[Spiritual needs of patients in an emergency room]. / Spirituelle Bedürfnisse von Patienten eines Notfallzentrums.

BACKGROUND: Spiritual needs (spN) are important for human beings-independently of religious affiliation. They can be a resource for coping with stressful situations, e.g., those triggered by the acute onset of a disease. Emergency rooms are hospital departments with high medical performance which may cause a particular insecurity among emergency patients. The present study is the first to examine spiritual needs in a sample of patients in the emergency room. METHODS: A total of 383 out of 479 patients were approached and asked to complete the German version of the Spiritual Needs Questionnaire (SpNQ-20). All consented to the collection of demographics and clinical data. The analysis encompassed descriptive statistics, correlations analysis, univariate and multiple variance analysis. RESULTS: The needs for inner peace and generative needs (to pass something on to others, to do something for others) were more important than religious (rN) and existential (eN) needs. We did not find a correlation between spN on the one hand and the reason for consultation, the severity, and the number of comorbidities on the other hand. Age did not play a decisive role, rather, patients' needs, especially rN, were significantly more important among women than among men. CONCLUSION: Even in an emergency situation, people are ready to express their spN. Early assessment of these needs exposes important nonmedical aspects of the sick person and helps to consider the assessed needs. Further studies will show whether this has an impact on the further course of treatment and the well-being of the patients.

Beam and installation improvements of the NIO1 ion source.

The NIO1 (Negative Ion Optimization phase 1) source can provide continuous beam operation, which is convenient for systematic parameter and equipment studies. Even in the pure volume production regime, the source yield was found to depend on conditioning procedures. Magnetic configuration tests continued adding magnets to the existing setup; the filter field component Bx has been progressively extended to span the -12 to 5 mT range, and as a trend, source performances improved with |Bx|. The progress of camera beam diagnostics and of the quality of the volume-produced H- beam is also shown. The status, off-line results, and reliability of a first NIO1 cesium oven are discussed; other upgrades in preparation (cavity ring down spectrometer, the end calorimeter, and conceptual tests of the energy recovery system) are also listed.

Inhibition of tissue factor-mediated coagulation markedly attenuates stenosis after balloon-induced arterial injury in minipigs.

BACKGROUND: Exposure and upregulation of tissue factor in the wall of balloon-injured arteries may result in prolonged activation of coagulation contributing to restenosis. This study was designed to determine whether brief or more prolonged inhibition of tissue factor-mediated coagulation with tissue factor pathway inhibitor (TFPI) attenuates neointimal formation and luminal stenosis after balloon-induced arterial injury. METHODS AND RESULTS: The carotid artery of minipigs fed an atherogenic diet was injured by repetitive balloon hyperinflations, a procedure that rapidly yields complex, plaque-like neointimal lesions and high-grade luminal stenosis. Recombinant TFPI (rTFPI) was administered intravenously beginning 15 minutes before balloon injury as either a high dose (0.5 mg/kg bolus and 100 microg x kg(-1) x min(-1)) for 3 hours (n=7) or 24 hours (n=6) or as a low dose (0.5 mg/kg and 25 microg x kg(-1) x min(-1)) for 24 hours (n=6). Control animals received intravenous heparin (100 U x kg(-1) x h(-1)) for 3 hours (n=6) or 24 hours (n=7) or aspirin (5 mg/kg P.O.) followed by heparin for 24 hours (n=7). Luminal stenosis, assessed histologically 4 weeks after injury, was 73+/-17% and 76+/-18% (mean+/-SEM) in animals that received rTFPI or heparin for 3 hours, respectively. In contrast, luminal stenosis was only 11+/-12% and 6+/-3% in pigs given high and low doses, respectively, of rTFPI for 24 hours compared with 46+/-22% in pigs given heparin for 24 hours and 40+/-19% in those given both heparin and aspirin (P<.0002). CONCLUSIONS: Inhibition of tissue factor-mediated coagulation during the first 24 hours after deep arterial injury appears to be particularly effective for attenuating subsequent neointimal formation and stenosis.

Inhibition of thrombin attenuates stenosis after arterial injury in minipigs.

OBJECTIVES: We sought to determine whether brief, profound inhibition of thrombin or prothrombin activation by factor Xa limits neointimal formation and stenosis after arterial injury. BACKGROUND: Thrombin has been implicated as a mediator of neointimal formation, but adjunctive administration of anticoagulant agents has not proven effective to decrease restenosis in patients undergoing coronary angioplasty. METHODS: We infused recombinant desulfatohirudin (r-hirudin, bolus of 2 mg/kg body weight followed by 2 mg/kg per h, n = 9), heparin (100 U/kg per h, n = 6) or recombinant tick anticoagulant peptide (rTAP, 1-mg/kg bolus followed by 3 mg/kg per h, n = 5), a specific inhibitor of factor Xa, intravenously, beginning 15 min before and for up to 3 h after repetitive balloon hyperinflations sufficient to disrupt the internal elastic lamina in a carotid artery of minipigs with hypercholesterolemia induced by feeding them an atherogenic diet. RESULTS: Partial thromboplastin time was increased six- to sevenfold over baseline levels at the end of the infusions of the anticoagulant agents. Lumen stenosis measured histologically 4 weeks after balloon-induced carotid injury was 29 +/- 16% (mean +/- SEM) in r-hirudin-treated, 52 +/- 19% in rTAP-treated and 76 +/- 18% in heparin-treated pigs (p < 0.02 for r-hirudin vs. heparin treatment). CONCLUSIONS: The marked reduction of stenosis in r-hirudin-treated animals indicates that thrombin plays a major role in neointimal formation after balloon-induced arterial injury. A relatively brief interval of profound, direct inhibition of thrombin may be particularly effective to attenuate restenosis after balloon angioplasty.

Echocardiography in the evaluation of patients with syncope.

OBJECTIVE: Echocardiography is frequently used as a screening test for cardiac disease in patients with syncope despite the lack of published data describing its utility in this regard. The goal of the study was to examine the frequency with which echocardiography was used in the evaluation of patients admitted to one medical center because of syncope and to examine the diagnostic information, over and above that provided by the initial history, physical examination, and electrocardiography, contributed by the echocardiogram. DESIGN: A retrospective review was performed of all patients admitted to the study institution because of syncope over a seven-month period. SETTING: University teaching hospital in an urban setting of 2.5 million population. PATIENTS/PARTICIPANTS: One hundred twenty-eight patients were identified: 47 men and 81 women (average age 67 +/- 17 years). Patients for whom syncope was of a known cause, those with near-syncope or vertigo, those with clinically obvious seizure, or those referred for electrophysiologic testing were excluded, leaving 128 patients for analysis. Details from the admission history, physical examination, and electrocardiography for each patient were recorded. The results of all other diagnostic tests ordered to evaluate syncope were recorded along with any consultations obtained. The cause of syncope was assigned by examining all physicians' notes and test results and with the use of previously published diagnostic criteria as guidelines. MEASUREMENTS AND MAIN RESULTS: Ninety percent of the patients underwent cardiac testing other than routine electrocardiography and continuous telemetry monitoring while in the hospital. An echocardiogram was obtained for 64% of the patients and did not reveal an unsuspected cause for syncope in any case. The echocardiogram was normal for 52% of the patients undergoing the test. Echocardiograms of patients with syncope and no clinical evidence of heart disease by history, physical examination, or electrocardiography either were normal (63%) or provided no useful additional information for arriving at a diagnosis (37%). Nearly half (46%) of the patients undergoing echocardiography fit this clinical profile. Among the patients for whom cardiac disease was suspected after history, physical examination, or electrocardiography, the echocardiogram confirmed the suspected diagnosis for 48% and served to rule out a suspected diagnosis for the remaining 52%. In no instance did echocardiography provide an unsuspected cause for syncope. The history, physical examination, and initial electrocardiography provided sufficient information to permit a diagnosis to be made for 37 of the 48 patients (77%) for whom a cause of syncope was ultimately determined. CONCLUSION: Echocardiography was frequently used in the evaluation of patients admitted to the hospital because of syncope of unclear cause. For patients without suspected cardiac disease after history, physical examination, and electrocardiography, the echocardiogram did not appear to provide additional useful information, suggesting that syncope alone may not be an indication for echocardiography. For patients with suspected heart disease, echocardiography served to confirm or refute the suspicious in equal proportions. These data provide an objective basis to prospectively define the optimal role of echocardiography in the evaluation of patients with syncope.

The biologic behavior of balloon hyperinflation-induced arterial lesions in hypercholesterolemic pigs depends on the presence of foam cells.

Lack of a large-animal model of accelerated atherosclerosis has limited study of the biologic behavior of atherosclerotic lesions. We hypothesized that mechanical vascular trauma combined with diet-induced hypercholesterolemia would result in rapid development of complex atherosclerosis-like lesions. Accordingly, we induced deep injury to a carotid artery by repetitive balloon hyperinflations in minipigs that were fed either an atherogenic diet (n = 30) or a standard diet (controls, n = 4) and examined the resultant lesions 1 month later. The neointimal lesions that evolved in 23 patent vessels from cholesterol-fed animals were complex, exhibiting infiltration of smooth muscle and foam cells and evidence of organized thrombus, recent thrombus, hemorrhage, and calcification. Lesions were separable histologically into two groups: foam-cell rich (n = 12), with 33 +/- 10 foam cells per high-power field, and foam-cell poor (n = 11), with 4 +/- 1 foam cells per high-power field. Minipigs with foam cell-rich lesions had higher serum cholesterol levels than those with foam cell-poor lesions (712 +/- 178 vs 468 +/- 240 mg/dL, P < .02). The incidence of intralesional thrombus was also significantly greater in foam cell-rich than in foam cell-poor lesions (50% vs 9%, P < .04). In addition, the degree of luminal stenosis was greater in the presence of lesions containing thrombus compared with those without thrombus (60 +/- 38% vs 30 +/- 29%, P = .05). Lesions in the control animals were fibrocellular and lacked foam cells and thrombus. Thus, hypercholesterolemia appeared to affect lesion composition and behavior.(ABSTRACT TRUNCATED AT 250 WORDS)

Sensitive detection of abnormal aortic architecture in Marfan syndrome with high-frequency ultrasonic tissue characterization.

BACKGROUND: Aneurysmal dilation of the aorta with subsequent rupture or dissection occurs frequently in patients with Marfan syndrome and is the primary cause of morbidity. These complications are related to the altered composition and disorganized structure of the aortic media. Our goal was to use high-frequency ultrasonic tissue characterization to identify these structural changes in abnormal aorta from patients with Marfan syndrome. We measured integrated backscatter and anisotropy of backscatter of ultrasound from specimens of aorta from patients with Marfan syndrome undergoing aortic root replacement and compared these values with those from aortic specimens of patients without clinical aortic pathology. METHODS AND RESULTS: Aortic tissue was obtained at the time of surgery from 11 patients with Marfan syndrome undergoing repair of an aortic aneurysm or dissection. Normal tissue was obtained at the time of autopsy from 8 patients without evidence of aortic disease. Acoustic microscopy at 50 MHz was performed to measure integrated backscatter from each specimen. The magnitude of ultrasonic anisotropy of backscatter for each tissue type was determined as an index of the three-dimensional (3D) organization of the vessel matrix. The collagen content of each specimen was determined with a hydroxyproline assay. Marfan aortas exhibited less backscatter than did normal aortas (-40.9 +/- 2.9 versus -32.6 +/- 2.2 dB for patients with Marfan syndrome and healthy subjects, respectively, P < .0001). No significant difference in collagen concentrations was observed between normal and Marfan aorta (262.7 +/- 52.7 versus 282.4 +/- 41.8 mg/g tissue for normal and Marfan aortas, respectively, P = .42), despite the large difference in backscatter. Histological analysis revealed striking differences in both the amount and organization of the elastin in the aortic aneurysm segments from patients with Marfan syndrome compared with normal aorta. Normal aorta was characterized by well-formed elastin fibers arranged in a lamellar pattern. The media from aneurysms in Marfan aorta exhibited a profound decrease in elastin content that was associated with loss of the highly aligned and ordered lamellar arrangement. The directional dependence of scattering, or ultrasonic anisotropy, also differed dramatically between the two tissue types. Backscatter from normal aorta decreased substantially when the media was insonified parallel compared with perpendicular to the principal axis of the elastin fibers. Marfan aorta exhibited a much smaller directional dependence of scattering. Normal aortas manifested a 14-fold greater ultrasonic anisotropy than did Marfan aortas (24.1 +/- 3.7 versus 12.4 +/- 3.3 dB for normal and Marfan aortas, P < .0001), which is indicative of the profound extent of matrix disorganization in Marfan syndrome. CONCLUSIONS: These data show that high-frequency ultrasonic tissue characterization sensitively detects changes in vessel wall composition and organization that occur in the aorta of patients with Marfan syndrome. Aortic segments from these patients manifested a significant decrease in integrated backscatter compared with normal aorta (approximately 8 dB, or greater than a 6-fold decrease in scattering). A 15-fold reduction in the ultrasonic anisotropy of Marfan tissue was observed, which suggests a marked disorganization of the 3D architecture of these aortas. These data support the hypothesis that high-frequency ultrasonic tissue characterization may be useful for identifying abnormalities of vessel wall composition, architecture, and material properties.

Ultrasonic tissue characterization of blood during stasis and thrombosis with a real-time linear-array backscatter imaging system.

BACKGROUND: The use of B-mode ultrasound in the diagnosis of thrombosis is still limited by problems that include transducer-related artifacts, the influence of system electronics on image formation, and the subjective nature of image interpretation. In this study we used a novel quantitative vascular imaging method based on the measurement of ultrasonic integrated backscatter to detect changes in the scattering from blood under conditions of stasis and coagulation. METHODS: Thrombi were created in excised sections of porcine aortae and imaged in a water tank over 2 h with a clinical integrated backscatter imaging system equipped with a 7.5 MHz linear-array transducer. Similar backscatter imaging was performed on anticoagulated whole blood that was allowed to remain quiescent for 2 h. Imaging was also performed on anticoagulated blood to which hetastarch was added to accelerate red cell aggregation. RESULTS: The integrated backscatter from thrombus increased by 19.4 +/- 2.1 dB from baseline. Blood that remained static but did not clot showed an increase in integrated backscatter of 12.6 +/- 0.9 dB; this increase was immediately and completely reversed by restirring. The addition of hetastarch produced a marked increase in scattering of 29.0 +/- 1.6 dB, and this value also returned to baseline after the blood was restirred. The increase in integrated backscatter after the addition of hetastarch was significantly greater than that observed for thrombosis, which in turn was greater than that for static blood. CONCLUSION: Quantitative integrated backscatter imaging of blood during stasis and coagulation is feasible using a clinically applicable real-time integrated backscatter imager. Ultrasonic tissue characterization of thrombi may provide data on thrombus age, composition, and stability, which may assist diagnosis and treatment.

Quantification of ultrasonic anisotropy in normal myocardium with lateral gain compensation of two-dimensional integrated backscatter images.

Anisotropy of ultrasonic scattering and attenuation in heart tissue depends on the specific orientation of myofibers with respect to angle of insonification. We used lateral gain compensation (LGC) to correct two-dimensional cardiac images for physiologic anisotropy. Normal hearts excised from three dogs and five pigs were insonified in a water tank with both 2.5 and 5.0 MHz phased-array transducers. Integrated backscatter was measured from a short-axis approach in the anterior wall perpendicular to the principal fiber axis, and in the septum parallel to the fiber axis. The gain in a vertical sector encompassing the septum was adjusted to compensate the image for anisotropy by matching the intensity of scattering from septal and anterior regions. The average gain required to compensate the septum for anisotropy was 16 dB at 2.5 MHz, and 20 dB at 5.0 MHz. Five healthy volunteers underwent imaging with a 2.5 MHz transducer from a parasternal short-axis view. The LGC required in vivo was approximately 16 dB at 2.5 MHz and was equivalent to that required for correction of septal anisotropy in excised hearts. Thus, normal myocardium exhibits substantial ultrasonic anisotropy that can be quantified and compensated for with clinically applicable tissue characterization techniques.