[Bladder dysfunction due to spinal cord compression. Treatment modes and results]

Bladder dysfunction is often observed in cases of spinal compression and is commonly caused by spinal tumors, trauma, or degenerative spine disease. Microsurgical decompression is the most important therapy. The earlier microsurgery is performed, the better the chances are for recovery of bladder function.

Hyperthermia after cardiac arrest is associated with an unfavorable neurologic outcome

BACKGROUND

Moderate elevation of brain temperature, when present during or after ischemia, may markedly worsen the resulting injury.

OBJECTIVE

To evaluate the impact of body temperature on neurologic outcome after successful cardiopulmonary resuscitation.

METHODS

In patients who experienced a witnessed cardiac arrest of presumed cardiac cause, the temperature was recorded on admission to the emergency department and after 2, 4, 6, 12, 18, 24, 36, and 48 hours. The lowest temperature within 4 hours and the highest temperature during the first 48 hours after restoration of spontaneous circulation were recorded and correlated to the best-achieved cerebral performance categories' score within 6 months.

RESULTS

Over 43 months, of 698 patients, 151 were included. The median age was 60 years (interquartile range, 53-69 years); the estimated median no-flow duration was 5 minutes (interquartile range, 0-10 minutes), and the estimated median low-flow duration was 14.5 minutes (interquartile range, 3-25 minutes). Forty-two patients (28%) underwent bystander-administered basic life support. Within 6 months, 74 patients (49%) had a favorable functional neurologic recovery, and a total of 86 patients (57%) survived until 6 months after the event. The temperature on admission showed no statistically significant difference (P =.39). Patients with a favorable neurologic recovery showed a higher lowest temperature within 4 hours (35.8 degrees C [35.0 degrees C-36.1 degrees C] vs 35.2 degrees C [34.5 degrees C-35.7 degrees C]; P =.002) and a lower highest temperature during the first 48 hours after restoration of spontaneous circulation (37.7 degrees C [36.9 degrees C-38.6 degrees C] vs 38.3 degrees C [37.8 degrees C-38.9 degrees C]; P<.001) (data are given as the median [interquartile range]). For each degree Celsius higher than 37 degrees C, the risk of an unfavorable neurologic recovery increases, with an odds ratio of 2.26 (95% confidence interval, 1.24-4.12).

CONCLUSION

Hyperthermia is a potential factor for an unfavorable functional neurologic recovery after successful cardiopulmonary resuscitation.

Dehydroepiandrosterone in the treatment of erectile dysfunction in patients with different organic etiologies

In 1994 the Massachusetts Male Aging Study described an inverse correlation of the serum levels of dehydroepiandrosterone sulfate (DHEAS) and the incidence of erectile dysfunction (ED). The positive results of a pilot study in the treatment in patients with no organic etiology prompted a detailed investigation on the efficacy of DHEA therapy for ED in patients with different organic etiologies, in a prospective study. The inclusion criteria included ED, a normal physical condition, normal serum levels of testosterone, prolactin and PSA and a serum DHEAS level < 1.5 micromol/l. The study patients comprised 27 patients (group 1) with hypertension, 24 patients (group 2) with diabetes mellitus, six patients with neurological disorders (group 3) and 28 patients (group 4) with no organic etiology were treated with 50 mg DHEA p.o. for 6 months. We assessed efficacy by using the responses to question 3 (frequency of penetration) and question 4 (maintenance of erections after penetration) of the 15-question International Index of Erectile Function (IIEF). DHEA treatment was associated with statistically significantly higher mean scores compared to baseline values for question 3 and question 4 of the IIEF in groups 1 and 4 after a period of 24 weeks. The differences between the mean scores of groups 2 and 3 and the baseline values were not statistically significant. Our results suggest that oral DHEA-treatment may be of benefit to patients with ED who have hypertension or to patients with ED without organic etiology. There was no impact of DHEA therapy on patients with diabetes mellitus or with neurological disorders.

Acute renal failure after successful cardiopulmonary resuscitation

OBJECTIVE

To assess the frequency and independent predictors of severe acute renal failure in patients resuscitated from out-of-hospital ventricular fibrillation cardiac arrest.

DESIGN

A cohort study with a minimum follow-up of 6 months.

SETTING

Emergency department of a tertiary care 2200-bed university hospital.

PATIENTS AND PARTICIPANTS

Consecutive adult (> 18 years) patients admitted from 1 July 1991 to 31 October 1997 after witnessed ventricular fibrillation out-of-hospital cardiac arrest and successful resuscitation.

MEASUREMENTS AND RESULTS

Acute renal failure was defined as a 25% decrease of creatinine clearance within 24 h after admission. Out of 187 eligible patients (median age 57 years, 146 male), acute renal failure occurred in 22 patients (12%); in 4 patients (18%) renal replacement therapy was performed. Congestive heart failure (OR 6.0, 95% CI 1.6-21.7; p = 0.007), history of hypertension (OR 4.4, 95% CI 1.3-14.7; p = 0.02) and total dose of epinephrine administered (OR 1.1, 95% CI 1.0-1.2; p = 0.009) were independent predictors of acute renal failure. Duration of cardiac arrest, pre-existing impaired renal function and blood pressure at admission were not independently associated with renal outcome.

CONCLUSIONS

Severe progressive acute renal failure after cardiopulmonary resuscitation (CPR) is rare. Pre-existing haemodynamics seem to be more important for the occurrence of acute renal failure than actual hypoperfusion during resuscitation.

Therapeutic hypothermia after cardiac arrest

This review discusses the mechanisms of neurologic damage during and after global cerebral ischemia caused by cardiac arrest. The different pathways of membrane destruction by radicals, free fatty acids, excitatory amino acids (neurotransmitters), calcium, glucose metabolism, and oxygen availability and demand in relation to metabolic rate are briefly discussed. The main focus of this review paper, however, lies in therapeutic (resuscitative) hypothermia after cardiac arrest. Two pioneering studies of the 1950s and four recent publications (in part preliminary results of ongoing studies) in humans are discussed in detail. The conclusions are as follows: (1) hypothermia holds promise as the only specific brain therapy after cardiac arrest so far; (2) hyperthermia is not tolerable after successful resuscitation; and (3) if the ongoing European multicenter trial of hypothermia after cardiac arrest finds a significant benefit to mild hypothermia, withholding hypothermia may be ethically hard to defend.

Mild resuscitative hypothermia to improve neurological outcome after cardiac arrest. A clinical feasibility trial. Hypothermia After Cardiac Arrest (HACA) Study Group

BACKGROUND AND PURPOSE

Recent animal studies showed that mild resuscitative hypothermia improves neurological outcome when applied after cardiac arrest. In a 3-year randomized, prospective, multicenter clinical trial, we hypothesized that mild resuscitative cerebral hypothermia (32 degrees C to 34 degrees C core temperature) would improve neurological outcome after cardiac arrest.

METHODS

We lowered patients' temperature after admission to the emergency department and continued cooling for at least 24 hours after arrest in conjunction with advanced cardiac life support. The cooling technique chosen was external head and total body cooling with a cooling device in conjunction with a blanket and a mattress. Infrared tympanic thermometry was monitored before a central pulmonary artery thermistor probe was inserted.

RESULTS

In 27 patients (age 58 [interquartile range [IQR] 52 to 64] years; 7 women; estimated "no-flow" duration 6 [IQR 1 to 11] minutes and "low-flow" duration 15 [IQR 9 to 23] minutes; admitted to the emergency department 36 [IQR 24 to 43] minutes after return of spontaneous circulation), we could initiate cooling within 62 (IQR 41 to 75) minutes and achieve a pulmonary artery temperature of 33+/-1 degrees C 287 (IQR 42 to 401) minutes after cardiac arrest. During 24 hours of mild resuscitative hypothermia, no major complications occurred. Passive rewarming >35 degrees C was accomplished within 7 hours.

CONCLUSIONS

Mild resuscitative hypothermia in patients is feasible and safe. A clinical multicenter trial might prove that mild hypothermia is a useful method of cerebral resuscitation after global ischemic states.

Asystole during dipyridamole infusion in patients without coronary artery disease or beta-blocker therapy

The authors report two patients without coronary artery disease who experienced asystole during the IV infusion of dipyridamole on routine TI-201 myocardial perfusion imaging and review the literature for possible explanations of this rare side effect. Until now, this side effect was only reported in patients with coronary artery disease or beta-blocker therapy. Yet, the cases lacked both concomitant factors and autonomic dysregulation is suggested as a cause for asystole.

Hemodynamic effects of active compression-decompression after prolonged CPR

BACKGROUND

This study was designed to test the effects of active compression-decompression (ACD) versus standard (STD) cardiopulmonary resuscitation (CPR) on hemodynamics after prolonged cardiac arrest (CA).

METHODS AND RESULTS

After nontraumatic prehospital CA, 21 patients were resuscitated in a prospective nonblinded setting sequentially with STD and ACD CPR at the emergency department, if it had not been possible to achieve restoration of spontaneous circulation (ROSC) before admission. The compression rate was 80/min with a 50% duty cycle, and 1 mg epinephrine was given every 5th min. Invasive arterial, central venous pressure and end tidal CO2 (ETCO2) were monitored. Comparing coronary perfusion pressure (CoPP) and ETCO2, no significant differences between STD and ACD CPR were found. In 3 cases ROSC could be achieved for a short time.

CONCLUSIONS

In our study, a comparison of STD and ACD CPR revealed no significant differences in coronary perfusion pressures and ETCO2. We conclude that after prolonged CA, ACD CPR does not provide an apparent hemodynamic advantage over STD CPR.

Systemic and cerebral oxygen extraction after human cardiac arrest

The aim of this study was to observe cerebral and systemic oxygen extraction after human cardiac arrest with return of spontaneous circulation. Eight adult patients after non-traumatic, cardiac arrest were included. Cerebral and systemic oxygen extraction ratios were measured together with haemodynamic variables beginning 2 hours after cardiac arrest and every 4 hours thereafter until 24 hours. Between 2 and 12 hours after cardiac arrest cerebral oxygen extraction values ranged from very low over normal to very high. In the further course these values were reduced until 24 hours in six patients. Two patients who were still alive after 6 months, both severely mentally disabled, had a higher cerebral oxygen extraction ratios in comparison with non-survivors. Systemic oxygen extraction seemed to vary more than the cerebral oxygen extraction. The two long-term survivors had normal to supranormal values from 8 to 24 hours. In conclusion cerebral oxygen extraction was higher in long-term cardiac arrest survivors than in non-survivors between 12 and 24 hours after the event. Further, a better quality of neurological recovery was associated with higher cerebral oxygen extraction. Systemic oxygen extraction was also impaired, but to a lesser extent, especially in long-term survivors.

Mild resuscitative hypothermia and outcome after cardiopulmonary resuscitation

Recovery without residual neurological damage after cardiac arrest with global cerebral ischemia is still a rare event. Severe impairment of bodily or cognitive functions is often the result. The individual, emotional, and social aspects of brain damage and rehabilitation are seldom taken into account. Efforts to improve the prevention of brain damage immediately after successful resuscitation of patients are missing. The efficacy of hypothermia in preserving neurologic function when instituted before and during certain no-flow cardiovascular states has been well documented both clinically and experimentally since the 1950s. Most studies have used moderate (28-33 degrees C) to deep (20-28 degrees C) hypothermia to demonstrate these protective effects. Considering the use of hypothermia for preservation and resuscitation, the lack of controlled outcome trials, the long period of time required to reach therapeutic hypothermia, and the incidence of rewarming complications such as infection, arrhythmia, and coagulopathy have made it difficult to apply these methods to emergency situations such as cardiac arrest. Recent experimental evidence in dogs has shown that hypothermia induced after cardiac arrest does indeed mitigate the effects of the postresuscitation syndrome and improves neurologic function and reduces histologic brain damage. More importantly, such benefits can be demonstrated with mild (34-36 degrees C) hypothermia, thus minimizing complications and requiring less time for induction of hypothermia. Ice water nasal lavage, direct carotid infusion of cold fluids, use of a cooling helmet, and peritoneal cooling are promising techniques for clinical cerebral cooling. External auditory canal temperature (e.g., tympanic membrane temperature changes) could provide an approximation to brain temperatures. For accurate temperature monitoring, however, a central pulmonary artery thermistor probe should be inserted. Temperature monitoring is needed to avoid temperature < 30 degrees C. Mild hypothermia may prove to be an important and secure component for cerebral preservation and resuscitation during and after global ischemia; it may also prove to be a useful method of cerebral resuscitation after global ischemic states, thereby promoting the prevention of neuromental diseases.

[Intravenous urapidil versus sublingual nifedipine in the treatment of hypertensive emergencies]

In a 6-month prospective study, the efficacy and safety of urapidil and nifedipine in an out-patient population with hypertensive urgencies (systolic blood pressure > 200 mmHg; diastolic blood pressure > 110 mmHg) was investigated. Response to treatment was defined as a stable reduction of systolic blood pressure below 180 mmHg and diastolic blood pressure below 100 mmHg 15 minutes after application of a single dose of either 25 mg urapidil intravenously (N = 26) or 10 mg nifedipine sublingually (N = 27). If the blood pressure was still elevated, a second dose of 10 mg nifedipine or 12.5 mg urapidil was given, and blood pressure response was evaluated 15 minutes after application of the second dose according to the aforementioned criterias. After the first application of nifedipine, 19 (70%) responders have been observed. Eight patients needed an additional 10 mg of nifedipine. In four of these patients, no reduction of blood pressure was observed after a second dose of nifedipine. In contrast, 24 (92%) patients responded well to the first application of 25 mg of urapidil. Two patients required a second dose of 12.5 mg of urapidil, but no nonresponder to urapidil was observed. No severe side-effects were noted in both groups. Intravenous urapidil is a highly effective drug in the treatment of hypertensive urgencies and is more effective than sublingual nifedipine, because the number of patients treated successfully was significantly higher.

Hormonal derangements in patients with severe alcohol intoxication

Controversial results of fluid and electrolyte derangements in patients with moderate alcohol intoxication have been described. However, no information is available about severe alcohol intoxication. We investigated differences of hormonal disorders between alcohol-habituated and alcohol-naive subjects with severe ethanol intoxication. The hormonal derangements and recommendations on therapy of these patients are discussed. Thirty-three patients [10 alcohol-naive (group A) and 23 alcohol-habituated (group B) subjects] with severe alcohol intoxication (blood ethanol > 200 mg/dl) were selected for the study. Electrolytes and osmolarity of serum and urine, blood ethanol, vasopressin, renin, and aldosterone were determined on admission 2, 4, and 6 hr later. Fluid balance was calculated for each hour. All patients received isotonic saline solution according to urine production. Group A: On admission, serum osmolarity was increased (308 mOsmol/kg). Concomitantly, vasopressin level was elevated on admission (9.12 pg/ml). Increased serum osmolarity was correlated with elevated vasopressin levels (r = 0.8211; p < 0.005). Serum electrolytes, renin, and aldosterone values were within normal ranges. Group B: On admission, vasopressin level was significantly decreased (0.9 pg/ml), despite an elevated serum osmolarity (309 mOsmol/kg). Serum osmolarity remained high despite a sufficient fluid substitution. In addition, vasopressin level remained suppressed over the observation period. Aldosterone level was significantly increased on admission (319 ng/ml). Accordingly, serum sodium was increased from 142 to 148 mM/liter, and serum potassium was decreased from 3.9 to 3.4 mM/liter. Response to hyperosmolarity due to severe alcohol intoxication is different in alcohol-naive and alcohol-habituated subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Estimated glucose requirement following massive insulin overdose in a patient with type 1 diabetes

A well-documented case of a 35-year-old male Type 1 diabetic patient who was admitted as an emergency after having injected 1500 international units (IU) of insulin (750 IU regular insulin,750 IU NPH-insulin) subcutaneously as a suicidal attempt is reported. Computing disappearance rates of glucose from its infused amounts necessary to maintain euglycaemia during 65 h after the insulin injection in analogy to experimental hyperinsulinaemic euglycaemic clamp examinations, a glucose consumption of 55.6 mumol kg-1 min-1 was found at peak serum insulin concentrations of about 14,400 pmol l-1. The insulin-induced glucose dynamics resemble closely those seen in healthy persons and Type 1 diabetic subjects during a 10 mU kg-1 min-1 euglycaemic clamp. This information may be useful in the handling of similar cases of insulin intoxication.

Intravenous urapidil versus sublingual nifedipine in the treatment of hypertensive urgencies

In a 6-month prospective study, the efficacy and safety of urapidil and nifedipine in an outpatient population with hypertensive urgencies (systolic blood pressure > 200 mm Hg; diastolic blood pressure > 110 mm Hg) was investigated. Response to treatment was defined as a stable reduction of systolic blood pressure below 180 mm Hg and diastolic blood pressure below 100 mm Hg 15 minutes after application of a single dose of either 25 mg urapidil intravenously (N = 26) or 10 mg nifedipine sublingually (N = 27). If the blood pressure was still elevated, a second dose of 10 mg nifedipine or 12.5 mg urapidil was given, and blood pressure response was evaluated 15 minutes after application of the second dose according to the aforementioned criterias. After the first application of nifedipine, 19 (70%) responders have been observed. Eight patients needed an additional 10 mg of nifedipine. In four of these patients, no reduction of blood pressure was observed after a second dose of nifedipine. In contrast, 24 (92%) patients responded well to the first application of 25 mg of urapidil. Two patients required a second dose of 12.5 mg of urapidil, but no nonresponder to urapidil was observed. No severe side-effects were noted in both groups. Intravenous urapidil is a highly effective drug in the treatment of hypertensive urgencies and is more effective than sublingual nifedipine, because the number of patients treated successfully was significantly higher.

[Amphetamine doping in leisure-time mountain climbing at a medium altitude in the Alps]

Although doping in leisure sports may potentially be of relevance for medical emergency situations, it has attracted much less attention than doping in elite athletes. The aim of our study was to evaluate the prevalence of amphetamine consumption in medium altitude mountaineering. Urine samples were taken from 253 males after a successful ascent. Analysis for amphetamines proved positive for 7.1% of mountaineers climbing above 3300 m. On peaks between 2500 to 3300 meters above sea level, 2.7% of the mountaineers we examined had amphetamines residues in their urine. Below 2500 meters, no positive sample was detected. For tourists living outside of the Alpine range, we noticed a significantly higher proportion of positive analyses. We conclude that attempts to induce a higher performance level by pharmacological means are not overly uncommon in leisure mountaineering. Such a behaviour may be of medical relevance in emergency situations.

Psychological factors of familial alcoholism in American Indians and Caucasians

Previous studies have reported on the familial transmission of alcoholism and its psychological concomitants. To date, investigators have not studied the familial factor and its relationship to transmission/risk in a group of American Indians (doubly at risk for alcoholism). In two related studies, we have assessed psychological adjustment and drinking behavior of (1) a group of Indians with one or more first-degree alcoholic relatives and a group of Indians without a history of familial alcoholism; and (2) Indians with a history of familial alcoholism compared to Caucasians with a history of familial alcoholism. Results indicate no psychological functioning differences between familial and nonfamilial Indians. However, the familial Indian group reported a style of drinking that more closely resembled that of an alcoholic group. Looking at these data cross-culturally, there are differences between Indians and Caucasians on psychological adjustment, as well as drinking behavior. These differences are present in spite of a shared familial history of alcoholism.

Tribal affiliation and prevalence of alcohol problems

Differences in tribal culture, history and settlement may explain why Indians in eastern Oklahoma have lower rates of alcohol-related arrests and deaths than do Indians in the western part of the state.