxyethyl starch infusion.

CONCLUSIONS

Infusion of hydroxyethyl starch 200 kDa/0.5 in clinically relevant doses does not alter glycoprotein IIb/IIIa expression in thrombocytopaenic patients with pre-existing platelet dysfunction after orthotopic liver transplantation. Accordingly, infusion of hydroxyethyl starch may have a beneficial effect on microvascular graft perfusion through the resulting haemodilution and reduced P-selectin expression with subsequent reduced leucocyte-platelet complexes and endothelial adhesion.

[Evaluation of percutaneous vertebroplasty in osteoporotic vertebral fractures using a combination of CT fluoroscopy and conventional lateral fluoroscopy]

PURPOSE

Evaluation of vertebroplasty using a combination of CT-fluoroscopy and conventional lateral fluoroscopy in patients with osteoporotic vertebral fractures.

MATERIALS AND METHODS

Fifty-eight patients (23male, 35 women, age 69.7 +/- 10.2 years) with painful osteoporotic vertebral fractures were treated with vertebroplasty in conscious sedation and local anesthesia. Spiral-CT with sagittal reconstructions of the respective vertebral bodies was used for classification of the fracture. The cannula was placed under CT-guidance in the ventral third of the respective vertebral bodies and cement instilled under CT fluoroscopy and lateral fluoroscopy. When cement migrated towards the vertebral canal, the injection was immediately stopped for 30 - 60 seconds. After polymerization in this location, the injection was continued until sufficient filling of the vertebra. Results were documented by spiral CT with sagittal reconstructions.

RESULTS

A total of 123 vertebral bodies were treated, comprising 39 thoracic and 84 lumbar vertebral bodies, with a mean of 2.1 +/- 1.3 (range 1 to 6) vertebral bodies in each patient and a maximum of 3 vertebral bodies per session. All interventions were successfully completed in conscious sedation and local anesthesia. A mean volume of 5.9 +/- 0.6 ml (range 2 to 14 ml) cement was applied for each vertebra, with 79.7 % of procedures performed using a unilateral access. To achieve a sufficient cement deposit, a bilateral access was used in 20.3 %. The dorsal wall of the vertebra was included in 23.6 % of the fractures. In one case, cement migration into the spinal canal was detected, reducing the diameter of the canal by 30 %. In two other cases, cement leakage was seen at the puncture site of the vertebra (one intercostotransversally in the 10 (th) thoracic vertebra and one dorsolaterally in the 1 (st) lumbar vertebra) with retrograde cement migration through the neuroforamen into the epidural space. In one of these cases, the cannulation of the vertebra had been changed before cement application resulting in a hole in the dorsolateral vertebral wall. However, all patients were discharged without evidence of neurologic complications. Multiplanar reconstructions of CT scans were used for the detection of extraosseous cement leaks: The incidence of extraosseous cement leaks was 4.1 % in epidural veins, 6.5 % in paravertebral vessels (6 veins, 2 arteries), and 17.9 and 11.4 %, respectively, for upper or lower end plates. At discharge, 25 patients (43.1 %) were free of pain and 28 (48.3 %) significantly improved with a considerable reduction of analgetic drugs. Significant complaints persisted in 5 patients (8.6 %) with concomitant degenerative disease in four and vasculitis in one case.

CONCLUSION

Percutaneous vertebroplasty is effective for stabilization and pain management of osteoporotic vertebral fractures. The procedure can be safely performed in conscious sedation and local anesthesia. Compared to conventional fluoroscopy alone, CT fluoroscopy provides an excellent additional monitoring of the procedure and probably contributes to the safety of the procedure.

[Anaesthesia in cataract surgery for elderly people]

OBJECTIVE

In the cataract surgery the problems of anaesthesia in ophthalmo-surgery and anaesthesia in elderly people are combined. For this patients we compared intravenous anaesthesia with balanced anaesthesia in cardiac and circulatory side effects (security), patients satisfaction and costs.

METHODS

In a prospective, randomised study we compared in 52 (26 vs. 26) elderly patients (ASA II and III, mean age 78.7 +/- 8.6 years) undergoing a cataract operation cardiac and circulatory side effects, recovery time and patients satisfaction with the either type of anaesthesia by a score from 1 = best to 6 = worse and the occurrence of nausea/vomiting (controlled 24 h). The difference in costs were measured by the hospital management.

RESULTS

Cardiac and circulatory side effects with hypotonic reactions were similar in both groups (TIVA 18 = 69.2 %/BA 20 = 76.9 %). Hypertonic reactions were mainly seen in BA (Tiva 1.9 %, BA 69.2 %/p < 0,001). There was no problem in the treatment of these side-effects. The frequency of postoperative nausea and vomiting was lower (but not significantly) in the TIVA group (TIVA 8 %/ BA 27 %) than in the BA group (7 and 4). The recovery times were shorter (p < 0.001) in TIVA, those patients were staying 24 (+/- 6.70) minutes in the post operative unit vs. 59 (+/- 28.83) minutes in BA. Patients satisfaction was better in the TIVA-group (1.65) than in the patients treated with BA. In the calculation of costs there was a disadvantage in BA.

CONCLUSIONS

This study showed, that in respect of cardiac and respiratory side effects TIVA and BA are safe methods in anaesthesia for elderly people in ophthalmic surgery. Nevertheless, because of shorter recovery-times, lower incidence of hypertonic reactiones, more patients satisfaction and lower costs TIVA had better results in this study. We have to ask for the evaluation of economy in anaesthesia that not only prices of medicaments but the complete costs of the cases have to be calculated.

Ensemble averaging and multiple statistical testing of EMG activities of cyclically repeated body motions. A tool for muscle function analysis in experimental and clinical orthopaedics

Coupled with suitable computerized signal recording and processing methods surface electromyography can be a powerful tool for the analysis of muscle activity in specific body movements. It can be used for this purpose in experimental and in clinical diagnostic orthopaedics as well as in physiotherapy. We describe in this paper a motion analysis system comprising this feature. It has been employed for the diagnosis of the basic angular kinematics and muscle function in human gait and other cyclically repeatable movements of the human locomotive system. Changes in the temporal characteristics of the movements and the muscle activity due to changed physical or experimental conditions can be systematically investigated this way. Such changes can be the result of surgical and/or conservative orthopaedic therapy, a long term physiotherapeutic program, or modified walking conditions as in experimental orthopaedics. They are displayed and validated by signal ensemble averaging and subsequent multiple statistical testing (e.g. by a suitably adapted Bonferroni criterion). The efficiency of the system is demonstrated by an exemplary gait analysis of selected kinematic and muscular effects caused by an experimental simulation of a leg length inequality.

Experimentelle Untersuchungen zur Reproduzierbarkeit von Ensemble-gemittelten elektromyographischen Ganganalysedaten im Bereich der experimentellen und klinischen Orthopädie / Experimental Investigation on the Reproducibility of Ensemble Averaged Electromyographic Gait Analysis Data in Experimental and Clinical Orthopaedics

With suitable application and signal processing methods, surface electromyography is a comparatively simple instrument for investigating the temporal pattern of the muscular activity of a walking subject. The influence of changes both in the external experimental conditions (e.g. orthopedic shoe design) and in the human locomotor system (due to disease or therapy) on the individual muscular gait characteristics can be documented in this way. The usefulness of this kind of investigation is basically limited by the reproducibility of the gait analytical findings of the subject, who is examined at different times with unchanged bodily state and under identical experimental conditions unchanged. In our experiments we observed that the reproducibility of electromyographic activity curves obtained by ensemble averaging over a sufficiently high number of full strides differs for different muscles and in different subjects. Within the same experimental session it is very high and considerably better than in experiments done on different days. In examinations done on different days the basic characteristics of the activity curves are reproduced better than the absolute height of the amplitudes. In view of these findings the differences observed in the gait analysis of patients in the course of operative or conservative therapy have to be interpreted very carefully as to their true origin.

[New pathways and current concepts in intensive care medicine--a summary of important articles of the last month]

One of the most outstanding critical care concepts of the last month is the definition of 5 therapy strategies by the Society of Critical Care for treatment of patients in septic shock. These strategies are: Low tidal volume of 6 ml/kg(-1) body weight in patients with ARDS, early goal-directed therapy, activated protein C therapy, moderate-dose corticosteroids, and tight control of blood sugar. Following further review of the main critical care medicine related journals for strategies to reduce mortality, the non-invasive ventilation is worthwhile mentioning. Moreover, this review summarizes articles on the topics of: Low-dose dopamine does not prevent acute renal insufficiency, increase of mortality is not related to albumin infusion, subglottic suctioning prevents early onset of ventilator associated pneumonia, prone position in ARDS patients has no influence on mortality, the safest site for central venous catheterization, and pulmonary-artery catheter directed therapy has no influence on mortality of high-risk surgical patients.

[Rationale and management of perioperative atrial fibrillation]

Atrial fibrillation is the most common clinically relevant arrhythmia. Anesthesiologists will be faced with atrial fibrillation of new or undetermined onset at their preoperative evaluation of patients as well as during intra- and post operative care. Because of fast electrophysical and structural remodeling, atrial fibrillation tends to persist and reoccur after successful conversion with increasing time of duration. Therefore, atrial fibrillation with an onset of less than 48 hours should be attempt to convert as soon as diagnostic work up has been made and possible causes have been corrected. New developments of electrophysiological and pharmacological treatment have improved the short term success rate of cardioversion. Further developments might give even more specific treatment options for the individual patient. In contrast, for treatment of chronic atrial fibrillation rate control therapy and thromboembolic prophylaxes seems to be more advisable with a lower risk of drug side effects and stroke. Anticoagulation should be initiated not later than 48 hours after the onset of atrial fibrillation. Finally, the development of implantable devices for the treatment of atrial fibrillation seem to be a promising therapeutic option for patients in end-stage heart diseases.

Respiratory burst activity of polymorphonuclear cells is dependent on the cell preparation technique

BACKGROUND

Controversial results have been reported regarding the effect of anaesthetics on superoxide anion production during the respiratory burst (RB) of polymorphonuclear cells (PMN). The differences could be caused by the cell preparation methods and the aim of this study was to compare two techniques.

METHODS

RB activity was measured in cell suspensions isolated with the single-step Ficoll procedure and in unfractionated whole blood. Two concentrations of propofol (therapeutic and 10-fold of this, 6 microg ml-1 or 60 microg ml-1) were investigated after cell preparation with both methods. RB was stimulated with Escherichia coli (E. coli), phorbol 12-myristate 13-acetate (PMA) or N-formyl-methionyl-leucyl-phenylalanine (fMLP) and measured by means of fluorescence intensity in a flow cytometer.

RESULTS

The percentage of PMNs in whole blood which generate superoxide anions in response to fMLP was significantly lower (2.5 +/- 0.7%; mean +/- SEM) than that in Ficoll isolated cell suspensions (15.1 +/- 1.7%). Incubation with propofol led to a concentration-related decrease of RB activity in Ficoll separated PMNs after both PMA and fMLP stimulation. No significant effect of propofol was observed on the RB in PMA stimulated whole blood samples.

CONCLUSION

The results suggest that the influence of cell preparation methods should be considered when the in vitro effects of anaesthetics on PMN functions are studied with flow cytometric methods.