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Gemäß der Leitlinie der Europäischen (2008) und der Deutschen Gesellschaft für Kardiologie (2009) wird für Patienten mit einer Lungenembolie im kardiogenen Schock zunächst die thrombolytische Therapie (Empfehlungsgrad I, Evidenzgrad A) empfohlen. Ist die Lyse kontraindiziert oder nicht erfolgreich, kann eine chirurgische Embolektomie (Empfehlungsgrad I, Evidenzgrad C) erwogen werden. Als weitere Optionen aufgeführt werden eine Katheterembolektomie oder eine Fragmentation des Thrombus in der proximalen pulmonalen Arterie genannt (Empfehlungsgrad IIb, Evidenzgrad C). Der Einsatz der venoarteriellen extrakorporalen Membranoxygenierung (ECMO) bleibt in den genannten Leitlinien unerwähnt. Eine PubMed-Literaturrecherche ergibt einige Fallberichte über erfolgreiche Anwendung der venoarteriellen ECMO bei reanimationspflichtigen Lungenemboliepatienten, wenn die Lysetherapie versagt. Vorgestellt wird ein Patient, der unmittelbar nach einem operativen Eingriff eine fulminante Lungenembolie entwickelt hatte, sich unter Lysetherapie weiterhin im kardiogenen Schock befand und schließlich nach der Anlage einer venoarteriellen ECMO stabilisiert werden konnte. Bei einer fulminanten Lungenembolie steht das akute Herzversagen im Vordergrund. Es kommt konsekutiv zur Hypoxämie mit drohender Hypoxie lebenswichtiger Organe. Der Einsatz der venoarteriellen extrakorporalen Membranoxygenierung ist eine therapeutische Option bei lebensbedrohlicher Lungenembolie. Entscheidend für einen Erfolg ist die sofortige Indikationsstellung und zügige Implantation des Systems. According to the guidelines of the European (2008) and German Societies of Cardiology (2009) thrombolysis is recommended for patients with pulmonary embolisms presenting with cardiogenic shock (recommendation level I, evidence level A). If there are contraindications or thrombolysis is not successful surgical embolectomy should be considered (recommendation level I, evidence level C). Additional options are catheter-based therapies in the proximal pulmonary artery (recommendation level IIb, evidence level C). The use of arteriovenous extracorporeal membrane oxygenation ( ECMO) was not included in these guidelines. A literature search in PubMed resulted in some case reports of the successful use of arteriovenous ECMO for resuscitation in patients with severe pulmonary embolisms following failed thrombolysis. In this article we present the case report of a patient who developed fulminant pulmonary embolism immediately after surgery. The patient was still in cardiogenic shock despite thrombolysis but the condition was stable following implementation of an arteriovenous ECMO. Acute heart failure and hypoxemia of all organs are the main symptoms of massive pulmonary embolisms. The use of arteriovenous ECMO represents a therapeutic option for life-threatening pulmonary embolism. A decisive factor for success is immediate diagnosis and rapid implementation of the system.

A detailed assessment of intra- and inter-reader variation in the interpretation of brain SPECT scans has been performed. A random sample was selected from scans performed at a communityteaching hospital in Seattle. Scans were interpreted independently by three experienced readers who were blinded to all patient information. Forty-eight scans were interpreted twice by each reader, for a total of 288 readings. Readers recorded detailed assessments of individual lesions and overall impressions using a standardized reporting form. Intra-observer agreement as reflected in per cent agreement for severity scores ranged from 65 to 100. Intra-observer agreement on the ‘overall impression’ was very good for Alzheimer's pattern (kappa 0.73-1.00), and fair to good for the ‘heterogeneous pattern’ (kappa 0.30-0.63). Inter-observer agreement, as reflected in per cent agreement, ranged from 29 to 100. Inter-observer agreement about the ‘overall impression’ was fair to moderate for Alzheimer's pattern (kappa 0.24-0.54) and was poor for the descriptors ‘heterogeneous’ and ‘normal’. It is concluded that brain SPECT has great potential value in many important conditions. This study demonstrates a need for further work in the areas of pattern definition and reduction of observer variation.

In der folgenden Arbeit wird die klinische Bedeutung der retrograden Kardioplegie überprüft. 416 Patienten erhielten einen Aortenklappenersatz, wobei wir ausschließlich retrograde Kardioplegie verabreichten. Es wurde beobachtet, daß die folgenden Faktoren einen statistisch signifikanten Einfluß auf das postoperative Ergebnis haben: Alter, Geschlecht, präoperativer Herzrhythmus, präoperative renale oder neurologische Erkrankungen, Hypertonie und Diabetes mellitus, Bypass- und Ischämiedauer sowie die Menge der verabreichten Kardioplegielösung. Auf Grund unserer positiven Erfahrungen können wir die Anwendung der retrograden Kardioplegie bei Aortenklappenersatzoperationen empfehlen. The aim of this study is to examine the outcome of aortic valve surgery where exclusively retrograde cardioplegia was administered. 416 patients received aortic valve replacement, where by we exclusively administered retrograde cardioplegia. It was observed that the following factors have statistical significant influence on the postoperative outcome: age, sex, preoperative cardiac rhythm, renal or neurological diseases, hypertension and diabetes mellitus, bypass and ischemic time as well as the amount of cardioplegia given. From our positive experiences using this method in aortic valve surgery we can recommend the use of the retrograde cardioplegia.

Medical patients' (75 with chronic fatigue complaints, 61 with dizziness, and 88 with disabling tinnitus; N = 224) current and past psychiatric diagnoses and personality characteristics were assessed to determine if they could independently explain the number of medically unexplained physical symptoms that the patients had experienced. Cloninger's Tridimensional Personality Questionnaire (TPQ) and the Diagnostic Interview Schedule based on DSM-III-R were used to assess the personality and psychiatric diagnoses, respectively. The results revealed that the number of lifetime medically unexplained symptoms were significantly, independently, and positively related to increasing numbers of current and past anxiety and depressive disorders and to the harm avoidance dimension of the TPQ. In a second analysis, the "worry/pessimism" and "impulsiveness" subscales were positively related to the number of medically unexplained symptoms. The results suggest that somatization is associated with current and past history of psychiatric illnesses and harm avoidance in this sample of medical patients.

Habitual short sleep duration is associated with adverse metabolic, cardiovascular, and inflammatory effects. Co-twin study methodologies account for familial (eg, genetics and shared environmental) confounding, allowing assessment of subtle environmental effects, such as the effect of habitual short sleep duration on gene expression. Therefore, we investigated gene expression in monozygotic twins discordant for actigraphically phenotyped habitual sleep duration.