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Summary Background Current literature suggests a positive influence of additive classical homeopathy on global health and well-being in cancer patients. Besides encouraging case reports, there is little if any research on long-term survival of patients who obtain homeopathic care during cancer treatment. Design Data from cancer patients who had undergone homeopathic treatment complementary to conventional anti-cancer treatment at the Outpatient Unit for Homeopathy in Malignant Diseases, Medical University Vienna, Department of Medicine I, Vienna, Austria, were collected, described and a retrospective subgroup-analysis with regard to survival time was performed. Patient inclusion criteria were at least three homeopathic consultations, fatal prognosis of disease, quantitative and qualitative description of patient characteristics, and survival time. Results In four years, a total of 538 patients were recorded to have visited the Outpatient Unit Homeopathy in Malignant Diseases, Medical University Vienna, Department of Medicine I, Vienna, Austria. 62.8% of them were women, and nearly 20% had breast cancer. From the 53.7% ( n =287) who had undergone at least three homeopathic consultations within four years, 18.7% ( n =54) fulfilled inclusion criteria for survival analysis. The surveyed neoplasms were glioblastoma, lung, cholangiocellular and pancreatic carcinomas, metastasized sarcoma, and renal cell carcinoma. Median overall survival was compared to expert expectations of survival outcomes by specific cancer type and was prolonged across observed cancer entities ( p Conclusion Extended survival time in this sample of cancer patients with fatal prognosis but additive homeopathic treatment is interesting. However, findings are based on a small sample, and with only limited data available about patient and treatment characteristics. The relationship between homeopathic treatment and survival time requires prospective investigation in larger samples possibly using matched-pair control analysis or randomized trials.

BACKGROUND AND PURPOSE: The initial angiographic occlusion rate is the strongest predictor of later rebleeding in previously ruptured coil-embolized cerebral aneurysms. Angiographic estimations of aneurysmal occlusion rates are, however, subjective in nature and confounded by methodologic problems. COR has been developed, and its superiority has been experimentally established to overcome subjective bias. The purpose of this study was to assess the clinical value of COR as a more objective predictor of aneurysm rebleeding when compared with SOR as described in the Raymond Classification. MATERIALS AND METHODS: We applied COR in a consecutive series of 249 patients. Two DSA projections were selected independently by 2 blinded investigators. In cases of disagreement on the selected projections, a consensus decision was obtained. SOR were determined by 2 independent observers according to the Raymond classification. COR was measured by 2 blinded investigators. Interobserver variations were determined for SOR and COR. COR results were compared with SOR results and stratified as 100%, 99.9%–90%, 89.9%–70%, and

Introduction Endotracheal intubation (ETI) is the most widespread method for emergency airway management. Several studies reported that ETI requires considerable skill and experience and if performed incorrectly, may result in serious adverse events. Unrecognized tube misplacement or oesophageal intubation is associated with high prehospital morbidity. This study investigates the usability of supraglottic airway devices compared to ETI and the skill retention of 41 previously inexperienced paramedics following training using a manikin model. Methods 41 paramedics participated in this study. None had prior experience in airway management, apart from bag-valve ventilation. After a standardised audio-visual lecture lasting 45min, the paramedics participated in a practical demonstration using the advanced patient simulator SimMan ® (Laerdal Medical, Stavanger, Norway). Afterwards, paramedics were instructed to perform airway-management using seven different techniques to secure the airway (ETI, Laryngeal mask unique [LMA], Proseal, Laryngeal tube disposable [LT-D ® ], I-Gel ® , Combitube ® , and EasyTube ® ) following a randomized sequence. Participants underwent reassessment after 3 months without any further training or practice in airway-management. Results During the initial training session, ETI was successfully performed in 78% of cases, while 3 months later the success rate was 58%. For the supraglottic airway devices, five out of six were successfully used by all paramedics at both time points, the exception being Proseal ® . Our data show successful skill retention (success rate: 100%) after 3 months for five out of six supraglottic airway devices. Time to ventilation (T3) was significantly less for LMA, LT-D ® and I-Gel ® at all time points compared to ETI. Conclusion ETI performed by inexperienced paramedics is associated with a low success rate. In contrast, supraglottic airway devices like LMA, LT-D ® , I-Gel ® , Combitube ® and EasyTube ® are fast, safe and easy-to-use. Within the limitations of a manikin-study, this study suggests that inexperienced medical staff might benefit from using supraglottic airway devices for emergency airway management.

Chronic thromboembolic pulmonary hypertension (CTEPH), subsequent to pulmonary embolism is a relatively frequent cause of pulmonary hypertension. Similar to patients with pulmonary arterial hypertension (PAH), CTEPH carries a poor prognosis. There is no hard evidence for any other therapy except pulmonary endarterectomy and none for those patients that are not eligible for this procedure.Fifty patients with confirmed, inoperable CTEPH receiving specific vasodilative therapy (prostanoids, endothelin receptor antagonists, PDE 5-inhibitors or combination) were included in this retrospective study (mean age 55 years, range 16-76 years; 36 female, 14 male). Kaplan-Meier plots of these patients were compared with Kaplan-Meier plots of two historical CTEPH patient groups without any specific vasodilative treatment by log rank tests.CTEPH patients treated with specific vasodilative compounds as used for therapy of PAH were followed up for 52 +/- 30 months and had a significantly improved survival compared with patients treated without PAH type vasodilators (por = 0.0002).Our data may generate the hypothesis that specific vasodilative treatment improves outcome in patients with inoperable CTEPH.

To evaluate the effectiveness, safety, ease of placement, and ventilatory parameters of a new alternate airway device, the EasyTube (EzT; Teleflex Ruesch, Research Triangle Park, NC), in comparison to the endotracheal tube (ETT).Prospective, randomized controlled trial.University Hospital.200 adult ASA physical status I and II patients scheduled for surgery.Patients were randomized to two groups, one to receive ventilation via the EzT (n = 100) or the ETT (n = 100). After preoxygenation and induction with fentanyl and propofol, patients received muscle relaxation. The respective airway device was then inserted and mechanical ventilation was instituted.Ease of insertion, number of insertion maneuvers, time until airtight seal of the airway was achieved, duration of surgery, leak pressure as well as arterial oxygen saturation (SpO(2)), and end-tidal carbon dioxide (ETCO(2)) data, were recorded.Mallampati airway class was higher in the EzT group (P0.029), while thyromental distance showed no difference between the two groups. Ease of insertion was noted in the EzT group (P0.043). Number of insertions was equal in both groups; insertion time was shorter with the EzT (15.5 +/- 3.6 sec vs. 19.3 +/- 4.6 sec; P0.0001). Leak pressure and SpO(2) were not significantly different, while ETCO(2) was lower with the ETT (P0.024). Adjustments had to be made for two EzT group patients. No difference in frequency of laryngo-pharyngeal discomfort was observed in either group.Insertion of an EzT appears to reduce time and facilitate placement of an airway device when compared with direct laryngoscopy and tracheal intubation.

OBJECTIVES The purpose of this study was to compare quantitative ECG-gated single-photon emission computed tomography (SPECT) (QGS) and model-based ECG-gated single-photon emission computed tomography (MBGS) for determination of end-diastolic cardiac volume (EDV), end-systolic cardiac volume (ESV), and left ventricular ejection fraction (LVEF). The accuracy of both methods was evaluated by measurements obtained from contrast left ventriculography (LVG). METHODS Forty-five patients (40 male, age: 55+/-11 years) with coronary artery disease were studied by angiography and ECG-gated SPECT using technetium-99m-sestamibi for the evaluation of myocardial perfusion and LVEF. Short axis SPECT images were analyzed by QGS and MBGS to estimate endocardial and epicardial surfaces and to derive EDV, ESV, and LVEF. RESULTS EDV by gated SPECT (QGS: 187+/-71 ml; MBGS: 191+/-76 ml) were lower than corresponding values by LVG (203+/-59 ml), whereas ESV by gated SPECT (QGS: 121+/-62 ml; MBGS: 108+/-54 ml) were higher than by LVG (105+/-49 ml). Thus, LVEFs by gated SPECT (QGS: 39+/-12%; MBGS: 45+/-9%) were significantly lower than by LVG (50+/-15%). LVEF by MBGS was significantly higher than by QGS (P

BACKGROUND AND PURPOSE: Computerized methods have been introduced for more objective quantification of angiographic occlusion rate and coil density as parameters of successful embolization. This study aimed 1) to evaluate this new computerized method for angiographic occlusion rating and coil density calculations by comparison with corresponding histometric parameters from retrieved human aneurysms, and 2) to compare the new computerized method with the present standard of subjective angiographic occlusion rating. MATERIALS AND METHODS: From 14 postmortem-retrieved human aneurysms, angiographic occlusion rate was determined by contrast medium attenuation-gradient distinction on digital subtraction angiographs after Guglielmi detachable coil (GDC) embolization. Angiographic coil density was calculated, approximating aneurysms as ellipsoid and coils as cylindric volumes. On surface-stained histologic ground sections of the respective aneurysms, the occluded aneurysm area and coil area were measured. Then, we calculated and compared the histometric occlusion rates and coil densities with the corresponding angiographic parameters by using the Wilcoxon paired signed-rank test and the Spearman rank correlation. RESULTS: Computerized angiographic occlusion rates (75%–100%) showed good correlation (r = 0.799; P < .01) with histometric occlusion-rates (61%–100%), resulting in no statistically significant differences (P = .2163). With 5.1% (±3.8), the mean difference between computerized angiographic occlusion rates and histometry was substantially lower compared with 10.7% (±8.7) mean difference between subjective angiographic estimations and histometry. Calculated angiographic coil density (13%–32%) significantly differed from histometric coil density (8%–35%; P < .05). CONCLUSIONS: For recanalized aneurysms, computerized angiographic occlusion rating showed better correspondence with histometry compared with subjective angiographic occlusion rating. Clinical application of this new tool may lead to more objective cutoff values for re-embolization indications. The value of coil density calculations seems limited by the approximation of the aneurysms as ellipsoid volumes.

Objective: This study compared the diagnostic accuracy of different approaches of case-based reasoning (CBR) for the assessment of coronary artery disease (CAD) using thallium-201 myocardial perfusion scintigraphy in comparison with coronary angiography. Methods and material: For each scintigraphic image set, regional myocardial tracer uptake was obtained by polar map analysis. CBR algorithms based on a similarity measure were employed to identify similar scintigraphic images within the case library, where each case contained the scintigraphic data together with results of coronary angiography. The angiographic data of retrieved cases were then used to determine whether significant CAD was present in one of the major coronary arteries. Three different approaches of CBR were compared: (1) case retrieval based on a global comparison of polar map data (GLOB), (2) case retrieval based on a territorial comparison of polar map data (TER), and (3) case retrieval based on a comparison of a given case with eight sub-libraries classified according to the involvement of the three major coronary vessels using a group similarity measure (GROUP). Two matching algorithms the best-match approach and an adapted retrieving approach were combined with all three case retrieval methods and their influence on the diagnostic accuracy were investigated. Results: For overall detection of significant CAD, the best-match approach of both TER and GROUP retrieval methods showed a higher diagnostic accuracy than the GLOB retrieval method (75% and 77% versus 70%, respectively). ROC analysis for the adapted retrieving approach showed a similar diagnostic accuracy for all three methods with an area under the curve of 0.79, 0.8, and 0.8 for GLOB, TER, and GROUP, respectively. Conclusion: The observed improvement in the diagnostic accuracy by the new approaches may lead to further improvements of CBR systems, which have the potential to offer valuable decision support for human readers, especially for less experienced investigators.

Background Data on mercury exposure of the Austrian population were inadequate. This study was performed to determine the causal factors underlying mercury exposure and selenium concentrations, and to estimate the gender-related health impacts. Methodology Venous blood samples of 78 women and 81 men were drawn at the Austrian Red Cross, Vienna. Mercury contents in acid-digested whole blood samples were measured after amalgam enrichment by CV-AAS, and selenium by AAS (heated quartz-cell) after hydrid formation. Results The average total mercury blood content of Austrians was low (2.38 ± 1.55 μgL− 1; N = 152). Mercury and selenium concentrations were not different between the genders (P > 0.05) but we observed discrepancies regarding the causal factors. Mercury levels in men were influenced not only by fish consumption but also by age, education level, and amalgam fillings, whereas in women, only the diet (fish/seafood, red wine consumption) determined blood mercury (P

Bystanders are reluctant to perform basic life support (BLS) because of fear of failure and of infection, especially with mouth-to-mouth resuscitation (MTM). A possibility to enhance willingness could be the giving of MTM or BLS instructions at a very early age to the potential rescuers. The study aimed to investigate the effectiveness of MTM with respect to ventilation and the time needed for performing 5 ventilations. In this study, MTM was performed on a mannequin by 57 children and adolescents aged 10 and 14 years. This study showed that 14-year-olds effectively perform MTM, reaching the recommended tidal volumes. Ten-year-old children have already developed sufficient motor skills for MTM with no significant time differences compared with the 14-year-olds. However, physical demands may be rather high at this age. Further long-term studies are needed to investigate clinical benefits of early teaching of MTM or BLS that may lead to international guidelines with low age limits.

Background Percutaneous cricothyroidotomy is a lifesaving procedure for airway obstruction in trauma victims who need airway establishment and cannot be intubated or in whom intubation has failed. Methods The purpose of this study was to examine whether there is a training effect using Seldinger technique emergency cricothyroidotomy (group 1; Arndt Emergency Cricothyroidotomy Catheter Set; Cook Critical Care, Bloomington, IN) versus standard surgical cricothyroidotomy (group 2). Twenty emergency physicians performed five cricothyroidotomies with each method in a total of 200 human cadavers, comparing efficacy and safety (speed, success rate, and injuries). Results Seven attempts in group 1 and six in group 2 had to be aborted. Time intervals from the start of the procedure to location of the cricothyroid membrane were not significantly different between the groups. However, time to tracheal puncture (P < 0.01) and time to first ventilation (P < 0.001) were significantly longer in group 2. No time effect could be observed in both groups. The airway was accurately placed into the trachea through the cricothyroid membrane in 88.2% (82 of 93) of the cadavers in group 1 and in 84.0% (79 of 94) in group 2 (not significant). No injuries were observed in group 1, whereas there were six punctures of the thyroid vessels in group 2 (P < 0.05). Conclusions With respect to time needed for the procedure, the participants performed Seldinger technique emergency cricothyroidotomy significantly faster as compared with standard surgical cricothyroidotomy. Even if no training effect had been observed, the authors believe that it is important to train residents in different methods of cricothyroidotomy in cadavers in addition to training in mannequins to achieve a higher level of efficacy in real-life situations. The shorter time to first ventilation and the fact that no injuries could be observed favor the Seldinger technique.

This prospective randomised study was performed to compare the use of the Esophageal-Tracheal Combitube(R) (ETC; Tyco Healthcare, Mansfield, MA; http://www.combitube.org) with a conventional tracheal airway (ETA) for airway management by experienced physicians of the Emergency Medical Services System of the City of Vienna in the prehospital setting. Access to the patient's head, time of arrival of the ambulance, ease of insertion, time of insertion, potential substitution by the alternate airway, efficacy of adrenaline (epinephrine) administered via the airway, survival to the intensive care unit (ICU) ward and survival to discharge from the hospital were evaluated. One hundred and seventy-two non-traumatic cardiac arrest patients (131 males, 41 females) were enrolled in this study during a 12 months period. In 83 patients (48.3%), the conventional ETA (group 1) was used for the initial intubation attempt which was successful in 78 patients (94%). The remaining five patients of group 1 could not be intubated with an ETA, but were successfully managed with the ETC. Eighty-nine patients (51.7%) were intubated with the ETC (group 2) as first choice (79 in oesophageal position (89%); eight in tracheal position: (9%)), which was successful in 87 (98%) patients. The remaining two patients in group 2 (2%) were successfully managed with the ETA. Success of intubation and ventilation with ETC was comparable to the ETA. Recorded time of insertion was shorter with the ETC versus ETA (P0.05). The Combitube worked well in cases of difficult access to the patient's head and in bleeding and vomiting patients. Both devices served as successful substitutes for each other. Adrenaline (epinephrine) applied via ETC with a 10-fold dosage was as effective as via the conventional ETA. To our knowledge this is the first study using physicians comparing ETC and ETA in the prehospital setting.

The 4G/5G polymorphism of the plasminogen activator inhibitor type I (PAI-I) gene is involved in coronary artery disease (CAD), with the highest risk in 4G/4G homozygotes. The role of PAI-I polymorphism in patients suffering from CAD and history of sudden cardiac death (SCD) has not been addressed yet. We studied the frequency distribution of the PAI-I gene to test the hypothesis that the 4G/4G genotype favors myocardial ischemia and, even in the absence of acute infarction, promotes SCD in patients with CAD. Methods: The PAI-I 4G/5G genotypes and PAI-I antigen plasma levels were determined in 97 patients with CAD and a history of SCD treated with an implantable cardioverter defibrillator (ICD) (defibrillator group) comparing to 113 patients with CAD but no history of SCD (control group). Results: The defibrillator group consisted of significantly more 4G/4G homozygotes and higher PAI-I levels than the control group (44% vs. 24%, 173±41 vs. 144±49 ng/ml; P

OBJECTIVE: To compare plasma concentrations and cardiovascular effects of epinephrine after application via a conventional endotracheal airway and via the esophageal lumen of a new emergency airway, the esophageal tracheal Combitube. DESIGN: Prospective, randomized study. SETTING: Center for Biomedical Research, University of Vienna. SUBJECTS: Fourteen juvenile swine received either an endotracheal tube (Group A) or a Combitube in esophageal position (Group B). INTERVENTIONS: In Part I of the study, epinephrine was administered during spontaneous beating of the heart; in Part II, epinephrine was administered during cardiopulmonary resuscitation, using a ten-fold higher dosage in Group B, respectively. MEASUREMENTS: Plasma epinephrine levels were measured 1, 2, 3, 5, 7, 10, 15, and 30 mins after application. Systolic arterial blood pressure and cardiac output in Part I, and end-tidal CO2 and coronary perfusion pressure in Part II were recorded. MAIN RESULTS: In Part I, increased levels of plasma epinephrine and systolic arterial pressure were maintained significantly longer in Group B when compared with Group A. In Part II, no significant differences between the groups were found with regard to plasma epinephrine levels and hemodynamic variables. CONCLUSION: Epinephrine applied via the esophageal lumen of the Combitube in a ten-fold higher dosage has similar effects on plasma epinephrine levels and hemodynamic variables compared to endotracheal administration.

Endovascular coil occlusion of ruptured cerebral aneurysms has a higher rate of rebleeding compared to surgical clipping. Initial aneurysm coil occlusion rate (OR) is the strongest available predictor of aneurysm rebleeding. Standard clinical subjective occlusion rating (SOR) is limited by subjective bias. Therefore, computerized occlusion rating (COR) was introduced. Its superiority was established for experimental and human aneurysms. In the present clinical study, we aimed to evaluate COR as a risk factor for postprocedural reruptures (PPRs) and intraprocedural reruptures (IPRs). In our series of 249 consecutive patients treated in our institution, we observed 7 (2.8%) cases with IPR and 7 (2.8%) cases with PPR. These patients were analyzed in the present study. Mean COR value was 85% (range 71-96%). In 12 (85.7%) cases, COR was lower than SOR. In aneurysms with a COR of 95% or higher, no PPR occurred. All patients with IPR harbored multiple aneurysms. In -conclusion, our data showed a distinct tendency of potentially dangerous overestimations when using SOR compared to the objectively measured COR values. IPR was always associated with multiple aneurysms.

Within the framework of a cooperative research project, turkey health as well as numerous aspects of animal welfare were examined in various intensive commercial farms with varying rearing forms. The present study demonstrates the prevalence of skin injuries concerning living animals as well as carcasses of slaughtered turkeys of both sexes. Although all turkeys were debeaked, prevalences of skin injuries at a value of 12.8% with male turkeys and 13.8% with female turkeys could be found at the age of 16 weeks. Within the scope of medically inspections skin injuries were mainly established in the head region, especially the snood as well as in the region of the back. By means of their clinical picture pecking wounds and scratch injuries could be distinguished. Skin lesion produced primary as a result of scratching the skin surface, could be enlarged by the animal itself or by conspecifics by beak pecking, especially after bleeding, in spite of debeaked upper beak. Injuries in the head region, especially of the snood, could be explained mainly as a result of pecking by conspecifics by reason of their clinical picture and were found mainly in male turkeys. Skin injuries in the region of the back, especially at the coxal tuberosity, were identified primarily as scratch marks. They were found mainly in female turkeys. A statistically significant correlation of the injury prevalence to particular husbandry parameters discussed in the literature as "predisposing" or "limiting" factors (e.g., population density, light regime or offer of employment material) could not be established in this study. At the meat inspection fresh scratching injuries at the chest and the hind legs were diagnosed most often. Especially fresh injuries of the carcass point to a misguided behaviour of the staff concerning animal handling during loading and transport which is not conform to animal welfare.

OBJECTIVE To assess the influence of age on the outcome of patients receiving prolonged mechanical ventilation. DESIGN Retrospective study. SETTING Intensive care unit. PATIENTS A total of 1,141 patients in our ICU during a 32-month period. A total of 536 patients required mechanical ventilation. After exclusion of 171 patients ventilated for less than 24 hrs after surgery, 365 patients were investigated. MEASUREMENTS AND MAIN RESULTS Two hundred sixty-six (73%) patients were aged less than 70 yrs; 99 (27%) patients were greater than or equal to 70 yrs. There was no significant difference in mortality rate between the younger and the older age groups. There was no significant influence of other important factors, such as severity of illness, duration of mechanical ventilation, or length of ICU stay. The only factor showing a significant influence on patient outcome was the reason for mechanical ventilation. There were more survivors in the group being ventilated because of ventilatory insufficiency than in the group with oxygenation impairment (57.8% vs. 23.9%, p less than .001). CONCLUSION An influence of age on the outcome of mechanically ventilated patients in the ICU could not be ascertained in this study.

Within the framework of a cooperative research project, sponsored by the Federal Ministry of Food, Agriculture and Consumer Protection in Germany (BMELV), turkey health as well as numerous aspects of animal welfare in various intensive commercial farms with varying rearing forms were examined. For this purpose extensive documentation of flock management and health status information was conducted over the past two years at the farms. Additional information was ascertained from the carcasses at the slaughterhouse. The first results of this study, which look at flock management, will be presented here. Upon reviewing the questionnaires, it is clear that on one hand almost all farmers orientate there stocking rate upon the allowed limits, on the other hand, however, when considering national general requirements, which are very important parameters thatargely influence animal health (i. e. litter quality and care of sick/injured animals) farmer compliance lacks. Especially the litter quality, which, among other parameters, plays a very important role in food pad health, proved to be unsatisfactory. Unfortunately, no instruments are available that measure the litter quality, yet. The status of footpad health was a major problem in all the rearing systems. However, the prevalence of epithelial necrosis and deep skin lesions varied immensely among different flocks of the same age.

The purpose of this study was to evaluate myocardial electrocardiography (ECG)-gated 13N-ammonia (13N-NH3) PET for the assessment of cardiac end-diastolic volume (EDV), cardiac end-systolic volume (ESV), left ventricular (LV) myocardial mass (LVMM), and LV ejection fraction (LVEF) with gated 18F-FDG PET as a reference method.ECG-gated 13N-NH3 and 18F-FDG scans were performed for 27 patients (23 men and 4 women; mean+/-SD age, 55+/-15 y) for the evaluation of myocardial perfusion and viability. For both 13N-NH3 and 18F-FDG studies, a model-based image analysis tool was used to estimate endocardial and epicardial borders of the left ventricle on a set of short-axis images and to calculate values for EDV, ESV, LVEF, and LVMM.The LV volumes determined by 13N-NH3 and 18F-FDG were 108+/-60 mL and 106+/-63 mL for ESV and 175+/-71 mL and 169+/-73 mL for EDV, respectively. The LVEFs determined by 13N-NH3 and 18F-FDG were 42%+/-13% and 41%+/-13%, respectively. The LVMMs determined by 13N-NH3 and 18F-FDG were 179+/-40 g and 183+/-43 g, respectively. All P values were not significant, as determined by paired t tests. A significant correlation was observed between 13N-NH3 imaging and 18F-FDG imaging for the calculation of ESV (r=0.97, SEE=14.1, P0.0001), EDV (r=0.98, SEE=15.4, P0.0001), LVEF (r=0.9, SEE=5.6, P0.0001), and LVMM (r=0.93, SEE=15.5, P0.0001).Model-based analysis of ECG-gated 13N-NH3 PET images is accurate in determining LV volumes, LVMM, and LVEF. Therefore, ECG-gated 13N-NH3 can be used for the simultaneous assessment of myocardial perfusion, LV geometry, and contractile function.

CONTEXT: In addition to heart massage, the primary goal of cardiopulmonary resuscitation is efficient oxygenation and ventilation. OBJECTIVE: To compare the ease of learning and handling of standard mouth-to-mouth resuscitation with the Combitube (Tyco Healthcare Nellcor, Pleasanton, CA) ventilation. METHODS: After a 30 minute theoretical introduction and demonstration of mouth-to-mouth resuscitation and use of the Combitube in mannequins, following American Heart Association guidelines, 26 adolescent school children (15 of them 14 years old, 11 of them 10 years old) undertook two ventilation trials, each consisting of five single ventilations, with each technique. Only the second trial with each technique was evaluated. Qualitative implementation (grades: very good, good, failed) was evaluated, several procedure-related time points were recorded, and tidal volumes (ml) were measured. RESULTS: With mouth-to-mouth resuscitation, the time interval until start of first ventilation was 36.5 seconds shorter than with the Combitube (P < 0.001). With the Combitube, the time needed for five single ventilations was 6.4 seconds less than with mouth-to-mouth resuscitation (P < 0.001) and mean tidal volumes were higher (mouth-to-mouth resuscitation, 450 ± 384 ml, versus Combitube, 735 ± 358 ml; P < 0.05). CONCLUSION: Most of the school children performed both techniques to a high qualitative level. The study shows that mouth-to-mouth resuscitation and use of the Combitube have equal ease of learning, a precondition for proficient retention of skills. Tidal volumes were significantly higher with the Combitube and, not surprisingly, the time interval until the start of first ventilation was significantly shorter with mouth-to-mouth resuscitation. Regardless of the ventilation technique or device, we believe that subsequent retraining of ventilation skills is very important.

Objective: Invasive diagnostic procedures such as bronchoalveolar lavage (BAL) with quantitative microbiological cultures are currently recommended for the diagnosis of nosocomial pneumonia. Commonly, in clinical practice, a threshold of ≥104 colony forming units/mL is used for therapeutic decisions. The use of these measurements in daily practice assumes that their repeatability is acceptable. However, many variations among the positive results have been noted. One of the most important is dilution of BAL, which may influence the quantitative results by minimizing bacterial counts. Knowledge of the extent of dilution may increase dramatically the value of quantitative cultures. The aim of this study was to determine to what extent specimens are diluted in BAL by measuring urea in BAL and blood. Furthermore, the impact of a potential dilution effect on the diagnosis of ventilator-associated pneumonia was studied. Patients and Setting: A total of 47 patients with ventilator-associated pneumonia in two medical intensive care units at the Vienna General Hospital, a university-affiliated facility. Design: Prospective study performed between January 2001 and July 2002. Methods: BAL fluid was divided immediately into two samples: one for direct microscopic examination of cytocentrifuge preparations for Gram staining to determine percentages of cells containing intracellular bacteria and one for quantitative cultures according to the Cumitech 7A guidelines. Epithelial lining fluid volume was calculated using urea as a marker of dilution and correlated with colony forming units per milliliter. Results: Nineteen out of 47 patients (40%) revealed significant bacterial growth (≥104 colony forming units/mL). Eight additional patients (17%) would have reached the cutoff level after correction of the dilution effect, which varied between 1.8- and 130-fold. Conclusions: Data suggest a great variation of dilution during BAL procedures, which influences quantitative results. Using urea to determine the dilution quotient could increase the value of bacterial thresholds in the diagnosis and therapeutic decision of ventilator-associated pneumonia.

Stringy, tenacious tracheal secretions may prevent extubation in patients weaned from the respirator. This prospective, randomized, double-blind, placebo-controlled study with parallel assignment was performed to assess the influence of sublingually administered potassium dichromate C30 on the amount of tenacious, stringy tracheal secretions in critically ill patients with a history of tobacco use and COPD.In this study, 50 patients breathing spontaneously with continuous positive airway pressure were receiving either potassium dichromate C30 globules (group 1) [Deutsche Homoopathie-Union, Pharmaceutical Company; Karlsruhe, Germany] or placebo (group 2). Five globules were administered twice daily at intervals of 12 h. The amount of tracheal secretions on day 2 after the start of the study as well as the time for successful extubation and length of stay in the ICU were recorded.The amount of tracheal secretions was reduced significantly in group 1 (p0.0001). Extubation could be performed significantly earlier in group 1 (p0.0001). Similarly, length of stay was significantly shorter in group 1 (4.20 +/- 1.61 days vs 7.68 +/- 3.60 days, p0.0001 [mean +/- SD]).These data suggest that potentized (diluted and vigorously shaken) potassium dichromate may help to decrease the amount of stringy tracheal secretions in COPD patients.

In this study, we evaluated whether median fibrillation frequency (MF) and mean fibrillation amplitude (AMP) reflect coronary perfusion pressure (CoPP) and predict successful defibrillation. MF, AMP, and CoPP were measured during prolonged ventricular fibrillation (VF) cardiac arrest and resuscitation in pigs. After 5 min of VF, cardiopulmonary resuscitation was started. At 10 min, the pigs received randomly a single dose of endothelin-1 50 mug (n = 7), 100 mug (n = 7), or 200 mug (n = 5), or repeated doses of epinephrine 0.04 mg/kg (n = 6), or saline (n = 6) every 3 min. At 25 min, the pigs were defibrillated to achieve restoration of spontaneous circulation (ROSC). In a nonparametric spectral analysis of the individual MF versus CoPP and AMP versus CoPP curves, we found no link between the different curves in different animals or therapies. No difference was found in MF in pigs with ROSC (n = 8) compared with animals not achieving ROSC (n = 23) immediately before defibrillation (P = 0.85). Our data suggest that, in prolonged VF cardiac arrest, MF and AMP might not be useful tools to reflect myocardial perfusion.

Measurement of myocardial blood flow (MBF) by dynamic nitrogen 13 ammonia (NH(3)) positron emission tomography (PET) uses tracer kinetic modeling to analyze time-activity curves. We compared 2 commonly used models with 2 compartments (2C) and 3 compartments (3C) for quantification of MBF and coronary flow reserve (CFR).Seventy-seven patients underwent NH(3) PET at rest and during hyperemia. Time-activity curves for blood pool and myocardial segments were obtained from short-axis images of dynamic sequences. Model fitting of the 2C and 3C models was performed to estimate regional MBF. MBF values calculated by 2C and 3C models were 0.98 +/- 0.31 mL.min(-1).g(-1) and 1.11 +/- 0.37 mL.min(-1).g(-1), respectively, at rest (P.0001) and 2.79 +/- 1.18 mL.min(-1).g(-1) and 2.46 +/- 1.02 mL.min(-1).g(-1), respectively, during hyperemia (P.01), resulting in a CFR of 3.02 +/- 1.31 and 2.39 +/- 1.15 (P.0001), respectively. Significant correlation was observed between the 2 models for calculation of resting MBF (r = 0.78), hyperemic MBF (r = 0.68), and CFR (r = 0.68).Measurements of MBF and CFR by 2C and 3C models are significantly related. However, quantification of MBF and CFR significantly differs between the methods. This difference needs to be considered when normal values are established or when measurements obtained with different methods need to be compared.

In this prospective, randomized study, we evaluated whether a closed suctioning (CS) system (TrachCare) influences crossover contamination between bronchial system and gastric juices when compared with an open suctioning system (OS). The secondary aims were an analysis of the frequency of ventilator-associated pneumonia (VAP) and an analysis of alteration in gas exchange. Antibiograms were performed from tracheal secretions and gastric juice aspirates on Days 1 and 3 of intubation in 24 patients in a medical intensive care unit. Five cross-contaminations were observed in the OS group on Day 3 versus Day 1; the 5 strains shared common genotypes as determined by random amplification of polymorphic DNA. No cross-contaminations were seen in the CS group (P = 0.037). VAP occurred in 5 patients of the OS group but in none of the CS group patients (P = 0.037). Spao(2) decreased significantly in the OS group compared with presuctioning values--the opposite of the CS group. Whereas presuctioning values were comparable between groups, postsuctioning Spao(2) was significantly higher in the CS group. CS significantly reduced cross-contamination between bronchial system and gastric juices and reduced the incidence of VAP when compared with OS. Hypoxic phases can be reduced by the help of CS.

Renal osteodystrophy is common in patients with chronic renal failure (CRF) on hemodialysis (HD), leading to reduced bone mineral density (BMD) and higher bone fracture incidences. Since growth hormone (GH) and insulin-like growth factor 1 (IGF-1) are known to enhance bone metabolism and BMD, and CRF patients exhibit GH and IGF-1 resistance, recombinant human GH (rhGH) therapy could be beneficial for these patients.This study evaluated the effects of a 12-month rhGH therapy on bone metabolism parameters; alkaline phosphatase (AP), osteocalcin (OC), procollagen I carboxyterminal propeptide (PICP), telopeptide ICTP, serum crosslaps, n-terminal propeptide of type III procollagen (PIIINP) and intact parathyroid hormone (iPTH), as well as on BMD of the lumbar spine and the femoral neck in 19 malnourished HD patients (10 females, 9 males) with a mean age of 59.3 +/- 13.4 yrs. Fourteen patients completed the 12-month study. RhGH (0.25 IU/kg) was given subcutaneously 3x/week after each dialysis session.IGF-1 concentrations rose significantly from 169.2 +/- 95.6 to 262.9 +/- 144.4 ng/mL (p0.01) after 3 months, followed by a slight decline over the next 9 months. PICP as a bone formation marker significantly increased after 3 months from 250.1 +/- 112.6 to 478.5 +/- 235.2 ug/L (p0.01), as well as PIIINP, whereas OC and bone resorption parameters like ICTP showed only a slight increase (ICTP: 50.3 +/- 18.5 to 70.0 +/- 39.5 ug/L after 3 months (ns)). All bone metabolism parameters slightly declined in the following 9 months, but remained above baseline values after 12 months. PTH rose from 198.0 +/- 139.2 to 456.0 +/- 268.7 ng/ml, p0.01 after 6 months. BMD of the lumbar spine showed a significant reduction after 3-month rhGH therapy (0.80 +/- 0.17 vs. 0.77 +/- 0.16 g/cm2, p0.01), but returned to baseline values after 12 months. BMD of the femoral neck remained stable during the entire study.In summary, 12-month rhGH treatment in patients on chronic HD caused a significant increase in IGF-1, together with an increase in bone turnover. In addition, there was a temporary reduction in BMD of the lumbar spine seen, which returned to baseline values after 12 months.

This study presents and evaluates a model-based image analysis method to calculate from gated cardiac (18)F-FDG PET images diastolic and systolic volumes, ejection fraction, and myocardial mass of the left ventricle. The accuracy of these estimates was delineated using measurements obtained by MRI, which was considered the reference standard because of its high spatial resolution.Twenty patients (18 men, 2 women; mean age +/- SD, 59 +/- 12 y) underwent electrocardiography-gated cardiac PET and MRI to acquire a set of systolic and diastolic short-axis images covering the heart from apex to base. For PET images, left ventricular radius and wall thickness were estimated by model-based nonlinear regression analysis applied to the observed tracer concentration along radial rays. Endocardial and epicardial contours were derived from these estimates, and left ventricular volumes, ejection fraction, and myocardial mass were calculated. For MR images, an expert manually drew contours.Left ventricular volumes by PET and MRI were 101 +/- 60 mL and 112 +/- 93 mL, respectively, for end-systolic volume and 170 +/- 68 mL and 189 +/- 99 mL, respectively, for end-diastolic volume. Ejection fraction was 44% +/- 13% by PET and 46% +/- 18% by MRI. The left ventricular mass by PET and MRI was 196 +/- 44 g and 200 +/- 46 g, respectively. PET and MRI measurements were not statistically significant. A significant correlation was observed between PET and MRI for calculation of end-systolic volumes (r = 0.93, SEE = 23.4, P0.0001), end-diastolic volumes (r = 0.92, SEE = 26.7, P0.0001), ejection fraction (r = 0.85, SEE = 7.4, P0.0001), and left ventricular mass (r = 0.75, SEE = 29.6, P0.001).Model-based analysis of gated cardiac PET images permits an accurate assessment of left ventricular volumes, ejection fraction, and myocardial mass. Cardiac PET may thus offer a near-simultaneous assessment of myocardial perfusion, metabolism, and contractile function.

The aim of this study was to evaluate the distribution of prostate cancer within the peripheral zone by prostate biopsies excluding the influence of the transition zone. A prospective, multicenter study was carried out using a consecutive series of men who underwent transrectal ultrasound guided prostate biopsies using different biopsy techniques at six institutions. Biopsies were directed strictly within the peripheral zone or strictly within the transition zone. A model of the peripheral zone with 18 sectors of similar volume was established and the biopsy cores obtained were associated with these sectors and analysed with respect to prostate cancer detection rate. A total of 904 men (mean age 66.8 years, range 42-86) with a median serum PSA of 8.1 ng/ml (2.2-940 ng/ml) entered the study. A total of 8,062 biopsy cores (mean 8.92/patient) were obtained. Each of the peripheral zone sectors tested by biopsies yielded a similar percentage of prostate cancer ( P=0.6). There was no increase in the incidence of cancer toward the lateral sectors compared to midline sectors ( P=0.53) of the peripheral zone. Biopsy sampling of the peripheral zone from the apex to the base yielded a similar percentage of prostate cancer ( P=0.47). Our data suggest that the distribution of cancer foci detected by biopsies in the peripheral zone of the prostate is homogeneous.

Background/Aims: Growth hormone (GH) resistance leads to enhanced protein catabolism and contributes to the malnutrition of patients with chronic renal failure (CRF). In short-term trials anabolic effects of rhGH therapy have been demonstrated in patients on chronic hemodialysis. Methods: This study was initiated to determine the effects of 12 months of rhGH therapy on polymorphonuclear leukocyte (PMNL) function as well as on nutritional and anthropometric parameters. 0.125 IU/kg rhGH was given 3 times a week during the first 4 weeks and 0.25 IU/kg thereafter to 19 malnourished hemodialysis patients with a mean age of 59.3 ± 13.4 years. Results: Insulin-like growth factor I (IGF-I) concentrations rose significantly from 169.2 ± 95.6 to 262.9 ± 144.4 ng/ml (p < 0.01) in the first 3 months, but declined thereafter. Phagocytic activity of PMNLs also increased significantly in response to rhGH therapy and this activation remained stable over the whole 12-month period. Other parameters of PMNL function were not influenced by rhGH therapy. In addition, nutritional parameters such as albumin, prealbumin, transferrin, cholesterol, HDL-cholesterol, cholinesterase, predialytic creatinine and blood urea nitrogen were not affected by rhGH therapy. A decline of total body fat (TBF) was observed after 3 and 9 months of rhGH therapy (17.5 ± 10 vs. 16.7 ± 10% after 3 months, p < 0.017 and 16.8 ± 8.7% after 9 months, p < 0.049), whereas lean body mass remained stable. Conclusions: Twelve months of rhGH therapy caused a significant increase in IGF-I levels, stimulated phagocytic activity of PMNLs and induced a decline of TBF. Other anthropometric and nutritional parameters were not affected, which might be related to the persistence of GH resistance.

The prevalence of coronary artery disease (CAD) is high in patients on renal replacement therapy; therefore, reliable noninvasive screening tests are needed. We retrospectively determined the sensitivity, specificity, and positive and negative likelihood ratios (LRs) for a history of chest pain, resting and exercise electrocardiography (ECG), thallium dipyridamole scintigraphy, and echocardiography in 42 patients undergoing chronic hemodialysis and 42 patients after renal transplantation who also underwent coronary angiography. In addition, the prognostic power of each test for the occurrence of a cardiovascular event after angiography (therapeutic intervention, myocardial infarction, or cardiovascular death) was evaluated during a follow-up of 37 months. Forty-three patients had significant CAD on angiography. Angina pectoris had a sensitivity of 65% and specificity of 66%, corresponding to a positive LR of 1.9 and a negative LR of 0.5. A variable number of patients underwent noninvasive tests before angiography. Results were similar in patients undergoing hemodialysis and after renal transplantation and in patients with or without angina pectoris. Exercise ECG could not be performed in the majority of patients, and resting ECG (sensitivity, 67%; specificity, 52%; corresponding to a positive LR of 1.4 and negative LR of 0.6) and scintigraphy (sensitivity, 80%; specificity, 37%; positive LR, 1.3; negative LR, 0.5) in patients on renal replacement therapy were not useful for the diagnosis of CAD. Angina also markedly increased the relative odds for the occurrence of a cardiovascular event during follow-up (relative odds, 4.6) compared with other noninvasive tests. Angina pectoris had the best informational and prognostic value of noninvasive screening methods, but angiography seems to be the only method to clearly document CAD in patients on renal replacement therapy.

This study determined the impact of clinical characteristics on shock occurrence and survival in patients with implantable cardioverter-defibrillator (ICD). Methods and Results: During a follow-up of 27 ± 18 months, the actuarial incidence of appropriate shocks in 200 consecutive patients was 18, 36 and 72% at 1, 3, and 5 years, respectively. Coronary artery disease was the only significant predictor for shock occurrence (relative risk 1.32, p = 0.03). The actuarial incidence of total mortality was 10, 17 and 33% at 1, 3, and 5 years, respectively. The most powerful predictors for total mortality were: New York Heart Association functional class (NYHA) III (relative risk 4.8, p = 0.001) and a history of congestive cardiac failure (relative risk 3.6, p = 0.01). Conclusion: During long-term follow-up, the majority of patients receive appropriate shocks. No strong predictors for shock occurrence can be identified from the data analyzed. A history of congestive cardiac failure and the NYHA III are the most powerful predictors for total mortality. These clinical factors may provide valuable criteria to identify patients who will benefit from the implantation of ICD.

Abstract —Tissue plasminogen activator (tPA) is the major plasminogen activator responsible for dissolving blood clots found in blood vessels. However, elevated concentrations of tPA antigen were found to be related to adverse events in patients with coronary artery disease (CAD). Considerable controversy about the significance of these results exists. The goal of this cross-sectional study was to identify independent determinants for tPA antigen concentrations in patients with CAD, to possibly clarify the above paradoxical relationship. The baseline tPA antigen concentrations of 366 patients with angiographic evidence of coronary sclerosis were determined. Univariate analysis showed that age ( P =0.013), angiographic extent of disease ( P P P =0.004), hypercholesterolemia ( P =0.045), hypertriglyceridemia ( P =0.015), and chronic intake of nitrates ( P P P P P P =0.005), the type of angina ( P =0.026), multivessel disease ( P =0.041), and hypercholesterolemia ( P =0.043) as significant and independent determinants of tPA antigen. While hypertriglyceridemia and hypercholesterolemia both are related to the underlying disease, the type of angina and the number of involved vessels are linked to the severity and extent of disease, and all of them are indicators of a prothrombotic state found during the progression of CAD. In contrary, low-dose aspirin rather would decrease the likelihood of thrombotic events. The relation of tPA antigen to PAI-1 activity furthermore underlines the relation between tPA antigen concentration and a prothrombotic state. Therefore, the positive or—in case of aspirin therapy—negative correlation of these parameters with tPA antigen concentration would indicate that thrombus formation and simultaneous endothelial cell activation might be major determinants for tPA antigen concentration in CAD.

In a retrospective study, we tested the hypothesis that anticoagulant therapy with warfarin sodium (Coumadin) has a beneficial influence on the long-term prognosis in patients with primary pulmonary hypertension (PPH) and aminorex-induced plexogenic pulmonary hypertension. The study included a total of 173 patients from two European cities. One hundred four of these patients took the anorectic drug aminorex (Menocil), which was available in some European countries almost 30 years ago; 69 patients had pulmonary hypertension of unexplained etiology, ie, PPH. Fifty-six of the 104 aminorex-treated patients and 24 patients in the PPH group received warfarin after diagnosis was established. For analysis, patients were divided into four groups according to their history of aminorex intake and anticoagulant therapy. Survival time, changes in hemodynamics (pulmonary arterial pressure), and improvement in quality of life (scored by the New York Heart Association [NYHA] classification) were compared and analyzed. We found that aminorex-treated patients had a better long-term prognosis than those with PPH (7.5 vs 3.9 years; por = 0.001). The best mean survival time of 8.3 years was found in anticoagulated aminorex-treated patients, compared to 6.1 years in nonanticoagulated aminorex-treated patients. Moreover, aminorex-treated patients who received anticoagulant therapy soon after the onset of symptoms showed significantly better prognosis (10.9 years) than those who commenced treatment 2 years thereafter (5.9 years) (por = 0.05). In patients with PPH, systolic pulmonary pressure was shown to influence survival time significantly (por = 0.0005); however, this correlation was not found in aminorex-treated patients. An improvement of symptoms like dyspnea on exertion was seen in 44.8% of the anticoagulated aminorex-treated patients, while deterioration was evident in 72.2% of the nonanticoagulated aminorex-treated patients. In conclusion, our study has shown that anticoagulant therapy had a positive influence on long-term survival and a significant improvement in quality of life in patients with PPH, in particular in patients with a history of anorectic drug intake.

Background: A plunge in platelet count is often observed after massive blood transfusions during major surgery. This study was designed to assess whether the prophylactic administration of prostaglandin E 1 (PGE 1 ) might prevent this drop in platelet count. Methods: Forty-five patients receiving massive transfusions of packed red blood cells (>10 units) during major orthopedic surgery were enrolled in a prospective, randomized, double-blind, placebo-controlled study and divided into two groups: group 1 (therapy group) received intravenous PGE 1 up to 30 ng/kg/min for 72 hours after surgery, and group 2 (placebo group) received a placebo during the same time period. Results: The patients in group I suffered no reduction in platelet count and thus required no platelet concentrate transfusions. In contrast, a significant postoperative drop in platelet count (p < 0.05) was observed in the placebo group between days 3 and 5 after surgery when compared to the therapy group, necessitating transfusions of platelet concentrates in this group. Similarly, red blood cell count and hemoglobin were far more stable in the therapy group, which required fewer transfusions of red blood cells than did the placebo group (p < 0.05). There seemed to be a tendency toward a consumptive coagulation disorder in the placebo group as indicated by a decrease of fibrinogen levels, prothrombin time, and antithrombin III activity, and an increase of partial thromboplastin time. The incidence of adult respiratory distress syndrome was slightly lower in the therapy group. Last but not least, the length of intensive care unit stay was significantly shorter in the therapy group (p < 0.05). Conclusion: In our study, the administration of PGE 1 prevented a reduction in platelet count. Furthermore, measurements of clotting activity furnished the possibility that PGE 1 might inhibit transfusion-induced coagulation disturbances. We recommend that PGE 1 should be considered in patients requiring massive transfusion during major surgery.

Objectives Magnetic resonance imaging was used to assess the effects of ventilation with positive end-expiratory pressure (PEEP) on cardiac volumes, especially on atrial volumes as well as to determine semiquantitative measurements of spatial interactions between heart, lungs and chest. Design Prospective study with healthy volunteers undergoing mechanical ventilation with different levels of PEEP during magnetic resonance imaging. Setting Magnetic resonance unit, Institute of Diagnostic Imaging, Rudolfinerhaus Hospital. Subjects Twelve healthy volunteers. Interventions Volunteers were imaged, using a multislice-multiphase technique during spontaneous breathing and with PEEP values of 0, 7, and 15 cm H2O. Measurements and main results Atrial as well as ventricular volumes, chest diameters, and midventricular contact between the heart and anterior chest wall were determined on transverse-oblique sections. Atrial volumes showed a progressive decline beginning at a PEEP of 7 cm H2O. Diastolic filling of both ventricles was reduced. A PEEP level of 15 cm H2O induced a significant increase in the sagittal-oblique but not in the transverse-oblique chest diameter. PEEP values of 7 and 15 cm H2O shortened the length of the midventricular contact between the heart and anterior chest wall. Conclusions Left and right ventricular end-diastolic volumes and stroke volumes decreased significantly during ventilation with PEEP at 15 cm H2O, as did end-systolic atrial volumes. Volume changes in association with changes of chest and heart configuration suggest external cardiac compression by the expanding lungs. Furthermore, this study illustrates the feasibility of magnetic resonance imaging in mechanically ventilated patients.

OBJECTIVE To assess the influence of different positive end-expiratory pressure (PEEP) levels on plasma atrial natriuretic peptide concentrations. DESIGN Prospective, randomized study. SETTING Intensive care unit of a university hospital. PATIENTS Twenty-seven patients who were mechanically ventilated due to acute respiratory failure. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The patients were randomized into three groups: in each group, a defined PEEP level (5, 10, or 15 cm H2O, respectively) was applied, alternating with zero PEEP (0 cm H2O) in consecutive order (reversal experiment). Blood samples for the determination of atrial natriuretic peptide concentrations were drawn from the pulmonary artery and the radial artery catheters. There were no decreases in atrial natriuretic peptide concentrations with a PEEP of 5 cm H2O, but significant decreases could be shown for PEEP values of 10 and 15 cm H2O. The patients of all groups were subjected to PEEP levels of 5, 10, 15, and 20 cm H2O in randomized order (step experiment). The data demonstrated a significant inverse correlation between changes in PEEP levels and changes in plasma atrial natriuretic peptide concentrations. CONCLUSION The data suggest that the release of atrial natriuretic peptide is influenced by a PEEP of > or = 10 cm H2O, while a PEEP of < or = 5 cm H2O does not disturb this cardiac endocrine function.

The effect of radio- and chemotherapy on auxological parameters was investigated in 30 children treated for acute lymphatic leukemia (ALL) or non-Hodgkins lymphoma (NHL). Growth velocity was decreased during the first year of treatment. Catch-up growth was insufficient during the following years. Thus, the whole group experienced a loss of height of 0.49 +/- 1.1 SD at 6.8 +/- 2.6 years after diagnosis. Height and growth velocity were not different between children who received 18 or 24 Gy cranial irradiation; however, growth velocity was significantly lower in children who were treated for more than 2 years or who had the more intensive chemotherapeutic protocol. Evaluation of the growth hormone (GH) response to pharmacological stimulation revealed reduced GH peaks in 47% of the patients, but there was no correlation of GH peak with growth or treatment parameters. In conclusion, the impairment of growth in children after treatment for ALL or NHL might be related to the intensity and duration of chemotherapy.

We investigated the relationship between serum total and free 1,25-dihydroxyvitamin D (1,25-OH2D) and the biochemical regulation of 1,25-OH2D production in premature infants. We measured 1,25-OH2D, vitamin D binding protein and related biochemical parameters and calculated the free 1,25-OH2D index in serum of 17 premature infants (birthweight 810-1700 g; gestational age 31-36 weeks) on two different occasions defined by body weight (Study A: 1,750-1,850 g, Study B: 2,100-2,200 g). Dietary calcium (Ca) intake was 1,5 or 2,6 mmol/kg/d, phosphorus (P) intake 1,7 mmol/kg/d and vitamin D intake 1,000 IU/d. Biochemical results were similar in infants with different Ca intakes and all were within reference ranges. Concentrations of vitamin D binding protein (Study A 0.15 +/- 0.03 g/l, Study B 0.14 +/- 0.03 g/l; means +/- SD) were lower, concentrations of 1,25 (OH)2D (Study A 180 +/- 67 pmol/l, Study B 216 +/- 53 pmol/l) were higher, and consequently the free 1,25-OH2D index (Study A 6.6 +/- 2.7, Study B 8.8 +/- 2.6) was 4 to 6 times higher than in previously studied term infants. 1,25-OH2D and the free 1,25-OH2D index increased significantly with age and were not correlated with serum P or parathyroid hormone. The data indicate that in premature infants with normal biochemical parameters of Ca and P metabolism elevated concentrations of 1,25-OH2D signify an increased fraction of free 1,25-OH2D and that increased production of 1,25-OH2D is not due to hypophosphatemia or hyperparathyroidism.

The kinetics of intravenously injected [14C]cholic acid have been investigated in 14 patients with fulminant hepatic failure, 24 to 36 hr after the development of grade IV encephalopathy. Radioactivity was measured in plasma samples and in the individual plasma bile acid fractions after separation by thin layer chromatography. Plasma disappearance curves of the free [14C]cholic acid were calculated by an iterative nonlinear least squares fitting procedure using a computer. The disappearance of total plasma radioactivity was similar in all patients and greatly prolonged compared with healthy subjects. However, the plasma disappearance of free [14C]cholic acid was significantly faster in the 8 patients who recovered consciousness than in the 6 who did not. Plasma disappearance of free [14C]cholic acid correlated highly significantly with the proportion of conjugated [14C]cholate in plasma. All patients in whom more than 70% of plasma radioactivity was in the conjugated fraction 3 hr after injection survived and left hospital, whereas all of those in whom less than 55% was conjugated died. Measuring the percentage conjugation of [14C]cholate 3 hr after injection may therefore be a useful test of residual liver function in hepatic failure, as a guide to prognosis and in evaluating new forms of treatment.

In a series of 56 patients (24 uncomplicated postoperative and 32 septic patients), neopterin and elastase alpha 1 protease inhibitor complex (E-alpha 1 PI) plasma levels were measured daily. The clinical course of each patient was evaluated with the Multiple Organ Failure (MOF) score according to Goris. Neopterin could differentiate between septic and nonseptic patients (p less than .001), and E-alpha 1 PI between septic nonsurvivors and nonseptic patients only (p less than .01). In septic patients, acute pulmonary insufficiency was indicated by elevated E-alpha 1 PI values (greater than or equal to 400 micrograms/L) 1 day before mechanical ventilation was performed with a sensitivity of 81% and a specificity of 82%. Defining a patient with MOF whose score was greater than or equal to 5 as a high-risk septic patient, a comparison neopterin greater than or equal to 40 nmol/L and E-alpha 1 PI greater than or equal to 400 micrograms/L, measured 1 day before the evaluation of an MOF score of greater than or equal to 5 yielded a sensitivity of 91% and a specificity of 99% when patients fulfilled both criteria. We conclude that neopterin and E-alpha 1 PI might be useful parameters for the diagnosis of septicemia and monitoring of the clinical course in septic patients. Moreover, they might indicate the possible central role of macrophage and PMN activation in the development of MOF.

Sotalol is a non-selective beta-adrenergic blocking agent with class III antiarrhythmic properties. Our study was intended to assess the efficacy of sotalol on exercise-inducible arrhythmias by oral administration to out patients. Thirty patients with exercise-inducible arrhythmias (80% coronary artery disease, 20% congestive cardiomyopathy) were studied after two baseline bicycle ergometric stress tests performed in upright position. Twenty-five patients (including nine crossover cases of the lower dose protocol) were given sotalol in a daily dose of 320 mg (group 1) and 14 patients in a dose of 160 mg (group 2). After 2 and 8 weeks, respectively, group 1 showed a mean reduction of the total number of inducible ventricular premature beats (VPBs) of 50% (P = 0.0042) and 61% (P = 0.0107), respectively and a significantly improved Lown score (P = 0.0002 and 0.0006, respectively). A significant antiarrhythmic response was not demonstrable for group-2 patients. Because of inefficacy, nine patients were changed from group 2 to group 1. Reduction of arrhythmias on the higher dose was significant (P = 0.0147) in this group. There was the same significant reduction of the heart rate pressure product with the low and high dosage indicating that the beta-blocker effect is achieved with the lower dosage. We conclude that sotalol is a powerful drug for reducing the number and complexity of ventricular arrhythmias in a dose of 320 mg daily. As the beta-blocking effect in both groups was the same, we assume that the reduction of arrhythmias is mainly due to class III action.

Differential effects of growth hormone therapy in malnourished hemodialysis patients.BackgroundMalnutrition is common in chronic hemodialysis patients and is associated with increased morbidity and mortality. Several factors such as metabolic acidosis, hyperparathyroidism, and insulin as well as growth hormone (GH) resistance may lead to enhanced protein catabolism. Recombinant human growth hormone (rhGH) has been proposed as treatment of malnutrition because of its anabolic effects.MethodsIn the present placebo-controlled, double blind study, the effects of three months of rhGH therapy on nutritional and anthropometric parameters, on bone metabolism and bone mineral density (BMD), as well as on polymorphonuclear leukocyte (PMNL) function and quality of life (QoL) were evaluated in 19 malnourished hemodialysis patients (10 females and 9 males) with a mean age of 59.3 ± 13.4 years. RhGH (0.125 IU/kg) was given three times a week during the first four weeks and 0.25 IU/kg thereafter three times a week after each dialysis session.ResultsInsulin-like growth factor I (IGF-I) concentration rose significantly from 169.2 ± 95.6 ng/mL to 262.9 ± 144.4 ng/mL (p< 0.01) in the group receiving rhGH. Albumin, prealbumin, transferrin, cholesterol, high-density lipoprotein (HDL) cholesterol, cholinesterase, predialytic creatinine, and blood urea nitrogen showed no significant changes during the three months in both groups. Total body fat (%TBF) was slightly reduced after three months (P = NS) in the patients receiving GH, whereas lean body mass (LBM) remained stable during therapy. Procollagen I carboxy terminal peptide (PICP), a marker of bone formation, increased significantly after three months from 250.1 ± 112.6 to 478.5 ± 235.2 μg/L (P < 0.01) in the GH-treated patients, whereas parameters of bone resorption like telopeptide ICTP showed only a slight increase (50.3 ± 18.5 vs. 70.0 ± 39.5 μg/L, P = NS). BMD at the lumbar spine decreased significantly after three months in the treatment group (0.8 ± 0.17 vs. 0.77 ± 0.16 g/cm2, P < 0.01), whereas BMD at the femoral neck remained stable in both groups. Phagocytic activity of PMNLs increased significantly after three months of therapy with rhGH, whereas other parameters of PMNL function were not affected by GH. QoL was slightly improved in the GH treated group, but decreased markedly in the placebo group.ConclusionsThree months of treatment with rhGH in malnourished patients on chronic hemodialysis causes a significant increase in IGF-I levels without significant changes in nutritional and anthropometric parameters. In contrast, bone turnover was enhanced with an initial decrease in BMD at the lumbar spine, and phagocytic activity of PMNLs was increased.

The usefulness of local textural analysis in identifying diseases of the liver has been evaluated. In comparing two areas texturally, a random distribution of one or several textural parameters indicates identical tissue, whereas a distinct clustering can be used to discriminate between different tissues. Using this procedure, various diseases of the liver were differentiated accurately whereas different images of the same state of the liver were classified as similar with high accuracy. The consistent results with different patients, sections, sample locations and scanner parameter settings demonstrate that these factors have no impact on the characteristics of the resulting pattern used for discrimination and therefore for the final diagnosis. The overall diagnostic accuracy of this method seems better than conventional sonographic evaluation of parenchymal liver disease and at least competitive with other computerized methods described. The most important result clinically seems to be the high accuracy in differentiating between hepatitis and normal liver, which cannot be achieved by conventional ultrasonography.

Thirty-three 10-year-old boys repeatedly performed six symptom-limited, spiroergometric exercise tests according to the vita maxima method over an observation period of 4 years. Submaximum and maximum performance parameters were assessed and their correlation was calculated. The correlation of the heart rate at 1, 2 and 3 watts/kg body weight with the values of maximum performance capacity (wattmax and VO2max) and with the body-weight-related, relative maximum values was statistically significant. The correlation factors for the relative values were about twice as high (r = 0.55) as the absolute values (r = 0.27). The heart rate at 1, 2 and 3 watts/kg therefore was more characteristic of the relative values, which represent the state of training, and less for the absolute performance capacity, which depends to a great extent on body weight. However, the statistically significant correlation factors were too low to estimate reliably the state of training in an individual case. The correlation of physical working capacity at an HR of 170/min (PWC 170) with the maximum ergometric Watt performance was r = 0.80 and therefore appears to be sufficient to estimate the maximum performance capacity in children. This is however only valid for children over the age of 11.

The survival rate of 2256 patients with pacemakers was analyzed. Patients paced for Adams-Stokes equivalents (e.g. dizziness) showed a significantly better survival rate than did patients with pacemakers implanted for Adam-Stokes attacks or heart failure (P less than 0.0001). The estimated survival of the latter two groups did not differ significantly. Of the deceased patients who had received a pacemaker for the treatment of heart failure, 54% died due to this condition despite pacemaker implantation. The relative percentage of cases of sudden death after pacemaker implantation was high in the groups with Adams-Stokes attacks (12%) and Adams-Stokes equivalents (13%). In patients paced for Adams-Stokes attacks, sudden death occurred more frequently in the first year after pacemaker implantation (P less than 0.015) than during the following years. Therefore, increased efforts should be made to monitor patients carefully after pacemaker implantation to enable prompt detection of malignant tachyarrhythmias, probably the cause of sudden death in a substantial number of patients with pacemakers.

This study compares the results of a new computer assisted evaluation programm of sonographic images of the prostate with the histological examination of the operative specimen. This computer program is based on the fact that the human eye is not capable of distinguishing picture distribution points which differ in higher than second order statistics. The sensitivity of the method was 89%, the specificity 86% and the diagnostic accuracy 88%. The results are discussed by comparing them to results of transrectal sonography and digital palpation as reported in the literature.

Fibronectin plasma concentrations were determined in 28 children with type I diabetes mellitus and 22 healthy children. No statistically significant difference was observed between the fibronectin concentrations in diabetic and non-diabetic children. Even in children with poor glycaemic control the fibronectin concentrations (glycosylated haemoglobin greater than 10%) were not significantly higher.

The acetabular angle (Hilgenreiner 1940) was determined on 2194 hip joints of 1097 unselected infants without history or suspicion of dysplasia at the admittance to the hospital. The mean values and standard deviations were compared to the values published by Tonnis and Brunken (1968) in Berlin and Kristen et al. (1976) in Vienna. The data of Tonnis and Brunken show considerably higher values than our investigations, probably due to some selection, as infants with a history of suspicious signs of dysplasia and repeated investigations at different ages in the same patients are included. The differences to the tables, given by Kristen et al. are of minor degrees and explainable with the small number of determinations. The serial X-ray investigations of apparently normal hip joints seemed to be justified as we used a standardized X-ray technique with gonad protection by a fenestrated lead shield in the shape of a butterfly (Krepler 1976) and ultra-high speed screen-film combinations. The radiation dose in the girls, measured in the rectum, was reduced to 0.12 mrad and in boys behind the testes less than 0.1 mrad. In the line of this investigation we found in 11.1% of the hip joints some radiologic suspicion of dysplasia, in 2.2% on account of an acetabular angle outside of the limit of +2 SD, 2.2% between 1 and 2 SD and in 6.4% because of only insufficient development of the acetabulum, especially the edge of the roof. In 9 infants (0.82%) the X-ray showed clear dislocation of the femoral head with urgent need for reposition treatment. The importance of early diagnosis of signs of dysplasia of the acetabulum by radiological investigations in infants beyond the age of 3 months is discussed in respect of prophylactic treatment, with the aim to prevent early arthrosis of the hip caused by incongruences of the femoral head and acetabulum. The mechanisms of a possible change for the worse of dysplasia in older infants must be different to accepted theories of the causation of congenital luxation in the newborn as laxity of the capsule and ligaments of the hip joints caused by maternal hormones. Instead of the laxity of the capsule, signs of contracture develop and the failure in the formation of the acetabular roof—if not corrected spontaneously or by early treatment—is an important secondary cause of later damage to the hip joint.

SummaryTo determine a possible relation of changes in plasma levels of plasminogen activator inhibitor 1 (PAI-1) and tissue plasminogen activator (t-PA) to the development of coronary restenosis after successful coronary angioplasty (PTC A), we followed 104 patients with a low grade residual stenosis after PTCA (less than 30%) for a period of 12 months. PAI-1 plasma levels (functional activity) and t-PA antigen were determined 1 day before PTCA and 3 days, 3 months and 6 months thereafter. Thirty-four patients (32.69%) developed angiographically proven coronary restenosis (group A) within a time range of 4-48 weeks (median 12.5 weeks) after PTCA while the remaining patients (group B) had neither clinical signs nor angiographic evidence of restenosis after 6 months. No significant differences could be demonstrated in t-PA antigen or PAI-1 activity (plasma levels between the two groups of patients the day before PTCA). During the whole observation period t-PA plasma levels were not significantly different between the two groups; however, PAI-1 plasma levels were significantly higher at 3 months and 6 months after PTCA in patients of group A (p