German evidence-based guidelines for the treatment of Psoriasis vulgaris (short version)

Psoriasis vulgaris is a common and chronic inflammatory skin disease which has the potential to significantly reduce the quality of life in severely affected patients. The incidence of psoriasis in Western industrialized countries ranges from 1.5 to 2%. Despite the large variety of treatment options available, patient surveys have revealed insufficient satisfaction with the efficacy of available treatments and a high rate of medication non-compliance. To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologische Gesellschaft and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the management of psoriasis. The guidelines focus on induction therapy in cases of mild, moderate, and severe plaque-type psoriasis in adults. The short version of the guidelines reported here consist of a series of therapeutic recommendations that are based on a systematic literature search and subsequent discussion with experts in the field; they have been approved by a team of dermatology experts. In addition to the therapeutic recommendations provided in this short version, the full version of the guidelines includes information on contraindications, adverse events, drug interactions, practicality, and costs as well as detailed information on how best to apply the treatments described (for full version, please see Nast et al., JDDG, Suppl 2:S1-S126, 2006; or http://www.psoriasis-leitlinie.de ).

Präklinisches Atemwegsmanagement in Norddeutschland

BACKGROUND

Out-of-hospital airway management confronts emergency medical teams with complex challenges. To date no specific data are available on the qualifications of emergency physicians (EPs) and the quality of emergency equipment in northern Germany.

MATERIALS AND METHODS

This study surveyed individual EPs at regional emergency dispatch centres about their personal knowledge and skills, and the procedures and equipment used in out-of-hospital airway management.

RESULTS

A total of 606 EPs from 59 of the 66 (89.4%) regional emergency dispatch centres surveyed responded and 56.1% of the EPs questioned were anesthesiologists. The other EPs were qualified in either internal medicine (22.6%), surgery (12.4%), general medicine (5.6%) or other specialties (3.3%). All (100%) of the EPs trained in anesthesia and 35.2% of the other EPs reported that they had performed more than 100 in-hospital endotracheal intubations (ETI). 93% of all EPs rated out-of-hospital ETI as more difficult than in-hospital ETI. A total of 33.0% of anesthesia-trained EPs and 6.1% of the other EPs used muscle relaxants for ETI in more than 20% of the cases. Of the anesthesia-trained EPs 38.1% used expiratory CO(2) monitoring to verify tube placement compared to 12.1% of the other EPs. A total of 97.8% of anesthesia-trained EPs reported having used an extra-glottic airway device more than 20 times compared to 11.1% of the other EPs. For the emergency equipment 44.4% included an extraglottic airway device, 57.8% a cricothyrotomy set and 27.1% CO(2) monitoring options.

CONCLUSION

Neither the emergency equipment nor the physicians' knowledge and skills were sufficient to meet the special demands of out-of-hospital airway management, particularly among non-anesthesiologists.

[TIVA with etomidate-fentanyl versus midazolam-fentanyl. The perioperative stress of coronary surgery overcomes the inhibition of cortisol synthesis caused by etomidate-fentanyl anesthesia]

Etomidate is a hypnotic with only minor effects on haemodynamics. Although its rapid elimination kinetics would suggest its use in total intravenous anaesthesia (TIVA) and sedation, its administration in higher doses or for a prolonged period has been discouraged due to its inhibitory effects on corticosteroid synthesis. Newer evidence that the suppression of cortisol synthesis might not be total requires a re-evaluation of this drug as a component of a TIVA technique. The effects of high-dose etomidate with fentanyl on spontaneous and stimulated corticosteroid levels as a measure of the magnitude and duration of adrenocortical suppression, as well as on plasma concentrations of adrenocorticotropic hormone (ACTH) beta-endorphin, and catecholamines during cardiac surgery were investigated in a prospective, randomised study and compared to those following the administration of midazolam-fentanyl. PATIENTS AND METHODS. Nineteen patients undergoing myocardial revascularisation were assigned to two groups: group 1: etomidate-fentanyl (n = 9) and group 2: midazolam-fentanyl (n = 10). Anaesthesia was induced with fentanyl 0.5 mg and either etomidate 0.3 mg/kg or midazolam 0.2 mg/kg. Relaxation was achieved with pancuronium 0.1 mg/kg. Anaesthesia was maintained during extracorporeal circulation (ECC) with an infusion of etomidate (0.36 mg.kg-1.h-1) or midazolam (0.16 mg.kg-1.h-1) and fentanyl 10 micrograms.kg-1.h-1. Blood samples were drawn before induction, before ECC, and 1, 6, and 20 h after surgery. Cortisol secretion was stimulated with 0.25 mg ACTH1-24 IV at 6 and 20 h postoperatively. RESULTS. The total drug doses were etomidate 87 +/- 3 mg and midazolam 46 +/- 2 mg. Plasma cortisol concentrations decreased in the etomidate group from 20 (10-31) to 10 (6-31) micrograms.dl-1 (median and range) before ECC, but had returned to baseline at 1 h and were significantly increased at 6 h [29 (15-47) micrograms.dl-1] and 20 h [46 (29-62) micrograms.dl-1]. There was no difference between the groups except at 20 h, when cortisol levels were higher in the etomidate group. The stimulated cortisol increase was markedly impaired in this group at both measuring points. ACTH and beta-endorphin were markedly increased in the etomidate group and ACTH concentrations were eight times greater than the corresponding values in the midazolam group after surgery (ACTH 141 vs. 18 pmol.l-1). Plasma catecholamine concentrations increased significantly in both groups. Noradrenaline concentrations were greater in the etomidate group at 6 h after surgery. Two patients in the midazolam group and none in the etomidate group required circulatory support with exogenous catecholamines. DISCUSSION. It is concluded that the stress of cardiac surgery can overcome the block in cortisol synthesis caused by the administration of high-dose etomidate by substantially increasing ACTH secretion. The administration of high-dose etomidate was not associated with cardiovascular instability. The use of etomidate as a component of TIVA can therefore not be ruled out on the grounds of insufficient cortisol secretion.

Endocrinological changes following etomidate, midazolam, or methohexital for minor surgery

Etomidate is known to inhibit adrenocorticosteroid synthesis. The extent and duration of the effects of etomidate (63 +/- 6.4 mg) on spontaneous and stimulated corticosteroid levels, as well as on plasma concentrations of ACTH, beta-endorphin, and catecholamines were examined and compared to those following administration of the new benzodiazepine, midazolam, or of methohexital. Twenty-nine healthy, young, male orthopedic patients were randomized into three groups receiving either etomidate/fentanyl (n = 12), midazolam/fentanyl (n = 8), or methohexital/fentanyl (n = 9). Etomidate caused cortisol levels to decrease from 12.5 +/- 1.2 micrograms/dl preoperatively to 5.9 +/- 0.8 micrograms/dl after operation (P less than 0.001), compared to an increase from 12.0 +/- 1.9 micrograms/dl to 18.5 +/- 2.9 micrograms/dl in the group receiving methohexital. At 6 and 20 h postoperatively, all cortisol levels were normal. The cortisol decrease from 12.5 +/- 1.7 to 7.6 +/- 1.5 caused by midazolam was similar to that following etomidate, but the response to exogenous ACTH was significantly impaired in patients receiving etomidate as compared to those receiving midazolam. ACTH and beta-endorphin levels increased in patients receiving etomidate, presumably as a result of the interruption of negative feedback due to cortisol synthesis inhibition. Midazolam on the other hand prevented the increase of ACTH and beta-endorphin levels. Etomidate completely suppressed spontaneous aldosterone levels (from 33 +/- 6.7 to 7 +/- 2.1 pg/ml), as well as the response to stimulation with exogenous ACTH without affecting serum electrolytes. Etomidate had no influence on plasma catecholamines, but midazolam attenuated the stress-related epinephrine increase.

[Malignant melanoma in husband and wife (author's transl)]

There have been three previous reports of malignant melanoma of the skin in husband and wife. The authors add an observation of their own and compare it with the previously reported ones. In their own case, the couple had been married for 27 years. The husband's tumour was noted eight years before that of his wife. The tumours were histologically very similar. None had HL-A-5 antigen.

[Diagnostic value of RAST-classes in various allergens]

Specific IgE-fractions can be determined in the blood serum by Radio-Allergo-Sorbent-Test (RAST). The positive tests are arranged into four groups, the so called RAST-classes, of which class 1 represents the lowest, class 4 the highest content of specific IgE. The diagnostical value of equal RAST-classes among the groups of allergens is different. We examined 13 600 allergens in 700 patients by RAST and found 2441 positive reactions. It turned out that especially in weeds, house dust and mould allergy, the lower RAST-classes are predominant with more than 90 per cent. In grass pollen allergy, a comparable percentage of positive tests accumulates in the range of RAST-class 3. From this distribution of positive tests we concluded, that in house dust, mould and weeds pollen allergy RAST-class 1 has a real diagnostical value and can be the basis of therapeutical consequences. In patients with lower RAST-classes in mould, house dust and weed pollen allergy, in our experience, the average total IgE is already in a pathological range; in patients with grass pollen allergy total IgE is increased pathologically almost until RAST-class 4.