[Dr. Jekyll and Mr. Hyde - A case report?] / Dr. Jekyll und Mr. Hyde ­ Ein Case Report?

Robert Louis Stevenson for many years had to lead the life of an invalid. He most likely suffered from hereditary haemorrhagic telangiectasia rather than from tuberculosis. His illness, however, did not prevent him from writing one of the most famous horror novels: "The Strange Case of Dr Jekyll and Mr Hyde". It is not a doctor's novel, and yet it can also be read as a medical case report. The literary figure Jekyll/Hyde shows a strange behavior which can be attributed to either illnesses such as epilepsia, syphilis, or dissociative identity disorder. Alternative explanations could be substance use disorder or side effects of a homemade antiepileptic therapy with potassium bromide. Dr. Jekyll commits suicide by ingesting hydrocyanic acid. The author died of cerebral haemorrhage, possibly triggered by vascular malformations in the context of his underlying disease. Reflecting on Stevenson's novella, the macabre and mystical setting serves as a stage to display good and evil, light and shadow - the eternal duality of human existence. The reader senses that we all inherit a destructive force, but we long to be able to control its momentum. It dawns upon us, however, that the diabolical promise given to Adam and Eve in the biblical creation story, i. e. "you will be like God and know what is good and evil" will remain wishful thinking.

[Christmas with Charles Dickens - The Man of Letters as Syndrome-Spotter and Good Moralist]. / Weihnachten mit Charles Dickens.

Charles Dickens, as a writer, was also a great master of patient observation. He described more than 40 syndromes, some of which were named after characters and titles of his literary works. Within these he often referred to the connection between illness, poverty and social misery. Some of his descriptions have withstood the litmus test of time and are still used in today's medicine: Amongst these are the characters Frederick, Little Dorrit's uncle, who suffers from Parkinson's disease, Fat Joe after whom the Pickwick-syndrome was named, Tiny Tim who is beaten with Pott's disease, Ebenezer Scrooge, a victim of posttraumatic embitterment disorder, and Mr. Krook who dies from spontaneous human combustion. Charles Dickens loved animals, and he was a member and supporter of The Royal Society for the Protection of Cruelty to Animals and actively engaged in public activities against vivisection. Furthermore he explicitly cared for children, and when his novel "Oliver Twist" appeared, the begging children received more alms, and the government improved the poor houses. Finally, there is probably no other author who has portrayed the power of Christmas so sensitively and impressively. Dickens hoped that in these days, just before the turn of the year, personal transformations would take place and redemption would be experienced as a result of new insights. For such transformations, he was convinced that man occasionally needs external stimuli.

[The Critically Ill Obese Patient: Too Big to Fail?] / Intensivtherapie bei Adipositas: Too Big to Fail?

Worldwide, currently more than 1.9 billion adults are overweight, 650 million of them are obese. Hereby they pose a significant burden on the budget of the health system and on the workload of intensive care units. Mechanical ventilation of critically ill obese patients needs to take into account the characteristic pathologic alterations of their respiratory system. Setting the respirator also requires careful consideration. Cornerstones include judicious preoxygenation, selection of a tidal volume of 6 - 8 ml/kg ideal body weight, a level of positive end-expiratory pressure titrated to compensate for the reduced functional residual capacity and concurrently protect the lung from ventilator associated lung injury. In selected cases recruitment manoeuvres may be required. In light of the recently published ART study that showed an increased mortality and higher incidence of pneumothorax and barotrauma, these need to be performed carefully. Correctly positioning the critical obese is an unrenounceable asset of intensive care. Prone position in mechanically ventilated obese ARDS-patients has been proven to be life-saving. However, specifically the supine position and the Trendelenburg position need to consequently be avoided. Failure to do so may result in obesity supine death syndrome. Finally, latest research documented lower mortality rates in obese individuals who require intensive care. This represents another hard to explain obesity paradox.

Intensive care in the obese.

Nearly 20% of all patients admitted to an intensive-care unit are obese. Their excess weight puts them at risk for several problems and complications during their intensive-care unit stay. Especially, pulmonary problems need particular attention, and comprehensive knowledge of the specific pathophysiologic changes of the respiratory system is important. Lung protective ventilation strategies, supplemented by lung-recruiting manoeuvres, may be feasible in critically ill obese patients with lung injury. Careful positioning of the obese is essential to optimise ventilation and facilitate weaning from mechanical ventilation. Optimal hypocaloric nutrition with a high proportion of proteins is advised to control hyperglycaemia. Because mortality in obese patients is similar to or lower than in non-obese ones, it is conceivable that obesity has a protective effect in the critically ill.

[Treatment of the obese patient in the Emergency Medical Services - an increasing problem]. / Die Akuttherapie adipöser Patienten--Ein zunehmendes Problem im Rettungsdienst.

The prevalence of obesity is high in Germany, almost half of the population are overweight. Hence emergency doctors are increasingly confronted with obese patients for whom special anatomical and physiological factors need to be considered. Furthermore this could lead to poorer quality and delayed treatment as normally available emergency therapy and transport are not designed for the special needs of patients with extreme obesity. The following article describes the special factors in the emergency treatment of these patients.

Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study.

OBJECTIVES: To re-examine the epidemiology of acute lung injury (ALI) in European intensive care units (ICUs). DESIGN AND SETTING: A 2-month inception cohort study in 78 ICUs of 10 European countries. PATIENTS: All patients admitted for more than 4 h were screened for ALI and followed up to 2 months. MEASUREMENTS AND MAIN RESULTS: Acute lung injury occurred in 463 (7.1%) of 6,522 admissions and 16.1% of all mechanically ventilated patients; 65.4% cases occurred on ICU admission. Among 136 patients initially presenting with "mild ALI" (200< PaO2/FiO2 < or =300), 74 (55%) evolved to acute respiratory distress syndrome (ARDS) within 3 days. Sixty-two patients (13.4%) remained with mild ALI and 401 had ARDS. The crude ICU and hospital mortalities were 22.6% and 32.7% (p<0.001), and 49.4% and 57.9% (p=0.0005), respectively, for mild ALI and ARDS. ARDS patients initially received a mean tidal volume of 8.3+/-1.9 ml/kg and a mean PEEP of 7.7+/-3.6 cmH2O; air leaks occurred in 15.9%. After multivariate analysis, mortality was associated with age (odds ratio (OR) =1.2 per 10 years; 95% confidence interval (CI): 1.05-1.36), immuno-incompetence (OR: 2.88; Cl: 1.57-5.28), the severity scores SAPS II (OR: 1.16 per 10% expected mortality; Cl: 1.02-1.31) and logistic organ dysfunction (OR: 1.25 per point; Cl: 1.13-1.37), a pH less than 7.30 (OR: 1.88; Cl: 1.11-3.18) and early air leak (OR: 3.16; Cl: 1.59-6.28). CONCLUSIONS: Acute lung injury was frequent in our sample of European ICUs (7.1%); one third of patients presented with mild ALI, but more than half rapidly evolved to ARDS. While the mortality of ARDS remains high, that of mild ALI is twice as low, confirming the grading of severity between the two forms of the syndrome.

Gender-based differences in children with sepsis and ARDS: the ESPNIC ARDS Database Group.

Male gender predisposes to severe sepsis and septic shock. This effect has been ascribed to higher levels of testosterone. The ESPNIC ARDS database was searched, to determine if there was evidence of a similar male preponderance in severe sepsis in prepubertal patients in spite of low levels of male sex hormones at this age. A total of 72 patients beyond neonatal age up to 8 years of age with sepsis were identified. The male/female (M/F) ratio was 1.7 (1.0;2.7) and differed significantly from non-septic ARDS patients in this age group [n = 209; M/F = 1.0 (0.8;1.3)]. The highest M/F-ratio was observed in the first year of life. The gender-ratio was the same as reported in adult patients with sepsis. In infants between 1 month and 12 months of age, the ratio was 2.8 (1.2;6.1) (Chi2= 5.6; P< 0.01), in children from 1 year to 8 years of age it was 1.2 (0.7;2.2) (n.s.). In a subgroup of patients with severe sepsis or septic shock, caused by other bacteria than Neisseria meningitidis, the M/F-ratio was 2.1 (1.2;3.6) (Chi2= 4.9; P<0.05), while in patients with meningococcal sepsis (n=20) the M/F-ratio was 1.0 (0.4;2.3). In prepubertal ARDS patients with sepsis an increased frequency of male patients is found, comparable to adults. No male preponderance exists in patients with ARDS due to meningococcal septic shock. Since levels of testosterone and other sex hormones are extremely low at this age, we conclude that factors others than testosterone are involved in the male preponderance in severe sepsis.

Reduced nitric oxide in sinus epithelium of patients with radiologic maxillary sinusitis and sepsis.

Radiologic maxillary sinusitis is an important risk factor for development of bronchopneumonia in mechanically ventilated patients. Nitric oxide produced within the paranasal sinuses is considered to provide an antibacterial environment and to modulate mucociliary clearance function. We hypothesized that a reduced formation of nitric oxide might contribute to the compromised local host defense in radiologic maxillary sinusitis and measured nitric oxide levels directly within maxillary sinuses of septic patients with radiologic maxillary sinusitis (n = 11), whose sinuses were fenestrated to eliminate a possible septic focus. Data were compared with those of patients without airway inflammation (n = 11, control subjects). Despite local inflammation and infection, we found considerably lower maxillary nitric oxide levels than in control subjects (31 +/- 10 versus 2554 +/- 385 parts per billion, mean +/- standard error of the mean, p < 0.001). Consistently, immunohistochemical and in situ hybridization investigations revealed strongly reduced expression of inducible nitric oxide synthase. By applying ultrastructural immunolocalization, we identified cilia and microvilli of the maxillary sinus epithelium as the major nitric oxide production site in control subjects. Our findings provide evidence of markedly reduced nitric oxide production in maxillary sinuses of patients with radiologic maxillary sinusitis and sepsis, implicating impaired local host defense and an increased risk for secondary infections.

Dose-response characteristics during long-term inhalation of nitric oxide in patients with severe acute respiratory distress syndrome: a prospective, randomized, controlled study.

Inhaled nitric oxide (NO) improves systemic oxygenation (PaO2/FIO2) in adult patients with acute respiratory distress syndrome (ARDS). However, individual response varies, and previous trials demonstrated no outcome benefit. This prospective, randomized study in 40 ARDS patients analyzed dose-response (DR) characteristics during long-term inhaled NO. Patients were randomized for conventional therapy (control) or continuous treatment with 10 parts per million (ppm) inhaled NO until weaning was initiated. We measured DR curves of PaO2/FIO2 versus the inhaled NO dose at regular intervals. Before treatment (Day 0), peak improvement in PaO2/FIO2 was achieved at 10 ppm for both control and NO-treated patients. After 4 days, the DR curve of the NO-treated patients was left shifted with a peak response at 1 ppm. At higher doses (10 and 100 ppm), oxygenation deteriorated, and the response to inhaled NO disappeared in several patients. This effect was not observed in the control group. There was no effect of inhaled NO on duration of mechanical ventilation or stay at the intensive care unit. In conclusion, long-term inhaled NO with constant doses of 10 ppm leads to enhanced sensitivity after several days and does do not allow reduction of ventilation parameters. Hence, previous trials on therapy with inhaled NO in ARDS should be carefully interpreted, as they used constant NO concentrations, which may have become overdoses leading to deterioration of oxygenation after several days.