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Objective: Hypothermia in trauma victims is a frequently observed phenomenon in acute care. Known complications of hypothermia are impaired wound healing, cardiac complications, hemodynamic instability, impaired immune function and increased blood loss. We compared active warming versus passive warming in hypothermia in critical-care patients undergoing intrahospital transfer from ICU to computer tomography (CT)., Methods: Thirty critically ill patients were randomized either to an actively warmed group, covered with a carbon-fiber heating blanket (set to 42 degrees C) during the entire transport including the time spent in the CT, or to a passively warmed group, covered with a carbon-fiber heating blanket (switched off) during the entire transport and in the CT. The carbon-fiber blanket was covered with a conventional wool blanket in both groups. Vital parameters and core temperatures were recorded., Results: Patients' characteristics and vital parameters were similar in each treatment group. Initial average core temperature in group A was 36.4 degrees C +/- 0.2 degrees C and remained stable at 36.4 degrees C +/- 0.1 degrees C; core temperature in group B started at 36.4 degrees C +/- 0.2 degrees C but decreased to 34.7 degrees C +/- 0.6 degrees C., Conclusions: Hypothermia is common when critically ill trauma patients require intrahospital transport for diagnostic procedures. Resistive heating during intrahospital transport kept the core temperature stable and assured normothermia in all actively warmed patients. We therefore recommend active warming for critically ill trauma patients during intrahospital transport.

Purpose: Based on previous studies showing that warming decreases trauma pain in emergency care we hypothesized that local active warming of the abdomen and lower back region could decrease pain in acute renal colic cases during emergency transport., Materials and Methods: After obtaining informed consent 100 patients were divided into 2 groups, including those who received active warming of the abdomen and lower back region (42C) and those who received no warming. Pain, nausea and anxiety were rated by the patients using visual analog scales. Statistical evaluation was performed using the t test with p <0.05 considered significant., Results: In group 1 a significant pain decrease was recorded in all cases using a visual analog score (VAS) (82.7 +/- 9.5 to 36.3 +/- 16.0 mm VAS, p <0.01). In group 2 patient pain scores remained comparable (81.8 +/- 13.0 to 80.6 +/- 12.3 mm VAS). In group 1 anxiety significantly decreased (79.0 +/- 8.9 and 30.7 +/- 14.1 mm VAS before and after treatment, respectively, p <0.01). In group 2 a nonsignificant change in score was noted (79.7 +/- 20.5 to 75.2 +/- 19.7 mm VAS). In group 1 a significant decrease in nausea was recorded in all cases (85.7 +/- 11.2 to 40.6 +/- 23.0 mm VAS, p <0.01). In group 2 patient nausea scores remained comparable (79.2 +/- 22.0 to 80.3 +/- 22.4 mm VAS, respectively)., Conclusions: Local active warming is an effective and easy to learn pain treatment for patients with acute renal colic in emergency care.

Background: Auricular acupuncture at the relaxation point has been previously shown to be an effective treatment for anxiety in the preoperative setting. The purpose of this prospective, randomized, blinded study was to determine whether auricular acupressure can reduce stress and anxiety during ambulance transport., Methods: Patients who required ambulance transport secondary to medical conditions were randomized to receive auricular acupressure at the relaxation point (n = 17) or at a sham point (n = 19). A visual analog scale was used to assess state anxiety as well as patient anticipation of hospital medical treatment (estimated waiting period for treatment, anticipated pain during treatment, attitude toward the physicians, and treatment outcomes). These variables were assessed at baseline and on arrival to the hospital., Results: Patients in the relaxation group reported significantly less anxiety than patients in the sham group on arrival to the hospital (visual analog scale mean +/- SD: 37.6 +/- 20.6 to 12.4 +/- 7.8 mm vs. 42.5 +/- 29.9 to 46.7 +/- 25.9 mm, respectively; P = 0.002). Similarly, patient perception of pain during treatment (mean visual analog scale +/- SD: 32.7 +/- 27.7 to 14.5 +/- 8.1 mm vs. 17.2 +/- 26.1 to 28.8 +/- 21.9 mm, respectively; P = 0.006) and treatment outcomes of their illnesses (mean visual analog scale +/- SD: 46.7 +/- 29.4 to 19.1 +/- 10.4 mm vs. 35.0 +/- 25.7 to 31.5 +/- 20.5 mm, respectively; P = 0.014) were significantly more positive in the relaxation group than in the sham group. No differences were found in the other variables assessed., Conclusion: It was concluded that auricular acupressure is an effective treatment for anxiety in prehospital emergency settings.

Unlabelled: Upper abdominal pain, a frequent symptom of the presence of gallstone disease, is the cause of 6% of the emergency calls of the Austrian emergency system. Pain resulting from cholelithiasis is characteristically severe. Recent data show that active warming during emergency transport of trauma victims is effective in reducing pain. Therefore, we hypothesized that local active warming of the abdomen would be an effective pain treatment for patients with acute cholelithiasis and could be provided by paramedics. Sixty patients (>19 yr) consented to participate in this study. They were divided into two groups: Group 1, who received active warming of the upper abdomen with a carbon-fiber warming blanket (42 degrees C), and Group 2, who received no warming of the abdomen. Neither group received any drug-based pain care. Patients were asked to rate their pain and anxiety by using visual analog scales (VAS). Statistical evaluation was performed with Student's t-test; P < 0.05 was considered significant. In Group 1, a significant (P < 0.01) pain reduction was recorded in all cases on a visual analog scale (VAS), from 86.8 +/- 5.5 mm to 41.2 +/- 16.2 mm. In Group 2, the patients' pain scores remained comparable, from 88.3 +/- 9.9 mm to 88.1 +/- 10.0 mm on a VAS. In comparing Group 1 with Group 2 on arrival at the hospital, pain scores showed a significant difference (P < 0.01). In Group 1, the VAS score changes for anxiety were significantly reduced (P < 0.01), from 82.7 +/- 10.8 mm before treatment to 39.0 +/- 14.0 mm after treatment. In Group 2, a nonsignificant change of this score was noted, from 84.5 +/- 14.6 mm to 83.5 +/- 8.4 mm. Comparing Group 1 with Group 2 on arrival at the hospital showed a significant difference in anxiety scores (P < 0.01). We conclude that local active warming is an effective and easy-to-learn treatment for pain resulting from acute cholelithiasis in emergency care., Implications: Active local warming of the upper abdomen is an effective treatment for patients with cholelithiasis being transported to the hospital by paramedics who are not permitted to provide any drug-based pain care. We observed no negative side effects of this treatment.

Objective: Infusion of cold fluids in a patient leads to a reduction of core temperature and subsequently worsens hypothermia. We evaluated the efficacy of a newly developed self-warming insulation device for use in pre-hospital rescue., Methods: We studied 50 trauma patients with a rescue time of more than one hour. They were randomly assigned to either infusions taken directly from a warming box in the ambulance (Group A, n = 25) or infusions taken from the warming box and packed in an insulation device (Group B, n = 25). We recorded ambient temperatures, infusion temperatures in five-minute-steps and transport duration of the infusions from the ambulance to the site of accident., Results: Ambient temperatures and transport duration did not differ significantly between both groups. In Group A the infusion temperature decreased from 36.0 +/- 6.4 degrees C to 19.8 +/- 6.8 degrees C during the transport from the ambulance to the site of accident. In Group B infusion temperature decreased only about 1 degree C. In Group A the temperature of the infusion continued to decrease until the end of measurements. In contrast in Group B the infusion temperature even increased by 0.5 degree C over the measurement period. These differences between the two groups were statistically significant., Conclusions: Our data show that even pre-warmed infusions from a warming box cool down considerably before they can be given to the patient. A self-warming insulation device can stabilize infusion temperature even under extreme conditions of prehospital trauma care.

Motion sickness adds to the discomfort of many patients being transported by ambulance. Recent research has demonstrated the effectiveness of oxygen therapy in reducing motion sickness during transport to hospital. However, patients reported negative reactions to wearing a facemask, which produced feelings of claustrophobia and anxiety. We therefore tested the hypothesis that supplemental oxygen inhaled from a new oxygen delivery device OxyArm, which avoids direct contact with the patient's skin, may reduce the incidence of motion sickness and increase patient satisfaction. Forty patients suffering from minor trauma were included in a prospective, randomised trial. Twenty patients received oxygen administered using a conventional Venturi mask (group 1), and 20 patients received oxygen using the new OxyArm device (group 2). Measurements made included oxygen saturation (SaO2), heart rate, systolic and diastolic blood pressures, and patients' subjective score of satisfaction with smell of the device, claustrophobia, inconvenience produced by the oxygen inhalation device and nausea were scored using a visual analogue scale. All patients were haemodynamically stable and comparable between the two groups. Peripheral SaO2 increased in both groups. The scores of nausea and claustrophobia were significantly lower in the OxyArm group, in addition, satisfaction with the OxyArm device was significantly higher. In conclusion, the use of OxyArm device produced a lower incidence of motion sickness combined with the additional benefit of greater patient satisfaction, when compared with a conventional facemask, during prehospital transfer of trauma patients.

We tested the hypothesis that the risk or discomfort associated with a clinical trial influence patients' decisions to participate. Simultaneously, we evaluated factors likely to influence patients' decisions such as understanding of the risk and discomfort associated with the study, patient age, educational level, and psychological status. With IRB approval, participants, who believed they were being asked to participate in a real trial, were presented one of three sham protocols: no risk or pain (Control, n = 48), pain but no risk (Pain, n = 51), or risk but no pain (Risk, n = 51). Patients were debriefed at the end of the interview. Our major outcome measures were (a) understanding risk or pain associated with the proposed studies, (b) the extent to which patients felt pressured to participate, and (c) willingness to participate. Whereas understanding was similar in all groups (Control, 68%; Pain, 67%; and Risk, 72%), willingness to participate differed significantly (Control, 64%; Pain, 35%; Risk, 26%; P < 0.001). Patients who understood the level of risk or pain associated with the protocols were twice as likely to participate than those who did not (49% versus 24%; P = 0.003). Nine percent agreed to participate in the risky or painful protocols without understanding the risks involved. Patients who felt pressured did not agree to participate. Thus, the consent process protected patients, although for unexpected reasons. Understanding was poor, but patients who did not understand the risks or pain involved or who felt pressured rarely consented. Consequently, relatively few patients unknowingly agreed to participate in risky or painful studies.

Unlabelled: Victims of trauma such as contusions and simple fractures are usually transported by paramedics. Because many victims are intoxicated with alcohol or other drugs, they are vulnerable to some risk of inadequate respiration. Thus, their oxygenation is monitored by noninvasive pulse oximetry. We tested the hypothesis that active warming of the whole body during transport to the hospital can improve the reliability of arterial oxygen saturation (SpO(2)) monitoring. Twenty-four trauma patients transported to hospital were included in the study and randomly assigned to two groups: one group (n = 12) was covered with normal wool blankets, and the other group (n = 12) was treated with resistive heating blankets during transport. We recorded core temperature, shivering, skin temperature at the forearm and finger, SpO(2), and hemodynamic variables. Before randomization, both groups were comparable. On arrival at the hospital, the actively warmed patients had significantly warmer core (36.1 +/- 0.3 degrees C versus 35.5 +/- 0.3 degrees C; P < 0.001) and skin (34.1 +/- 1.5 degrees C versus 24.9 +/- 1.4 degrees C; P < 0.001) temperatures. In the actively warmed group, the pulse oximeter had significantly fewer alerts (31 versus 58) and a significantly less time of malfunction (146 +/- 42 s versus 420 +/- 256 s) and provided more constant measurements in the actively warmed group (P < 0.001). In this study we showed that active warming improves pulse oximeter monitoring quality in trauma patients during transport to the hospital., Implications: Clinical trials show that pulse oximeter signal quality is limited by hypothermia. In this study we show that active whole-body warming of trauma victims improves monitoring quality during transport to the hospital.

Unlabelled: Untreated pain during the transportation of patients after minor trauma is a common problem in emergency medicine. Because paramedics usually are not allowed to perform invasive procedures or to give drugs for pain treatment, a noninvasive, nondrug-based method would be helpful. Acupressure is a traditional Chinese treatment for pain that is based on pain relief followed by a short mechanical stimulation of specific points. Consequently, we tested the hypothesis that effective pain therapy is possible by paramedics who are trained in acupressure. In a double-blinded trial we included 60 trauma patients. We randomly assigned them into three groups ("true points," "sham-points," and "no acupressure"). An independent observer, blinded to the treatment assignment, recorded vital variables and visual analog scales for pain and anxiety before and after treatment. At the end of transport, we asked for ratings of overall satisfaction. For statistical evaluation, one-way analysis of variance and the Scheffé F test were used. P < 0.05 was considered statistically significant. Morphometric and demographic data and potential confounding factors such as age, sex, pain, anxiety, blood pressure, and heart rate before treatment did not differ among the groups. At the end of transport we found significantly less pain, anxiety, and heart rate and a greater satisfaction in the "true points" groups (P < 0.01). Our results show that acupressure is an effective and simple-to-learn treatment of pain in emergency trauma care and leads to an improvement of the quality of care in emergency transport. We suggest that this technique is easy to learn and risk free and may improve paramedic-based rescue systems., Implications: We tested, in a double-blinded manner, the hypothesis that acupressure could be an effective pain therapy in minor-trauma patients. Our results show that acupressure is an effective and simple-to-learn treatment of pain in emergency medical care and can improve the quality of care.

Objective: To test the hypothesis that oxygen administration reduces nausea and vomiting in patients with minor trauma during ambulance transport., Patients and Methods: This study, conducted from January to April 2000, consisted of 100 patients older than 60 years with minor trauma, who were randomly assigned to breathe air or 100% oxygen at 10 L/min through a facemask during ambulance transport. A paramedic, blinded to treatment, recorded vomiting episodes during transport. Patients, also blinded to treatment, rated their levels of pain, nausea, vomiting, anxiety, and overall satisfaction with their care on 100-mm visual analog scales, with greater values indicating more intense sensation. Results from the 2 groups were compared with chi2 or unpaired 2-tailed t tests and presented as means +/- SDs., Results: Before randomization, patients subsequently assigned to receive oxygen had significantly greater pain and nausea. On arrival at the hospital, oxygen saturation was higher in the 50 patients given oxygen (99% +/- 1 % vs 96% +/- 2%; P<.001) than in the 50 patients who breathed air. Reported pain remained greater in the oxygen group. However, those given oxygen had less nausea (22 +/- 29 vs 54 +/- 38 mm; P<.001) and vomiting (4 vs 19 episodes; P<.001), lower heart rates (86 +/- 12 vs 94 +/- 13 beats/min; P<.001), and higher overall satisfaction scores (54 +/- 33 vs 33 +/- 23 mm; P<.001)., Conclusion: Our results indicate that supplemental oxygen during ambulance transport reduced nausea scores by 50% and decreased vomiting 4-fold. Consequently, patients reported greater satisfaction with their care. Thus, we recommend that patients be given supplemental oxygen during ambulance transport.

Objectives: To determine the occurrence of hypothermia in patients with minor trauma, to test the hypotheses that resistive heating during transport is effective treatment for hypothermia and that this treatment reduces patients' thermal discomfort, pain, and fear, and to evaluate the accuracy of oral temperatures obtained at the scene of injury., Patients and Methods: In December 1999 and January 2000, 100 patients with minor trauma were randomly assigned to passive warming or resistive heating. All patients were covered with a carbon-fiber resistive warming blanket and a wool blanket, but the warming blanket was activated only in those assigned to resistive heating. Core (tympanic membrane) and oral temperatures, heart rate, pain, fear, and overall satisfaction of patients were compared between the 2 groups on arrival at a hospital., Results: Hypothermia was noted in 80 patients at the time of rescue. Mean initial core temperatures were 35.4 degrees C (95% confidence interval [CI], 35.2 degrees C - 35.6 degrees C) in the patients who received passive warming and 35.3 degrees C (95% CI, 35.1 degrees C - 35.5 degrees C) in those who received resistive heating. From the time of rescue until arrival at the hospital, mean core temperature decreased 0.4 degrees C/h (95% CI, 0.3 degrees C/h - 0.5 degrees C/h) with passive warming, whereas it increased 0.8 degrees C/h (95% CI, 0.7 degrees C/h - 0.9 degrees C/h) with resistive heating. Oral and tympanic membrane temperatures were similar. Mean heart rate decreased 23 beats/min in those assigned to resistive heating but remained unchanged in those assigned to passive warming. Patients in the resistive heating group felt warmer, had less pain and anxiety, and overall were more satisfied with their care., Conclusions: Oral temperatures are sufficiently accurate for field use. Hypothermia is common even in persons with minor trauma. Resistive heating during transport augments thermal comfort, increases core temperature, reduces pain and anxiety, and improves overall patient satisfaction.

Unlabelled: Supplemental oxygen maintained during and for 2 h after colon resection halves the incidence of nausea and vomiting. Whether supplemental oxygen restricted to the intraoperative period is sufficient remains unknown. Similarly, the relative efficacy of supplemental oxygen and ondansetron is unknown. We tested the hypothesis that intraoperative supplemental oxygen reduces the incidence of postoperative nausea and vomiting. Patients (n = 240) undergoing gynecological laparoscopy were given a standardized isoflurane anesthetic. After induction, they were randomly assigned to the following three groups: routine oxygen administration with 30% oxygen, balance nitrogen (30% Oxygen group), supplemental oxygen administration with 80% oxygen, balance nitrogen (80% Oxygen group), and Ondansetron 8 mg (immediately after induction), combined with 30% oxygen, balance nitrogen (Ondansetron group). The overall incidence of nausea and/or vomiting during the initial 24 postoperative h was 44% in the patients assigned to 30% oxygen and 30% in the Ondansetron group, but only 22% in those given 80% oxygen. The incidence was thus halved by supplemental oxygen and was significantly less than with 30% oxygen. There were, however, no significant differences between the 30% oxygen and ondansetron groups, or between the ondansetron and 80% oxygen groups. We conclude that supplemental oxygen effectively prevents postoperative nausea and vomiting after gynecological laparoscopic surgery; furthermore, ondansetron is no more effective than supplemental oxygen., Implications: Supplemental oxygen reduces the risk of postoperative nausea and vomiting (PONV) as well or better than 8 mg of ondansetron. Because oxygen is inexpensive and essentially risk-free, supplemental oxygen is a preferable method of reducing PONV.

Objective: Psychosocial intervention during the course of cancer is still being controversially disputed in psychosomatic studies. Immunological and endocrinological parameters can serve as links in observing the influence of the interactive processes involved., Material and Methods: The approach to determine whether psychotherapeutic intervention can lead to an improved quality of life on the one hand, and to a change in immune defenses in breast cancer patients as well, employed using the EORTC QLQ-C30 and optimistic self-efficacy (OKE) as well as evaluating lymphocyte subpopulations, lymphocyte proliferation and NK cell activity. Fifty-three breast cancer patients were offered the chance to participate in a psychosocial intervention group. Twenty-three accepted the offer. Randomized sampling of the group participants was determined twice by using the 30 EORTC QLQ-C30 parameters. In addition, immune function was measured before beginning (T1) and after completing the group intervention sessions (T2). This data was compared with that of the declining group., Results: The analysis of the individual EORTC parameters in the pre- and post-comparison showed a decrease in "emotional strain" and an increase in "all-around quality of life" at the T2 test period. NK cell activity was increased at T2 as well in the participating group and was higher than that of the declining group both at T1 and T2 testing times., Conclusion: Participation in the psychosocial intervention group resulted in a marked decrease in the emotional strain and an increase in the quality of life. The increased NK-cell activity with lowered T-cell activation in comparison to the decliners hints at a coherence between coping behaviour and changes of the immunological cell function. The results of this study will be investigated further in a greater sample.

Unlabelled: We evaluated the effects of aggressive warming and maintenance of normothermia on surgical blood loss and allogeneic transfusion requirement. We randomly assigned 150 patients undergoing total hip arthroplasty with spinal anesthesia to aggressive warming (to maintain a tympanic membrane temperature of 36.5 degrees C) or conventional warming (36 degrees C). Autologous and allogeneic blood were given to maintain a priori designated hematocrits. Blood loss was determined by a blinded investigator based on sponge weight and scavenged cells; postoperative loss was determined from drain output. Results were analyzed on an intention-to-treat basis. Average intraoperative core temperatures were warmer in the patients assigned to aggressive warming (36.5 degrees +/- 0.3 degrees vs 36.1 degrees +/- 0.3 degrees C, P< 0.001). Mean arterial pressure was similar in each group preoperatively, but was greater intraoperatively in the conventionally warmed patients: 86+/-12 vs 80+/-9 mm Hg, P<0.001. Intraoperative blood loss was significantly greater in the conventional warming (618 mL; interquartile range, 480-864 mL) than the aggressive warming group (488 mL; interquartile range, 368-721 mL; P: = 0.002), whereas postoperative blood loss did not differ in the two groups. Total blood loss during surgery and over the first two postoperative days was also significantly greater in the conventional warming group (1678 mL; interquartile range, 1366-1965 mL) than in the aggressively warmed group (1,531 mL; interquartile range, 1055-1746 mL, P = 0.031). A total of 40 conventionally warmed patients required 86 units of allogeneic red blood cells, whereas 29 aggressively warmed patients required 62 units (P = 0.051 and 0.061, respectively). We conclude that aggressive intraoperative warming reduces blood loss during hip arthroplasty., Implications: Aggressive warming better maintained core temperature (36.5 degrees vs 36.1 degrees C) and slightly decreased intraoperative blood pressure. Aggressive warming also decreased blood loss by approximately 200 mL. Aggressive warming may thus, be beneficial in patients undergoing hip arthroplasty.

Exocrine pancreatic secretion is under partial control of endocrine pancreatic hormones. We studied the interaction of three doses of acetylcholine (Ach), a stimulator of exocrine and endocrine pancreatic secretion, with one dose of gastric inhibitory polypeptide (GIP) which is strongly insulinotropic, but has no effect on exocrine pancreatic secretion. The effects of Ach and GIP on insulin secretion from the rat pancreas were additive at 0.05 X 10(-6) M Ach and slightly, but not significantly less than additive at 0.25 or 2.5 X 10(-6) M Ach. GIP had an augmenting effect on amylase and volume secretion from the pancreas, when pancreatic secretion was stimulated by 2.5 X 10(-6) M Ach, but not by 0.05 or 0.25 X 10(-6) M. Exogenous rat insulin could exert an effect similar to that of GIP, although a higher dose was required. Atropine inhibited the effect of Ach on exocrine and endocrine pancreatic secretion, but not the insulinotropic action of GIP. It is hypothesized that GIP could play a role in regulating exocrine pancreatic secretion by its insulinotropic action.

Utilizing scanning electron microscopy and isolated, vascularly perfused rat pancreas, we studied the angioarchitecture and the effect of the insulinotropic hormone, gastric inhibitory polypeptide (GIP), on cholecystokinin (CCK)-stimulated exocrine secretion. We tried to correlate the microcirculation with the physiological effect of insulin on the pancreatic secretion in the same species. We found a vascular pattern consisting of direct insuloacinar connections, a venous drainage system of islets, and a direct arterial supply of acini. GIP at a concentration as low as 2 ng/ml or exogenous rat insulin potentiated CCK-stimulated pancreatic enzyme secretion. To have similar effects as insulin which is endogenously released by GIP, about 30 times more exogenous rat insulin has to be infused. We conclude that based on the angioarchitecture, insulinotropic hormones like GIP could link the metabolic and the digestive function of the pancreas.