Impact of epicardial adipose tissue volume upon left ventricular dysfunction in patients with mild-to-moderate aortic stenosis: A post-hoc analysis.

BACKGROUND: Aortic stenosis (AS) may lead to diastolic dysfunction and later on heart failure (HF) with preserved left ventricular ejection fraction (HFpEF) via increased afterload and left-ventricular (LV) hypertrophy. Since epicardial adipose tissue (EAT) is a metabolically active fat depot that is adjacent to the myocardium and can influence cardiomyocytes and LV function via secretion of proinflammatory cytokines, we hypothesized that high amounts of EAT, as assessed by computed tomography (CT), may aggravate the development and severity of LV hypertrophy and diastolic dysfunction in the context of AS. METHODS: We studied 50 patients (mean age 71 ± 9 years; 9 women) in this preliminary study with mild or moderate AS and mild to severe LV diastolic dysfunction (LVDD), diagnosed by echocardiography, who underwent non-contrast cardiac CT and echocardiography. EAT parameters were measured on 2nd generation dual source CT. Conventional two-dimensional echocardiography and Tissue Doppler Imaging (TDI) was performed to assess LV function and to derive myocardial straining parameter. All patients had a preserved LV ejection fraction > 50%. Data was analysed using Pearson's correlation. RESULTS: Only weak correlation was found between EAT volume or density and E/é ratio as LVDD marker (r = -.113 p = .433 and r = .260, p = .068 respectively). Also, EAT volume or density were independent from Global Strain Parameters (r = 0.058 p = .688 and r = -0.207 p = .239). E/é ratio was strongly associated with LVDD (r = .761 p≤0.0001) and Strain Parameters were moderately associated with LV Ejection Fraction (r = -.669 p≤0.001 and r = -.454 P≤0.005). CONCLUSIONS: In this preliminary study in patients with AS, the EAT volume and density as assessed by CT correlated only weakly with LVDD, as expressed by the commonly used E/é ratio, and with LV strain function. Hence, measuring EAT volume and density may neither contribute to the prediction nor upon the severity of LVDD, respectively.

Maximum number of repetitions, total weight lifted and neuromuscular fatigue in individuals with different training backgrounds.

The aim of this study was to evaluate the performance, as well as neuromuscular activity, in a strength task in subjects with different training backgrounds. Participants (n = 26) were divided into three groups according to their training backgrounds (aerobic, strength or mixed) and submitted to three sessions: (1) determination of the maximum oxygen uptake during the incremental treadmill test to exhaustion and familiarization of the evaluation of maximum strength (1RM) for the half squat; (2) 1RM determination; and (3) strength exercise, four sets at 80% of the 1RM, in which the maximum number of repetitions (MNR), the total weight lifted (TWL), the root mean square (RMS) and median frequency (MF) of the electromyographic (EMG) activity for the second and last repetition were computed. There was an effect of group for MNR, with the aerobic group performing a higher MNR compared to the strength group (P = 0.045), and an effect on MF with a higher value in the second repetition than in the last repetition (P = 0.016). These results demonstrated that individuals with better aerobic fitness were more fatigue resistant than strength trained individuals. The absence of differences in EMG signals indicates that individuals with different training backgrounds have a similar pattern of motor unit recruitment during a resistance exercise performed until failure, and that the greater capacity to perform the MNR probably can be explained by peripheral adaptations.

Impact of simulator training and crew resource management training on final-year medical students' performance in sepsis resuscitation: a randomized trial.

BACKGROUND: We developed a 1.5 days crew resource management (CRM) course on situation awareness (SA) to improve the participants' ability to recognise critical situations in crisis scenarios. Objective of the study was to evaluate the influence of the CRM course on SA and medical performance in crisis scenarios and to compare the results with the effects of a purely clinical simulator training. METHODS: Sixty-one final-year medical students, randomized into three groups, took part in a pre-intervention test scenario of septic shock in a patient simulator setting. Medical performance and SA were assessed using a checklist and the Situation Awareness Global Assessment Tool (SAGAT), respectively. All students received a lecture about the sepsis guidelines. The simulator (SIM) group took part in a 1.5-day simulator training on sepsis resuscitation. The CRM group took part in a course on situation awareness. The control group (CG) did not obtain any training. All students accomplished a post-intervention test scenario comparable to the pre-intervention scenario. RESULTS: The SAGAT score rose from 10.6±2.3 to 11.9±1.7 (preintervention vs. postintervention test, P=0.04) in the SIM group, whereas no significant changes could be shown in the CRM group and the control group, respectively. The clinical performance scores in the post-intervention test did not differ from those in the preintervention test. CONCLUSION: Neither the 1.5 days simulator training nor the 1.5 days CRM course did influence the clinical performance scores. SAGAT scores were higher after the simulator training, but not after the CRM training.

[Improvement of team competence in the operating room : Training programs from aviation]. / Verbesserung der Teamkompetenz im OP : Trainingsprogramme aus der Luftfahrt.

Growing attention has been drawn to patient safety during recent months due to media reports of clinical errors. To date only clinical incident reporting systems have been implemented in acute care hospitals as instruments of risk management. However, these systems only have a limited impact on human factors which account for the majority of all errors in medicine. Crew resource management (CRM) starts here. For the commissioning of a new hospital in Minden, training programs were installed in order to maintain patient safety in a new complex environment. The training was planned in three parts: All relevant processes were defined as standard operating procedures (SOP), visualized and then simulated in the new building. In addition, staff members (trainers) in leading positions were trained in CRM in order to train the complete staff. The training programs were analyzed by questionnaires. Selection of topics, relevance for practice and mode of presentation were rated as very good by 73% of the participants. The staff members ranked the topics communication in crisis situations, individual errors and compensating measures as most important followed by case studies and teamwork. Employees improved in compliance to the SOP, team competence and communication. In high technology environments with escalating workloads and interdisciplinary organization, staff members are confronted with increasing demands in knowledge and skills. To reduce errors under such working conditions relevant processes should be standardized and trained for the emergency situation. Human performance can be supported by well-trained interpersonal skills which are evolved in CRM training. In combination these training programs make a significant contribution to maintaining patient safety.

[Success factors in the German healthcare market. Hospitals between cluster formation and privatisation]. / Erfolgsfaktoren im deutschen Krankenhausmarkt. Kliniken zwischen Verbundbildung und Privatisierung.

The German hospital market is in a state of transition due to the introduction of diagnosis-related groups (DRGs) and a constant change of the reimbursement, demographic, economical and technical framework. To date mainly public hospitals were bought by private hospital chains, but this trend has currently reached university hospitals. During recent months a consolidation within the market of private hospitals took place, while new market players such as foreign hospital chains, US universities and private equity firms emerged on the scene. The target of the privatisation process, however, turns more and more to larger hospitals. Central key values remain the cluster formation and centralisation of key competences such as food supply, purchasing and pharmacy. Within a network of clinics the representation of different care components (basic, regular and maximum care provider) and care levels (low, normal, intermediate and intensive care) remain important elements of efficient hospital management. Today, successful hospital operation is based on the successful competition for patients and even more for qualified staff. In this aspect, university hospitals could play a decisive role, because of their combination of maximum acute care provision and educational mandate. No such network has yet been formed due to the different interests of the owners, however, given the new market situation this alternative concept could become more attractive.

Validation of a self-administered modified CAGE test (CAGE-C) in a somatic hospital ward: comparison with biochemical markers.

OBJECTIVE: The time frame for the original CAGE questionnaire is lifetime and it does not quantify drinking frequency and may be less suitable in a population with very few teetotalers. The purpose of this study was to validate a variant of the CAGE questionnaire and compare it with the outcome of a thorough interview according to DSM-III and ICD-10 criteria and to the outcome of biochemical markers in inpatients in a somatic hospital setting. MATERIAL AND METHODS: The questionnaire and biochemical markers were tested on a random sample of 130 patients admitted to a department of orthopedic surgery. The result of a diagnostic interview with a trained staff member from the local alcohol treatment unit was used as the gold standard. Data were analyzed by means of receiver operating characteristic (ROC) curves. RESULTS: In this population 25 % had an alcohol problem and the questionnaire proved to be valid, with a sensitivity and specificity of 0.94 and 0.88, respectively, while the positive predictive value (PVpos) was 0.73 and the negative predictive value (PVneg) was 0.98. Carbohydrate-deficient transferrin (CDT) had a sensitivity and a specificity of 0.47 and 0.96, and PVpos and PVneg of 0.80 and 0.85, respectively. CONCLUSIONS: This new diagnostic questionnaire is simple, easy to administer and suitable for screening purposes in populations with a high prevalence of at-risk drinkers.

High-dose intravenous paraoxon exposure does not cause organophosphate-induced delayed neuropathy (OPIDN) in mini pigs.

Organophosphorus compounds are inhibitors of serine hydrolases. Some of these compounds produce, in addition to their high acute toxicity, a more persistent effect: organophosphate-induced delayed neuropathy (OPIDN). The putative molecular entity whose inhibition is thought to be responsible for OPIDN is the neuropathy target esterase (NTE). Although in vitro NTE is resistant to paraoxon (PX), occasional case reports have associated PX with OPIDN. To assess clinically whether or not high-dose i.v. PX causes OPIDN in mini pigs, 14 mini pigs were anaesthesized, intubated and mechanically ventilated. In a first set of experiments eight pigs received 1 mg PX kg(-1) body weight (BW) dissolved in alcohol. Two control animals received alcohol in a corresponding amount. After infusion of PX, survival of the animals during the acute phase of intoxication was achieved by intensive-care support, using appropriate drugs and fluids according to a pre-established protocol. The mini pigs were extubated 1036 +/- 363 min later (mean +/- SD). The pigs were observed prior to PX application and for 6 weeks thereafter for any abnormalities and/or signs of OPIDN, such as leg weakness, ataxia and paralysis. Observations were graded on a scale for three categories (position, motor deficiency, reaction), with a maximal cumulative score of 9. In a second set of experiments (four additional pigs) larger PX doses were used (3, 9, 27 and 81 mg kg(-1) BW). After recovering from general anaesthesia/surgery, within 2 weeks all animals reached the initial score on the scale. It can be concluded that high-dose i.v. PX exposure does not induce OPIDN in mini pigs during the 6-week observation period.

L-lactate reduces in vitro the inhibition of butyrylcholinesterase (BChE) by paraoxon (E 600).

Intoxication with the organophosphorus compound paraoxon (POX), an inhibitor of serine hydrolases, is frequent. Oximes are the only enzyme reactivators clinically available. Serendipitous observation led us to the hypothesis that lactate might attenuate some of the POX effects. In vitro effects of lactate on the inhibition of butyrylcholinesterase (BChE) by POX were assessed in plasma of 12 healthy human volunteers. The determinations were repeated using different lactate and different POX concentrations. The BChE activity determinations were performed in the following settings: (i) baseline untreated plasma (BL); (ii) after addition of POX to plasma (pl+POX); (iii) after POX and plasma were incubated and then lactate was added (pl+POX/lact); (iv) after addition of lactate to plasma (pl+lact); (v) after lactate and plasma were incubated and then POX was added (pl+lact/POX); (vi) after lactate and POX were incubated and then added to plasma (lact+POX/pl). In the micro- and millimolar ranges, lactate is able to abolish in vitro the inhibition of BChE by POX in human plasma when added to plasma prior to POX or when incubated with POX prior to addition to plasma. Lactate added to plasma after POX has no protective effect. In a second set of experiments, the effect of lactate on BChE activity was determined. At high millimolar concentrations, lactate itself inhibits BChE to an extent comparable to POX. Lactate is a mixed inhibitor of BChE, being able to interfere with the enzyme-substrate complex (inhibition constant for the enzyme-inhibitor-substrate complex K'I(EIS) = 81 mM) and the enzyme (inhibition constant for the enzyme-inhibitor complex K(I) (EI) = 26 mM).

Lung function and respiratory health of long-term fiber-exposed stonewool factory workers.

The present study was undertaken to examine the respiratory health of a Danish workforce exposed to man-made vitreous fibers (MMVF) during production. Workers with more than 5 yr occupational exposure to MMVF (n = 377) were compared to a group without MMVF exposure (n = 381). Respiratory health was assessed by questionnaire, dynamic spirometry, and measurement of transfer factor. Overall response rate was 63%. A sample of nonresponders was assessed by questionnaire and spirometry. On most spirometric indices the two groups had comparable values. However, a larger proportion (14.5%) of the exposed subjects had an obstructive flow pattern compared with the control subjects (5.3%). Subgroup analyses showed that the elevated risk of airways obstruction associated with exposure was restricted to heavy smokers. Transfer factor and prevalences of symptoms and self-reported disease were similar in the two groups. There is no indication of excess risk of lung fibrosis. However, a number of exposed workers have some degree of airflow obstruction, which cannot be explained by known confounders. An additive or synergistic action between smoking and fiber exposure on airflow obstruction can be speculated.

Preventing disulfiram hepatitis in alcohol abusers: inappropriate guidelines and the significance of nickel allergy.

Disulfiram hepatitis, although sometimes fatal, is a very rare complication of alcoholism treatment. A disproportionate number of cases are associated with disulfiram treatment for nickel allergy and unrecognized nickel sensitivity may partly explain the surprisingly high proportion of female victims- about 60%. US guidelines formulated in 1988 suggest that alcoholic patients should not be started on disulfiram unless liver toxicity tests have been done and, if elevated, returned to normal. This advice is unsound and contrasts with medical attitudes to the prevention of other rare side effects. It has led to significant delays in starting treatment which are probably much more hazardous than the very slight risks of hepatotoxicity. We recommend that the guidelines be modified in favour of an approach which emphasizes the education of patients and their carers and clinical rather than laboratory monitoring.

[Alcohol drinking patterns of the Danes 1979-1992]. / Danskernes alkoholforbrug 1979-1992.

A questionnaire-based interview on alcohol drinking pattern in a random sample of 4,016 men and 4,179 women in 1992 was compared to an identical interview from 1979. In coherence with alcohol sale statistics, the average alcohol intake was unchanged in the population. Nevertheless, during the period drinking patterns have changed among Danes. Thus, 20 to 39 year-olds drank less, 40 to 59 years-olds drank more, fewer Danes drank during daytime, and fewer drank on weekdays at the second survey.

[Detoxication in hospital contra detoxication in detention]. / Afrusning i hospitalsregi kontra detentionsafrusning.

In the present study, 61 persons taken into police custody due to drunkenness were compared with 57 persons admitted to hospital due to intoxication with alcohol. The persons with alcohol problems taken into police custody numbered more younger men, fewer retired persons and the alcohol problems were more often acute intoxication than alcohol dependence. None of the persons placed in police custody were advised to seek help for their alcohol problems in contrast to 45 out of the 57 admitted to the hospital who started treatment. Detoxification in hospitals is far more suitable to motivate persons with alcohol problems to seek help. Detoxification should, for non criminal intoxicated people, be performed in hospitals.

[Sensible drinking limits]. / Genstandsgraenser.

A large number of prospective population studies from many countries have described a J- or U-shaped relation between alcohol intake and mortality. Both heavy drinkers and abstainers are at a higher risk of dying from all causes than individuals with light to moderate alcohol intake. This makes information to the public about sensible drinking limits more complex than, eg, that concerning smoking. The present paper aims at identifying upper thresholds for harmless alcohol intake. The review is mainly based on epidemiological evidence concerning somatic morbidity and mortality. It is concluded that the present Danish recommendations--14 drinks per week for women and 21 drinks per week for men--should be maintained. It is emphasized that these limits apply to adults who are at no risk of dependency and that they do not apply to pregnant women. Information about a potentially beneficial effect of a moderate alcohol intake should be reserved for individuals already at risk of coronary events.

The prognosis of patients with alcoholic liver disease. An international randomized, placebo-controlled trial on the effect of malotilate on survival.

The aim of this study was to examine the effect of malotilate on survival in patients with alcoholic liver disease and to determine prognostic variables for survival. Four hundred and seven patients with alcoholic liver diseases, from seven European liver units, entered a randomized placebo-controlled, double-blind trial: 140 patients received malotilate 1500 mg/day, 133 patients received 750 mg/day, and 134 patients received placebo. The patients were included in the study over a period of 3 1/2 years, and the study was closed 1 year after the entry of the last patient. Eighty-four patients died (35, 19, 30 patients in groups 1500 mg/day, 750 mg/day, and placebo, respectively). Survival was slightly better in the 750 mg/day group than in the two other treatment groups, when tested by conventional log-rank tests (p = 0.06). However, a treatment effect was supported by a highly significant (p = 0.006) non-proportionality of the death intensity in patients receiving 750 mg/day against those receiving either 1500 mg/day or placebo. Prognostic variables for survival were evaluated using the multiple Cox regression analysis of clinical and laboratory variables and with or without liver histology variables, as determined at entry into the study. The analysis was stratified for the three treatment regimens. In the analysis including liver histology variables, independent significant prognostic variables were: years of high alcohol intake, prothrombin index, alkaline phosphatases, creatinine, immunoglobulin M, white blood cell count, and liver cell steatosis. In the analysis without liver histology variables, prognostic variables were: years of high alcohol intake, prothrombin index, alkaline phosphatases, creatinine, and immunoglobulin M.