Search

Die Evidenz der nichtinvasiven Beatmung (NIV) bei akuter respiratorischer Insuffizienz ist sehr gut belegt. Neben der Praklinik und der Intensivstation gewinnt die NIV in der klinischen Akut- und Notfallmedizin an Bedeutung. Das primare Ziel dieser Studie ist es, erstmalig einen Uberblick uber die Verfugbarkeit, Umsetzung und Akzeptanz der NIV in deutschen Notaufnahmen zu geben und sekundar konkrete Anwendungsdaten wie Voreinstellung der Respiratoren oder Analgosedierungsmasnahmen darzustellen. Im Jahr 2017 wurden bundesweit 276 Notaufnahmen mittels Onlinefragebogen zu Strukturmerkmalen ihrer Kliniken, zur NIV-Verfugbarkeit, NIV-Anwendung sowie Akzeptanz und Qualitatssicherung befragt. Die Rucklaufquote betrug 45,3 %. In 72,0 % der Notaufnahmen ist die NIV derzeit verfugbar. 59,0 % der Notaufnahmen gaben an, die NIV erst innerhalb der letzten 5 Jahre neu implementiert zu haben. Spitzenreiter sind die Notaufnahmen der neuen Bundeslander mit 94,6 %. Eine signifikant hohere Mitarbeiterakzeptanz erzielten die Notaufnahmen mit eigenstandiger arztlicher Leitung und festem Mitarbeiterstamm. Kein Zusammenhang konnte demgegenuber zur Versorgungsstufe einer Klinik hergestellt werden. Am haufigsten wurde die NIV bei akuter Exazerbation einer chronisch obstruktiven Lungenerkrankung (AECOPD), akutem kardialen Lungenodem (ACPE), aber auch bei Pneumonie, zur Palliativtherapie, beim Leitsymptom Atemnot, Kohlenmonoxidintoxikation, Asthmaanfall, Thoraxtrauma oder Ketoazidose eingesetzt. Nur 6,3 % gaben an, NIV-Behandlungspfade und 38,5 % NIV-SOPs („standard operating procedure“) vorzuhalten, wobei 61,0 % der Notaufnahmen Respirator-Voreinstellungen definiert haben. Knapp drei Viertel der Teilnehmer fuhrten wahrend der NIV-Adaptationsphase eine Analgosedierung durch. Trotz zunehmender NIV-Verfugbarkeit und breiter Indikationsstellung ist die NIV-Akzeptanz in den Notaufnahmen limitiert. NIV-Behandlungspfade oder Protokolle zur Analgosedierung sind bisher nicht ausreichend etabliert.

The early detection and treatment of diabetic nephropathy (DN) is of crucial importance as patients with diabetes mellitus represent the largest proportion of patients on dialysis, with the highest morbidity and mortality. Currently, the first clinical sign of incipient DN is microalbuminuria, but its precision is not optimal. Many studies now report that proteins and peptides are new biomarkers in urine that primarily depict the pathophysiology of DN and thus allow for improved diagnosis of DN.The presentation of new concepts for the early detection and treatment of DN for better patient management.A systematic literature search was carried out.Many potential markers have been described in the search for new biomarkers to diagnose DN by urinary proteome analysis. However, many of these studies were not meaningful due to the small number of samples. This limitation led to inadequate validation of proteins that could not be confirmed as markers. However, the diagnostic benefit of CKD 273, a multimarker of 273 protein fragments, was sustainably demonstrated for the early diagnosis of DN. This multi-marker shows significant advantages in the precision of diagnosis and prognosis compared to albuminuria. Furthermore, many of its peptide markers map the molecular pathophysiology of DN.Clinical urinary proteome analysis shows great benefits and is already an appropriate tool for the early detection of incipient DN.

ZusammenfassungWir berichten von einem 62 jährigen Patienten, der im massiven hämorrhagischen Schock eingeliefert wurde. Als Ursache fand sich – erstmalig in der Literatur beschrieben – eine Ruptur der Arteria pulmonalis verursacht durch die Metastase eines Nierenzellkarzinoms. Der Primärtumor (pT2,pN0,M0,R0) war 25 Jahre zuvor reseziert worden. Der Fall demonstriert, dass noch nach Jahrzehnten nach einer kurativen Nephrektomie, eine pulmonale Metastasierung erfolgen kann. Deshalb müssen diese Patienten lebenslang nachbetreut werden.

We report a case of a 62 year old patient, who was hospitalised due to haemorrhagic shock. The cause was a rupture of the pulmonary artery due to metastasis of a renal cell carcinoma. This cause is now reported for the first time. The primary tumour (pT2,pN0,M0,R0) was resected 25 years ago. This case demonstrates that after curative nephrectomy pulmonary metastasis can occur, even after decades. This is why patients of this type need lifelong follow-up.Wir berichten von einem 62 jährigen Patienten, der im massiven hämorrhagischen Schock eingeliefert wurde. Als Ursache fand sich – erstmalig in der Literatur beschrieben – eine Ruptur der Arteria pulmonalis verursacht durch die Metastase eines Nierenzellkarzinoms. Der Primärtumor (pT2,pN0,M0,R0) war 25 Jahre zuvor reseziert worden. Der Fall demonstriert, dass noch nach Jahrzehnten nach einer kurativen Nephrektomie, eine pulmonale Metastasierung erfolgen kann. Deshalb müssen diese Patienten lebenslang nachbetreut werden.

Background Severe, uncontrollable intra thoracic haemorrhage is a life threatening situation for the patient in extremis and a challenge for the surgeon. Due to bleeding several serious pathophysiological changes occur in the organism. In addition to the threat of exsanguination itself, a “lethal triad” of acidosis, hypothermia and coagulopathy drive the patient into a hazardous situation.

An intercostal artery laceration is a rare iatrogenic complication following thoracocentesis and concerns especially elderly patients. We report a case of a severe hemorrhagic shock in a 93-year old patient due to diagnostic thoracocentesis.Eine Verletzung der Interkostalgefäße bei einer Pleurapunktion ist eine seltene iatrogene Komplikation und betrifft vor allem geriatrisches Patientengut. Wir berichten über das Notfallmanagement bei einem 93-jährigen Patienten mit schwerem hämorrhagischen Schock nach einer diagnostischen Pleurapunktion.

Hintergrund: Thoraxverletzungen finden sich bei einem Grosteil aller Unfallverletzten. Durch ein Thoraxtrauma erhoht sich die Letalitat. Eine adaquate zeitgerechte Versorgung nach Thoraxtrauma muss praklinisch beginnen, auch wenn die Verhaltnisse praklinisch weniger komfortabel sind als in der Klinik. Das Anlegen einer Thoraxdranage sollte jedem Notarzt gelaufig sein. Patienten und Methode: Notarzte der Rettungshubschrauberstation Christoph 20 legten zwischen 01. 01. 2007 und 31. 12. 2010 bei 49 Patienten praklinisch eine Thoraxdranage. Diese Patienten wurden reidentifiziert und ihr klinischer Verlauf nachbeobachtet. Mittels der apparativen klinischen Diagnostik konnte eine Lageanalyse der Dranagenspitze erfolgen. Anschliesend konnte ein Vergleich des Patienten-Outcomes nach Gute der praklinischen Thoraxentlastung erfolgen. Ergebnisse: Die praklinische Anlage einer Thoraxdranage war uberwiegend nach stumpfen Thoraxtrauma notwendig. Im Vordergrund standen Verkehrsunfallopfer. Es lies sich eine deutliche Bevorzugung des mannlichen Geschlechts finden. 42 Patienten wurden am Klinikum Bayreuth weiterversorgt, sodass hier eine Lageanalyse der Thoraxdranage mittels CT durchgefuhrt werden konnte. Sechs Patienten waren doppelseitig entlastet worden, sodass 48 Dranagenspitzen auf ihre Lage untersucht werden konnten. Von den 48 Dranagen wurden 46 von lateral eingebracht. Der sogenannte Monaldi-Zugang wurde nur in 2 Fallen gewahlt. Insgesamt konnten 9 Fehllagen uberwiegend im interlobaren Spalt rechts nachgewiesen werden. Schlussfolgerung: Im untersuchten Kollektiv zeigte sich eine deutliche Praferenz des lateralen Zugangs. Insgesamt zeigte sich eine 19 %ige Haufigkeit von Fehllagen, d. h. die Dranage lag entweder im Lungenparenchym, im interlobaren Spalt oder extrathorakal. Bei Betrachtung des Outcomes zeigte sich kein statistisch signifikanter Unterschied des Verlaufs nach Fehllage. Das Unterlassen einer indizierten praklinischen Thoraxdranageanlage stellt sicherlich ein groseres Versaumnis mit weitreichenderen Folgen dar als die Fehlanlage.

Bei einer 83-jahrigen Patientin erfolgte wegen einer unklaren Anamie eine gastroenterologische Untersuchung, dabei konnte jedoch keine Blutungsquelle identifiziert werden. Wegen des hohen Alters wurde auf weitere diagnostische Masnahmen verzichtet und eine Eisenmangelanamie vermutet. Nach 3 Wochen erforderte ein akutes Abdomen mit diffuser Peritonitis eine Notfalllaparotomie, die eine Perforation im Jejunum durch einen holzernen Fremdkorper ergab. Nach Extraktion des Fremdkorpers und Ubernahung der Dunndarmperforation verlief die Heilung komplikationslos.

ZusammenfassungEine Verletzung der Interkostalgefäße bei einer Pleurapunktion ist eine seltene iatrogene Komplikation und betrifft vor allem geriatrisches Patientengut. Wir berichten über das Notfallmanagement bei einem 93-jährigen Patienten mit schwerem hämorrhagischen Schock nach einer diagnostischen Pleurapunktion.

Until 1982 we have performed 1410 chest wall corrections in our clinic. 0.5 percent were related to cleft sternum or osteocartilagineous defects, 2.3 percent to premature sternal synostosis, 0.5 percent followed the reconstruction of congenital diaphragmatic hernias. Another 17 percent were characterized by extreme flat chest, atypical anterolateral asymmetric or extreme position of the punctum maximum. Morphological parameters are taken by pelvimeter and profile measurements, operative consequences derived from the morphological typing and grading and the clinical finding.

Meanwhile vacuum-assisted closure (V.A.C.) therapy belongs to the standard procedures in cardiovascular surgery. Its intra-thoracal application is mentioned in one unique case-report in literature. We like to show our first experiences with this technique demonstrating three cases with pleural infection. One patient with bronchial stump insufficiency, one with pleural empyema and one with penetrating abscess of the chest was treated with V.A.C.-therapy. We applied a combination of microporous silicon fleece and polyurethane foam in direct neighbourhood to ventilated lung areas inside the thoracic cavity. One patient died of metastasis of his cancer disease, while wound situation and bronchial stump insufficiency could be treated well. Two patients could be treated successfully and be discharged out of the hospital. No complications due to V.A.C.-therapy could be seen, such as fistulas of the lung or bleeding of the mediastinal organs. Intra-thoracal V.A-C.-therapy can be performed as a good therapeutic option in the treatment of septic diseases inside the chest.

Liposarkome sind die haufigsten Sarkome im Erwachsenenalter, kommen jedoch nur sehr selten im Bereich des Mediastinums vor. Wir berichten uber einen 69-jahrigen Mann, bei dem ein riesiger Tumor im Bereich der rechten Pleurahohle zu einer Totalatelektase der rechten Lunge gefuhrt hatte. Der Tumor konnte vollstandig entfernt werden, die histologische Begutachtung zeigte ein hochdifferenziertes Liposarkom des Mediastinums. Ein Jahr nach Resektion besteht kein Hinweis auf ein Lokalrezidiv oder eine Metastasierung.

Renal artery stenosis (RAS) is the leading cause of secondary hypertension. Magnetic resonance (MR) imaging and in particular MR angiography have evolved into important diagnostic tools for the detection and grading of RAS due to the lack of ionizing radiation and nephrotoxic contrast agent. This review describes state-of-the-art MR angiographic techniques and introduces the reader to current concepts of RAS grading with MR angiography. We compare MR angiography with conventional angiography and intravascular ultrasound as a standard of reference. The technical basis of functional imaging techniques such as arterial spin labeling perfusion measurements, contrast-enhanced perfusion measurements, and MR flow measurements are explained. Their value for the grading and detection of RAS and for the differentiation of renovascular from renal parenchymal disease is discussed. An overview about imaging during and after interventional therapy of RAS and an introduction to the current understanding of prediction of successful interventional therapy finishes this review.

UNLABELLED Compared to other surgical disciplines the significance of V.A.C.-therapy is rarely noticed in abdominal surgery. This may be due to uncertainty in defining clear indications or lack of technical know-how. METHODS We report on five selected septic cases in abdominal surgery without clearly defined indications for V.A.C.-therapy (ischiorectal abscess, perforation in Crohn's disease, pelvic abscess due to perforation caused by rectal carcinoma, abdominal compartment syndrome, anastomotic leak after rectal resection). RESULTS Regarding the individual aspects of indication, V.A.C.-therapy could be used successfully in the demonstrated cases. Under the palliative aspect, V.A.C.-therapy on a malignant wound bed allowed an early treatment with chemotherapy. DISCUSSION According to the literature dealing with V.A.C.-therapy, enterocutaneous fistulas, exposed viscera, enteral surfaces as well as malignancy in the wound bed are considered to be contraindications for the method. Reffering to our observations, these diagnoses should not be strictly regarded as contraindications. Elaboration of clear guidelines that point out clearly defined indications for V.A.C.-therapy should be the goal for the future.

BACKGROUND AND OBJECTIVE Symptomatic patients with multivessel coronary disease (MVD) benefit from both coronary artery bypass grafting (CABG) and percutaneous coronary angioplasty (PTCA). The >>German Angioplasty Bypass Investigation<< (GABI-I) trial randomized patients to one of these treatment strategies between 1986 and 1991. In order to evaluate the impact of current technology, in particular coronary stents, the GABI-II trial was initiated, which in 1996 and 1997 prospectively enrolled patients according to the initial GABI-I criteria. PATIENTS AND METHODS Into the study 136 consecutive patients (108 men, 28 women; 63 +/- 12 years) were included. Patients from GABI-I served as controls. RESULTS A mean of 2.1 +/- 0.5 vessels were treated per patient (vs. 1.9 +/- 0.5 vessels in the PTCA arm of GABI-I) and 63 % of the lesions were covered with stents. With respect to the primary endpoint less patients remained with a CCS class III or IV in GABI-II after 12 months (1,5 % vs. 8 % in the PTCA arm of GABI-I, p

Wir berichten von 2 praklinischen Tracheotomien, die wegen eines Larynxabrisses bzw. -zertrummerung an der Unfallstelle durchgefuhrt werden mussten. Intubationsversuche schlugen fehl, da massive Blutungen aus begleitenden Mittelgesichts-, und Kieferfrakturen die Einstellung der Stimmritze, verhinderten. Alternative Atemwegshilfen (z.B. Larynxtubus) kommen bei diesem Verletzungsmuster nicht in Frage, da ein „blindes“ Einfuhren zur Knochenfragmentdislokation und somit zum kompletten Atemwegsverschluss, fuhren. Nur spontan atmende Patienten haben eine Uberlebenschance. Die in diesen verzweifelten Fallen als letzte Moglichkeit empfohlene Koniotomie, war wegen der Zerstorung der entsprechenden anatomischen Strukturen nicht moglich. Auserdem lies ein massives Hautemphysem am Hals und im Gesicht eine Orientierung durch Verlust der anatomischen Orientierungspunkte (z.B. Kehlkopf), nicht zu. Deshalb musste die Trachea wie bei einer Strumaresektion durch einen „Kocher„schen Kragenschnitt“ mit Spaltung der geraden Halsmuskulatur, freigelegt werden. Um die Spontanatmung nicht zu beeintrachtigen, wurde zuvor ein Lokalanasthetikum injiziert und nur Ketamin intravenos zur systemischen Analgesie, appliziert. Nach „U-formiger“ Exzision des 2. Trachealringes und Plazieren eines 6 – 0er Tubus, konnte dann die Narkose mit Fentanyl und Midazolam vertieft und mit 100% Sauerstoff, beatmet werden. Anschliesend erfolgte die Hubschrauberverlegung in ein Traumazentrum. Ein 35-jahriger Landwirt hat ohne neurologischen Folgeschaden uberlebt und geht wieder seiner Arbeit nach. Ein 15-jahriger Jugendlicher ist seinen schweren zusatzlichen Hirnverletzungen (u.a. Subduralhamatom, A. basilaris-Ruptur), erlegen. Aber durch die praklinische Stabilisierung mit normalen Parametern bei Klinikeintreffen (RR 120/80 mm Hg; O2-Sattigung 95%), konnte er als Organspender fungieren, so dass am 2. posttraumatischen Tag mehrere Transplantationen erfolgreich durchgefuhrt werden konnten. Bei diesen sehr seltenen „Extremtrauma“ bot nur die vor Ort durchgefuhrte Tracheotomie die einzige Uberlebenschance. In der Literatur sind dies bezuglich nur sehr wenige Falle eines erfolgreichen Verlaufes, beschrieben.

OBJECTIVESWe sought to evaluate whether oral anticoagulant (AC) therapy given for five months was superior to standard (control) therapy in patients with unstable angina receiving aspirin.BACKGROUNDThe long-term risk of myocardial infarction (MI) or death remains high in patients with unstable angina, despite the use of aspirin. Therefore, additional treatments are necessary.METHODSOf the 10,141 patients entering the main trial, 3,712 were randomized 12 to 48 h later to receive oral AC therapy (n = 1,848) or standard therapy (n = 1,864).RESULTSOne-hundred forty patients (7.6%) suffered from cardiovascular death, MI or stroke while receiving oral AC, compared with 155 patients (8.3%) on standard therapy (relative risk [RR] 0.90, 95% confidence interval [CI] 0.72 to 1.14; p = 0.40). The rates of the primary outcomes plus refractory angina were 16.7% (n = 308) versus 17.5% (n = 327) (RR 0.95, 95% CI 0.81 to 1.11; p = 0.53). Countries were divided into good or poor compliers (based on the use of oral AC above or below 70% at 35 days), without knowledge of results by country. In good-complier countries, oral AC was discontinued in only 10.4% of patients at seven days and in 23.6% by five months, compared with 27.6% and 44.9%, respectively, in poor complier countries. There were significant reductions in the risks of both the primary (6.1% vs. 8.9%; RR 0.68, 95% CI 0.48 to 0.95; p = 0.02) and secondary outcomes (11.9% vs. 16.5%; RR 0.70, 95% CI 0.55 to 0.90; p = 0.005) with oral AC in the good-complier countries. There was little difference in the poor-complier countries (9.0% vs. 7.8% for the primary and 21.3% vs. 18.5% for the secondary outcomes, tests for interactions comparing the RRs for the primary and secondary outcomes were p < 0.02 and p = 0.002, respectively, between the two sets of countries). In the overall study, there was an excess of major bleeding (2.7% vs. 1.3%; p = 0.004), which was larger in the good-complier countries (RR 2.71) compared with the poor-complier countries (RR 1.58). There were also reductions in cardiac catheterization (RR 0.80; p = 0.004) and coronary revascularization procedures (RR 0.82; p = 0.06) in the good-complier countries, but not in the poor-complier countries (RR 0.98 and 1.06, respectively, p for interaction of 0.06 and 0.04, respectively).CONCLUSIONSOverall, oral AC led to a small, nonsignificant reduction in the risk of the primary and secondary outcomes. Stratifying the countries or centers by their rates of compliance to oral AC suggested that good compliance to oral AC could potentially lead to clinically important reductions in major ischemic cardiovascular events.

Background Other than aspirin, there are few oral antithrombotic treatments with proven efficacy in patients with acute coronary syndrome. In this report, we present the rationale, design and baseline characteristics of the Clopidogrel in Unstable angina to prevent Recurrent ischaemic Events (CURE) trial, which includes a meta-analysis of the effects of thienopyridines in patients with vascular disease. Methods and Results Combined data from randomized trials of thienopyrindines in patients with atherosclerotic disease demonstrated a 29% reduction in vascular events when compared with placebo/control (n=2392) (OR 0.71, 95% CI 0.58-0.86, P=0.0006) and a 10% reduction in vascular events when compared with aspirin (n=22 254) (OR 0.91, 95% Cl 0.84-0.99, P=0.039). Similarly, randomized trials of aspirin plus thienopyridines in patients undergoing intracoronary stenting, demonstrated marked benefit of aspirin plus ticlopidine in reducing death or myocardial infarction compared with aspirin alone (OR 0.23, 95% CI 0.11-0.49, P=0.0001) or aspirin plus warfarin (OR 0.51, 95% CI 0.33-0.78, P=0.002). Whether these benefits extend to the much larger population of patients with acute coronary syndrome is unknown. CURE is an international, randomized, double-blind trial, in which patients with acute coronary syndrome will be randomized to receive either a bolus dose of clopidogrel (300 mg) followed by 75 mg per day for 3-12 months, or matching placebo. Both groups will receive aspirin. The co-primary efficacy end-points of CURE are: (1) the composite of cardiovascular death, myocardial infarction or stroke; and (2) the composite of cardiovascular death, myocardial infarction, stroke or refractory ischaemia. CURE will recruit approximately 12 500 patients with acute coronary syndrome (from 28 countries) and its power to detect moderate treatment benefits will be in the region of 80-90%, while maintaining an overall type I error (a) of 0.05. The baseline characteristics of the study population are consistent with at least a moderate risk group of patients with acute coronary syndrome. Conclusions Randomized trials of thienopyridines in patients with vascular disease demonstrate that thienopyridines are effective in reducing vascular events when compared with placebo/control or aspirin, as well as when used in combination with aspirin in patients undergoing intracoronary stent implantation. The CURE trial is a large international study to determine if acute and longterm treatment with the combination of clopidogrel and aspirin is superior to aspirin alone in patients with acute coronary syndrome. (C) 2000 The European Society of Cardiology.

Background Severe hyperbilirubinemia is known to exert multiple toxic effects. Thus, a reduction in bilirubin by use of various adsorbent columns has been reported for a variety of hepatic disorders, but no experience with liver transplant patients is available as yet. Methods Plasma separation and bilirubin adsorption by an anion-exchange adsorbent column (BR-350) were performed in two patients with severe jaundice (total serum bilirubin > 55 mg/dl) and multiple organ failure that had developed after orthotopic liver transplantation. Results The procedure resulted in an 18% to 35% reduction in total bilirubin after each session, accompanied by a remarkable clinical improvement. Both patients finally recovered and had a favorable outcome. No complications or side effects of bilirubin adsorption were observed during any of the six sessions. Conclusions Bilirubin adsorption is a safe and effective treatment. It should be considered as supportive therapy for excessive hyperbilirubinemia after liver transplantation. In selected cases, retransplantation may thus be avoided.

Es wird uber einen Patienten mit Kolonkarzinom berichtet, bei dem es zu einer Panaritium-ahnlichen Lasion am linken Zeigefingerendglied gekommen war. Letztere erwies sich als Knochenmetastase eines 20 Monate zuvor kurativ resezierten Kolonkarzinoms. Neben der bislang zum Thema publizierten Literatur wird die Bedeutung dieses seltenen Befundes im Hinblick auf die metastatische Ausbreitung kolorektaler Karzinome diskutiert. Diagnostische und therapeutische Konsequenzen werden unter Berucksichtingung der Tatsache erortert, das Knochenmetastasen im Verlaufe einer Kolorektalen Karzinomerkrankung fruher und haufiger auftreten konnen als bislang vermutet.

Summary Aim: The clinical impact of perfusion scintigraphy versus color coded Duplex sonography was evaluated, with respect to their potential in assessing minimal allograft perfusion in vitally threatened kidney transplants, i.e. oligoanuric allografts suspected to have either severe rejection or thrombosis of the renal vein or artery. Methods: From July 1990 to August 1994 the grafts of 15 out of a total of 315 patients were vitally threatened. Technetium-99m DTPA scintigraphy and color coded Duplex sonography were performed in all patients. For scintigraphic evaluation of transplant perfusion analog scans up to 60 min postinjection, and time-activity curves over the first 60 sec after injection of 370-440 MBq Tc-99m diethylenetriaminepentaacetate acid (DTPA) were used and classified by a perfusion score, the time between renal and iliac artery peaks (TDiff) and the washout of the renogram curve. Additionally, evaluation of excretion function and assessment of vascular or urinary leaks were performed. By color coded Duplex sonography the perfusion in all sections of the graft as well as the vascular anastomoses were examined and the maximal blood flow velocity (Vmax) and the resistive index (Rl) in the renal artery were determined by means of the pulsed Doppler device. Pathologic-anatomical diagnosis was achieved by either biopsy or post-explant histology in all grafts. Results: Scintigraphy and color coded Duplex sonography could reliably differentiate minimal (8/15) and not perfused (7/15) renal allografts. The results were confirmed either by angiography in digital subtraction technique (DSA) or the clinical follow up. Conclusion: In summary, perfusion scintigraphy and color coded Duplex sonography are comparable modalities to assess kidney graft perfusion. In clinical practice scintigraphy and color-coded Doppler sonography can replace digital subtraction angiography in the evaluation of minimal allograft perfusion.

The adsorption behavior of cationic aggregating substances such as antimicrobial quats or phenothiazine derivatives on silica surfaces in aqueous media has been extensively investigated. However, the chemical stability of adsorbates in such systems was unknown. Propantheline bromide (PPBr) was selected as a model to investigate the stability of hydrolyzable substances in silica-containing aqueous dispersions or in adsorbates on silica carriers used for solid drugs. The quaternary ester PPBr showed an appreciable adsorption on the silica surface, the extent of which was increased by raising the pH of the aqueous phase or by the addition of neutral salts such as NaNO3. In parallel to the adsorption process, hydrolysis of PPBr occurs in these aqueous silica dispersions to yield xanthene carbonic acid and a quaternary alcohol component. Adsorption and hydrolysis were found to be mutually influencing reactions. Because of the adsorption of PPBr, the rate of ester decomposition was enhanced in these silica dispersions when compared to aqueous solutions of PPBr at the same pH. Simultaneously, an increase in PPBr adsorption is observed, as well as adsorption of the decomposition product xanthene carbonic acid. This result can be attributed to ion-pair adsorption of the latter with PPBr. The rate constants of PPBr decomposition were found to depend directly on the silica content of the dispersion, although at higher concentrations a decreased catalytic effect was observed. These phenomena are discussed on the basis of the adsorbate structure and exchange processes.

Thorax injuries are to be found in approximately 78 % amongst all victims of accidents. Moreover they implicate an increase in mortality rate. Consequently an adequate contemporary treatment has to begin preclinically, even if the conditions are less comfortable than in a clinical setting. Emergency doctors need to be familiar with the placement of chest tubes.From 01.01.2007 to 31.12.2010 emergency doctors of the rescue helicopter site Christoph 20 had to place chest tubes directly at the scene of an accident in 49 patients. These patients were now reidentified and their clinical course reevaluated. By means of apparative diagnostics it was possible to analyse the location of the tips of the tubes. A comparison of the patient outcome versus the quality of preclinical thoracic drainage could be made.The preclinical placement of a chest tube became necessary mainly because of a blunt thoracic trauma. This was predominantly related to victims of traffic accidents, whereas male victims clearly dominated. 42 of those patients received further treatment at the Klinikum Bayreuth, enabling an analysis of the tube locations by CT scans. Six patients had been drained on both sides, contributing to the 48 tube tips that could be examined concerning their location. Of the 48 chest tubes 46 had been placed from a lateral approach. The ventral access according to Monaldi had only been chosen in two cases. Altogether nine incorrect placements, mainly within the right interlobe gap, were detected.The study collective showed a significant preference to the lateral approach when placing a chest tube at the emergency scene of an accident. In total a prevalence of 19 % incorrect placements could be revealed, meaning the chest tube had either been placed within the lung parenchyma, the interlobe gap or extrathoracically. Concerning the patient outcome no statistically significant difference regarding the clinical course after incorrect chest tube placement could be identified. The omission of an indicated preclinical thoracic drainge is certainly a more serious error than its incorrect placement with more serious consequences.

The adsorption of codeine from aqueous solution onto colloidal silica and silica surface-modified with chemiadsorbed octadecyl dimethyl silane (ODDMS) or dimethyl silane (DMS) groups was studied in the presence of neutral electrolytes at different pH values. From codeine-hydrochloride solutions codeine cations are strongly bound to negatively charged silica surfaces. Inorganic salts (NaCl, NaNO3) reduce the adsorption of the organic cation. On silica modified by ODDMS (10% of surface silanol groups are occupied), codeine cations are adsorbed to a higher extent at pH 6, while at pH 8 the adsorbed amounts are lower than on the bare silica surface. Neutral electrolytes reduce codeine adsorption on the ODDMS modified silica. On the hydrophobic silica, completely covered by DMS groups, codeine adsorption is considerably lower than on the bare silica, but neutral salts increase the adsorption. The adsorption of codeine is compared with the adsorption of aggregating surfactant ions. Common and different features of their interactions with silica surfaces are outlined.

The adsorption of tetradecylpyridinium (TDPy) and lauryl sulphate (LS) ions on polar, low charged adsorbents, i.e. fumed silica (Aerosil Ox 50) and fumed titanium dioxide (P25), was studied, as well as in the presence of chemisorbed octadecyldimethylsilane (ODDMS) residues on the adsorbent surfaces. The influence of different counterions on the adsorption of TDPy and of ODDMS group density is demonstrated on silica at low pH values and, consequently, low surface charge density. The adsorption on ODDMS groups is confirmed for TDPy on surface-modified TiO 2 . The LS anions, not adsorbed to bare silica, are also adsorbed to the negatively charged silica surface in the presence of ODDMS groups. The results are discussed taking into consideration different proposals for the structure of the adsorbates, in particular the state of saturation adsorption. The behaviour of the surfactant ions can be best explained assuming small surface aggregates (micelles) if the surface density of primary adsorption sites, including ODDMS anchor groups, is lower than 0.3 mmol m −2 .

A gastroenterologic examination was performed on an 83-year-old woman due to unexplained anemia; however, no bleeding site could be identified. Because of the advanced age of the patient, no further diagnostic efforts were made and iron-deficiency anemia was suspected. After 3 weeks, an emergency laparotomy was performed for acute diffuse peritonitis, which was diagnosed as perforation of the jejunum by a wooden foreign body. After extraction of the foreign body and closure of the perforation in the small intestine, healing proceeded without complications.

Aneurysms of the pulmonary artery are very rare pathological vascular conditions. Peripheral pulmonary aneurysms have been reported only in a few cases. The causes of these aneurysms include extensive degenerative changes, traumas, infection and congenital malformations. Because of the imminent danger of rupture, surgical treatment should always be preferred. The following case report demonstrates one of a multitude of possible misdiagnoses for rupture of a pulmonary aneurysm.

A novel technique for the manufacture of water-insoluble film coatings on drug-loaded saccharose pellets is described. The method is based on the simultaneous spraying of aqueous solutions of a film-forming polymer and an appropriate crosslinking agent. Crosslinking of the polymer was achieved in situ in the film during coating of the pellets in a fluidized bed. Uniform film coatings were formed without additives. Pan coating with sequential spraying of the components yielded similar results, however, it was more time consuming. The anionic polymer, sodium alginate, was combined with different cationic crosslinking agents, such as calcium ions, aluminum ions, Cetrimide (tetradecyltrimethylammonium bromide), and Eudragit E (copolymer of dimethylaminoethylmethacrylate and neutral methacrylic acid esters) (in 0.1 N HCl) in aqueous solutions. The swelling behavior of the cast films in water depended on the crosslinking component and the film thickness. For studying the in vitro drug release through the film coatings, the pellets were drug-loaded with acetaminophen and indomethacin as model drugs. Alginate films crosslinked with calcium ions showed the most promising features for controlled drug release. The release rate of the model drug acetaminophen proved to be almost independent of the pH of the dissolution fluid (pH 7.4 phosphate buffer, 0.1 N HCl). During drug release, the coatings did not disintegrate in 0.1 N HCl, but slowly disintegrated in buffer solution. Indomethacin was released at considerably smaller rates.

The hydrolysis of the chemisorbate of p -hydroxybenzoic acid methyl ester (PHBAME) on porous silica (KG 100) incorporated in lipophilic vehicles such as liquid paraffin, synthetic oil Miglyol® 818 and white petrolatum was examined in dissolution media at pH 2 and 7.4, respectively. Chemisorbed PHBAME on KG 100 is released more rapidly in alkaline than in acidic dissolution fluids. Dispersions of the PHBAME-KG 100 chemisorbate in lipophilic vehicles modify the hydrolysis significantly. Drug release from chemisorbate dispersed in lipophilic vehicles may be controlled by the polarity of the vehicles. However, the viscosity of the vehicle, and not the polarity, exerts the strongest influence on the drug release.

Chitosan, a natural, biocompatible polymer, is becoming popular in dosage form design. In our study the design factors affecting the release of lidocaine and lidocaine chloride from chitosan hydrocolloids and gels were studied. In hydrocolloids a relatively high viscosity was found at low concentrations of chitosan caused by the increased effective volume of the polymer molecules, due to the reflection of the same charges in the chains. The drug release is slow and sustained, being influenced by the chitosan content. The mechanism of chitosan gel formation is not known exactly, but it is clear that for gel formation the length of the chitosan chains and the degree of reacetylation are responsible. The release profile of gels follows almost zero order kinetics. Also, the degree of reacetylation is responsible for the release behaviour. The rotational motion of nitroxides (Tempol, spin-labeled lidocaine) determined by EPR experiments showed practically equal rotational motion at different degrees of reacetylation. Thus, it was concluded that the free spaces, available for nitroxide rotation, were not changed significantly. The degree of reacetylation affects the translational diffusion more strongly.