Validation of the blood pressure measurement device Beurer BM 28 according to the European Society of Hypertension International Protocol revision 2010

OBJECTIVE

The aim of the present study was to validate the blood pressure (BP) monitor Beurer BM 28 according to the International Protocol of the European Society of Hypertension (ESH-IP) revision 2010.

METHODS

In 33 subjects of age 27-81 years, BP measurements were performed according to the ESH-IP protocol, which alternates reference mercury sphygmomanometer and device-under-test (Beurer BM 28) measurements, resulting in a total of 99 comparisons.

RESULTS

As to part 1 of the protocol, an absolute difference within 5 mmHg between the Beurer BM 28 and the test device was found in 83 out of 99 comparisons for the SBP and 82 out of 99 comparisons for the DBP. In 95 out of 99 SBP comparisons and 96 out of 99 DBP comparisons, the difference was found to be within 10 mmHg, whereas only one outlier was noted with an SBP difference higher than 15 mmHg. Mean difference between the test device and the reference was 0.4 ± 4.4 mmHg for SBP, and 0.5 ± 4.3 mmHg for DBP. According to part 2 of the protocol, 30 out of 33 subjects for SBP, and 28 out of 33 for DBP had a minimum of two out of three comparisons staying within the range of 5 mmHg. In none of the subjects, all three comparisons stayed outside the 5 mmHg absolute difference, while in three subjects this was the case for the DBP.

CONCLUSION

The Beurer BM 28 met all requirements of the ESH-IP revision 2010 and can be recommended for BP measurements in the study population under investigation.

Impact of dehydroepiandrosterone on hepatocarcinogenesis in the rat (Review)

The role of dehydroepiandrosterone (DHEA) in liver carcinogenesis remains a topic of widespread research. Studies in rats suggest a hepatocarcinogenetic effect of DHEA. The incidence of DHEA-induced hepatocellular neoplasms depends on the rat strain, the gender, and the dose and duration of the treatment. Gender specific differences observed regarding the incidence of DHEA-induced hepatocellular neoplasms suggest a hormonal impact of the treatment. Studies in rats, which initially had been treated with chemical carcinogens and subsequently underwent a DHEA administration with various doses, disclose both, DHEA associated hepatic tumour promotion and hepatic tumour inhibition. These findings depend on the type, dose and duration of the initial intoxication and of the DHEA treatment. DHEA administration to rats also induces multiple profound alterations of the liver metabolism. Metabolism during DHEA treatment is characterized by an overall increase in energy expenditure. Lipid and glucose metabolism of the liver is changed profoundly switching from an anabolic to a catabolic state. This energy waste may be related to the inhibitory action of DHEA on tumour growth. Tumour enhancement is due to promotion of a specific type of preneoplastic liver lesions with a basophilic phenotype. This review summarizes the current knowledge on DHEA effects on the liver and discusses molecular and functional aspects that may explain the paradoxical effects of DHEA regarding hepatocarcinogenesis.

Induction and modulation of hepatic preneoplasia and neoplasia in the rat by dehydroepiandrosterone

Dehydroepiandrosterone (DHEA), the main adrenal steroid in humans and a precursor in androgen and estrogen biosynthesis, acts as a peroxisome proliferator and as a hepatocarcinogen in rats. Neoplasms emerge from a glycogenotic/amphophilic/basophilic preneoplastic cell lineage. A higher female tumor incidence suggests a relevant influence of sex hormones. DHEA enhances hepatocarcinogenesis induced by N-nitrosomorpholine (NNM), which is characterized by the glycogenotic/basophilic cell lineage. The tumor promoting effect is related to an additional amphophilic/basophilic preneoplastic lesion sequence and to faster proliferation of the basophilic preneoplastic lesions. Nevertheless, hepatocellular carcinomas provided under DHEA treatment seem to have a less malignant phenotype compared to tumors induced by NNM only. Further, DHEA treatment reduces growth and generation of glycogen storage foci (GSF) in initial NNM-treated rats. Thus, DHEA treatment results in both, a growth stimulation of the late basophilic lesion type with an additional amphophilic lesion sequence, and in a growth inhibition of early preneoplastic lesions, addressing especially GSF. DHEA also inhibits the growth of physiologically proliferating liver tissue. This might be explained by a DHEA related cellular metabolism, which results in significant energy consumption. Additionally, a DHEA-induced alteration of cytokine levels might contribute to this growth inhibition as well.

[Pseudoaneurysm of the pediatric popliteal artery after arthroscopic meniscus resection]

Arterial injuries following arthroscopic procedures are extremely rare, but may have dramatic consequences without early diagnosis and appropriate treatment. We report a case of popliteal artery pseudo-aneurysm a following arthroscopic meniscectomy in a child. Non-invasive diagnostic workup included Doppler flow color imaging and computed tomography with contrast and 3D workup. The arterial lesion was repaired surgically by an posterior approach using a vein patch plasty. The popliteal artery is in close relationship to the posterior capsule of the knee joint. During knee flexion the vessel is positioned forward and placed even closer to the horn of the lateral meniscus. For this reason arthroscopic surgical manipulation in the posterior aspects of the knee joint must be performed under direct visualization. Indistinct swelling in the popliteal fossa and calf following arthroscopic surgery should arouse suspicion of an arterial injury.

[Errors in blood pressure measuring with modern automated machines. Effects of errors in non-invasive oscillometric blood pressure measuring]

Automatic blood pressure measuring devices with digital display are now in common use, both among lay persons and physicians. The oscillometric method is, however, associated with a number of possible sources of error which, among other things, make comparison with the standard Riva-Rocci method difficult. Methodological errors arise from physiological/anatomical variations: circumference of the forearm and wrist, position of the arteries, structure of the surrounding tissue, arterial diameter and also vasomotor function. The latter represents an appreciable uncertainty factor, in particular with measurements obtained from the finger. Technological sources of error play a role in pronounced hypotension or severe hypertension, since the devices are calibrated only for a range extending from 120 to 180 mmHg. The processing by the device of arrhythmic pulses is also critical. Additional sources of error are in handling and interpretation. Overall, these sources of error are such that not all the various types of device available are equally suitable for use by the patient, and it is necessary to place limitations on the application of such devices and to establish rules for their use.

[Ultrasound diagnosis of iliopectineal bursitis--contribution to differential diagnosis of leg swelling]

PURPOSE

To describe the pathognomic sonographic morphology of iliopectineal bursitis as a contribution to the differential diagnosis of leg swelling.

METHODS

Characterization of the enlarged iliopectineal bursa by sonography (including CCDS) (n = 6) and comparison with CT (n = 4) and MRI findings (n = 1).

RESULTS

There were 6 enlarged iliopectineal bursas in 5 female patients which exhibited an elongated oval form and were typically located in the groin region lateral and dorsal of the vessels and in the pelvis lateral to the iliac vessels. On sonography, cystic structures with echo-free contents (n = 1) in arthrosis, homogeneous echoic contents (n = 3) in abrasive reactions after hip TEP, and with inhomogeneous, pseudo-tumorous contents (n = 2) in PCP.

CONCLUSIONS

Sonography enables the reliable diagnosis of an iliopectineal bursitis by means of its elongated oval from and extension from the groin region in continuity to the pelvis with medial displacement of the femoral and iliac vessels. It can thus help to avoid unnecessary operations or biopsies. In cases of doubt, use of CT or MRT enables a certain anatomical assignment.

[Pulse oximetry in the air rescue service. 2: Methods of increasing the stability of pulse oximetry measurements--ECG-synchronized pulse oximetry and adhesive sensors]

Pulse oximetric monitoring in air rescue service (rescue helicopter) is primarily influenced by motion artifacts (especially those of a passive nature), by low perfusion and by the problem of probe dislocation. In a prospective study involving 162 unselected emergency patients treated by the medical team of the emergency helicopter service "Christoph 22" (Ulm), we studied the possibility of reducing these adverse factors by applying available state-of-the-art technology, such as ECG-synchronization and adhesive probes. By applying the thus modified methods of monitoring, the interference factor was reduced to S = 0.056, that is only 5.6% of measurement time was adversely effected. The increase in measurement stability resulted from the reduction in number of described artifacts (motion artifacts and low perfusion), as well as from the reduction in duration of interfered measurement time. ECG-synchronization very effectively influenced the passive motion artifacts. Their frequency was reduced by the factor 8.2, respectively 42. An effective reduction in number of probe dislocations can be achieved by applying adhesive probes. The high costs of such probes presently limits their application. Radiation can be eliminated by redesigning the probe. ECG-synchronization of pulse oximetric signal has proved to be a method to reduce the artifacts frequently experienced in air rescue and has considerably contributed to the increase of emergency patient safety.

[Pulse oximetry in the air rescue service. 1: Quantitative detection of interfering factors on the method]

The introduction of pulse oximetric monitoring in prehospital emergency medicine considerably contributed to emergency patients' safety, stability and protection. As inherent in any method of measurement, certain factors can interfere with it and limit its practical application. The emergency helicopter service at Ulm, in a prospective study involving 400 patients, systematically collected data on these limiting factors and evaluated them. The index "S" was established to quantify the time lost due to malfunctioning. Within the study group, the index average was S = 0.269, that is 26.9% of measurement time was subject to interference. The major cause was motion artifacts (68%) sensor probe dislocation (15%), low perfusion (14%) and radiation (3%). Regarding the volume of time lost due to specific interfering factors, motion artifacts (61.8%) and low perfusion (25.5%) were dominant, followed by sensor probe dislocation (10.3%) and radiation (2.4%). Interference therefore, both in time and frequency was primarily due to motion artifacts and low perfusion. The conclusions from this study led to the evaluation of two methods by which the interfering factors could be reduced: 1. ECG-synchronisation of the pulse oximetric signal; 2. The use of adhesive sensors.--The degree of increase in pulse oximetric measurement stability achieved by these two methods will be investigated in part 2 of this study.

[The elimination of carboxyhemoglobin--gender-specific and circadian effects]

We investigated sex-specific and circadian variations of carboxyhemoglobin (COHb) elimination in healthy volunteers. COHb elimination follows an exponential function with a baseline found in nonsmoking women at 1.72% and in nonsmoking men at 1.79% COHb saturation. During the day, the elimination half-life time (t1/2), determined by eleven hourly samples after stopping smoking was significantly (Wilcoxon-test, p less than .01) shorter in women (3.2 +/- .4 hours, mean +/- standard deviation, n = 7) than in men (4.5 +/- 0.4, n = 6). During the night, too, t1/2 calculated from 2-point measurements after the smoking halt was significantly (Wilcoxon-test, p less than .05) shorter in women (4.3 +/- 1.1, n = 4) than in men (8.0 +/- 1.6, n = 5). In men, t1/2 during the night was significantly longer (p less than .01, Wilcoxon-test) than during the day. The day/night difference may be caused by reduced alveolar ventilation during sleep. Less muscle mass and, therefore, less myoglobin as a depot for carbon monoxide may account for the shorter half-life time of carboxyhemoglobin in women. We conclude that these variations of COHb-elimination should be taken into account when a smoking halt is advised, for instance, preoperatively.

[Carbomonoxyhemoglobin and methemoglobin in patients with and without a smoking history during ambulatory anesthesia. Consequences for the use of pulse oximetry]

Carboxyhemoglobin (COHb) and methemoglobin (MetHb) in venous blood were determined by oximetry in 1000 non-hospitalised preoperative patients. 370 of them were smokers (S), 630 non-smokers (NS). In addition, in five S we compared the oxygen saturation measured by pulse oximetry (SaO2, p) with that measured by in vitro oximetry (SaO2) and that calculated with reference to COHb (SaO2,korr). MetHb (0.66 +/- 0.21%, mean +/- standard deviation) was found to be of no relevance. COHb in S (5.12 +/- 2.25%, maximum 12.4%) was significantly higher than in NS (1.82 +/- 0.3%, range 0.9%-4.0%) and is therefore of importance in S for the oxygen transport and for the interpretation of SaO2, p, which overestimated SaO2 at a COHb level of 4.4 +/- 0.7% by 4.5 +/- 0.9%. The difference between SaO2, korr (calculated according to Forstner) differed from SaO2 by 0.66 +/- 0.5% only. We conclude that there is an indication for in vitro oximetry in non hospitalised smokers or cases of unknown smoking history. If oximetry is not available, both a reduction of O2-binding hemoglobin and an overestimation of SaO2 by pulse oximetry in an order of ten per cent should be taken into account. To compensate for dyshemoglobin fractions, pulse oximetry using more than two wavelengths is desirable.

[Respiratory disorders in trauma patients. Pulse oximetry as an extension of prehospital diagnostic and therapeutic possibilities]

The early diagnosis and adequate treatment of respiratory complications in trauma cases has a decisive influence upon the patients' posttraumatic development. Pulse oximetry enables us to evaluate and monitor the prehospital respiratory situation objectively for the first time. Within a prospective study conducted from October 1988 to October 1989 in 336 unselected, primarily traumatized, emergency patients rescued by our "SAR Ulm 75" helicopter team, to determine the possibilities and limitations of this method, we maintained continuous pulse oximetric monitoring in all cases. The practical applicability and functional stability of the pulse oximeters used were adequate. On-the-spot intubation was necessary in 45% of the patients (or they were intubated prior to our taking over). Oxygen inhalation by nasal cannula was needed in 55%. While not being decisive for immediate intubation, monitoring with a pulse oximeter does play an essential role in controlling respiratory therapy. In 32% of our cases, pulse oximetric monitoring permitted early adjustment of the respiratory therapy to meet the patients requirements. This method is of special value in disclosing life-threatening respiratory complications (9.3%) i.e., valve pneumothorax. Within a group with a high percentage of multiple traumas (27%) and thorax traumas (39%), this was of enormous assistance in the differential diagnosis. Level and rate of increase of oxygen saturation can be an indication of the severity of a thorax trauma. The limitations of pulse oximetric monitoring, especially those resulting from low peripheral perfusion in trauma cases (7 patients), are fairly rare.

[Carboxyhemoglobin in smokers and a preoperative smoking cessation]

The proportion of carbon monoxide-haemoglobin (COHb) in blood was determined before elective surgery on 50 patients (12 women and 38 men; mean age 39.5 [21-68] years) who were smoking at least 20 cigarettes a day, at two moments: during ad lib smoking and after a smoking halt of more than nine hours. 50 nonsmokers (25 women and 25 men; mean age 29.5 [20-48] years) served as controls. COHb proportion before smoking halt averaged 6.9 +/- 1.8%, after halt it averaged 3.8 +/- 1.1% (P less than 0.001). Individual values over 6% were found even after abstinence. COHb proportion in nonsmokers was 1.8 +/- 0.2% (nonsmokers vs. smokers: P less than 0.001 with and P less than 0.01 without smoking halt). The results show that measures to improve oxygen transport capacity, such as blood transfusion or oxygen breathing, are indicated early, especially in an emergency, in smokers and those with uncertain smoking habits. Smoking halt of at least nine hours should be recommended to all heavy smokers before elective surgery.

[Transient global amnesia]

The clinical picture of transient global amnesia (TGA) is discussed on the basis of the clinical findings in 19 patients. The central symptom is an acute memory loss, leading to disorientation, helplessness and pseudo-confusion. The symptoms last for several hours and then fade away. Pathogenetically a functional impairment of the limbic system is proposed. Most cases of TGA are due to ischaemic disease; rare causes are epileptic seizures, tumours, encephalitis and toxic or metabolic conditions. In order to clarify the aetiology and initiate appropriate therapy meticulous neurological investigation is necessary. The spontaneous prognosis of ischaemic forms is favourable, whilst in other cases it depends on the primary condition.