Making the transition: the role of helical CT in the evaluation of potentially acute thoracic aortic injuries.

OBJECTIVE: The purpose of this study was to show that helical CT could be used at our center in lieu of routine aortography to examine patients who have had serious blunt chest trauma. We also wanted to assess the potential savings of using CT to avoid unnecessary aortography. MATERIALS AND METHODS: The institutional review board approved the parallel imaging-CT immediately followed by aortography-of patients presenting with blunt chest trauma between August 1997 and August 1998. To screen patients for potential aortic injuries, we performed parallel imaging on 142 patients, and these patients comprised our patient population. CT examinations of the patients were reviewed for signs of injury by radiologists who were unaware of each other's interpretations and the aortographic results. Findings of CT examinations were classified as negative, positive, or inconclusive for injury. Aortography was performed immediately after CT. The technical and professional fees for both transcatheter aortography and helical CT were also compared. RESULTS: Our combined kappa value for all CT interpretations was 0.714. The aortographic sensitivity and negative predictive value were both 100%. Likewise, the sensitivity and negative predictive value of CT were 100%. The total costs of performing aortography were estimated at approximately $402,900, whereas those for performing helical CT were estimated at $202,800. CONCLUSION: Helical CT has a sensitivity and negative predictive value equivalent to that of aortography. Using CT to eliminate the possibility of mediastinal hematoma and to evaluate the cause of an abnormal aortic contour in a trauma patient allows us to use aortography more selectively. Avoiding the performance of unnecessary aortography will expedite patient care and reduce costs. We report the results of our experience with CT and how our center successfully made this transition in the initial examination of patients with serious thoracic trauma.

Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi.

PURPOSE: We compare the efficacy of percutaneous nephrostomy with retrograde ureteral catheterization for renal drainage in cases of obstruction and infection associated with ureteral calculi. MATERIALS AND METHODS: We randomized 42 consecutive patients presenting with obstructing ureteral calculi and clinical signs of infection (temperature greater than 38 C and/or white blood count greater than 17,000/mm.3) to drainage with percutaneous nephrostomy or retrograde ureteral catheterization. Preoperative patient and stone characteristics, procedural parameters, clinical outcomes and costs were assessed for each group. RESULTS: Urine cultures obtained at drainage were positive in 62.9% of percutaneous nephrostomy and 19.1% of retrograde ureteral catheterization patients. There was no significant difference in the time to treatment between the 2 groups. Procedural and fluoroscopy times were significantly shorter in the retrograde ureteral catheterization (32.7 and 5.1 minutes, respectively) compared with the percutaneous nephrostomy (49.2 and 7.7 minutes, respectively) group. One treatment failure occurred in the percutaneous nephrostomy group, which was successfully salvaged with retrograde ureteral catheterization. Time to normal temperature was 2.3 days in the percutaneous nephrostomy and 2.6 in the retrograde ureteral catheterization group, and time to normal white blood count was 2 days in the percutaneous nephrostomy and 1.7 days in the retrograde ureteral catheterization group (p not significant). Length of stay was 4.5 days in the percutaneous nephrostomy group compared with 3.2 days in the retrograde ureteral catheterization group (p not significant). Cost analysis revealed that retrograde ureteral catheterization was twice as costly as percutaneous nephrostomy. CONCLUSIONS: Retrograde ureteral catheterization and percutaneous nephrostomy effectively relieve obstruction and infection due to ureteral calculi. Neither modality demonstrated superiority in promoting a more rapid recovery after drainage. Percutaneous nephrostomy is less costly than retrograde ureteral catheterization. The decision of which mode of drainage to use may be based on logistical factors, surgeon preference and stone characteristics.

Effective lovastatin therapy in elderly hypercholesterolemic patients - an antioxidative impact?

The effect of 3 months lovastatin therapy on serum lipids, apolipoproteins, alpha-tocopherol and red cell membrane fatty acid pattern was assessed in twelve elderly ambulatory patients (mean age 70.9+/-8.0 years) with hypercholesterolemia type IIa according to Fredrickson. After a run-in period of 4 weeks without drug therapy, the patients were given a daily dose of 20 mg lovastatin. The treatment resulted in statistically significant decreases in mean serum low density lipoprotein cholesterol (LDL-CH, -34%), in the atherogenic index LDL-CH/HDL-CH (-35%) and in the concentration of apolipoprotein B (-26%). No change in the vitamin E status, as related to plasma total lipids, was observed during the 3 months of therapy. The fatty acid pattern of phospholipids from red cell membranes showed an increase in linoleic acid metabolites and a decrease in the precursor linoleic acid, indicating an induction of fatty acid desaturases by lovastatin. In addition, an increase in the plasmalogen portion of erythrocyte membrane phospholipids was exhibited by increases in the proportion of fatty aldehyde dimethyl acetals (DMA) in the fatty acid pattern. The plasmalogens increase may counteract the slow but consistent decrease in their concentration in red cell membranes and human aortas with increasing donor age and in arteriosclerosis. Since plasmalogens may function as physiological antioxidants, the observed increase in DMA concentration might reflect a previously unrecognized antioxidative principle of a lovastatin therapy.

On the efficacy of piracetam in geriatric patients with acute cerebral ischemia: a clinically controlled double-blind study.

Using a randomized, double blind group comparison, the efficacy and tolerance of piracetam as an additional therapy of hydroxyethyl starch, venous infusion and low dose heparin treatment, which are the basis of therapy in our hospital, has been studied in patients displaying acute cerebral ischemia. A total of 56 patients were enrolled, of whom 27 were given piracetam and 29 served as a control during a 28-day period. Using single photon emission computer tomography (SPECT) analysis, we observed that in 23 piracetam-treated patients (85.2%) a reduction in the area of brain regions displaying an impaired flow rate occurred (P < 0.001; Fisher's exact two-sided test). Only six of placebo-treated patients (20.7%) showed an improved flow rate. Analysis of the recorded computer tomography map gave an improvement coefficient >2 (flow rate marginally or better improved) for 23 piracetam patients as compared with 5 placebo patients (P < 0.001, Uleman test).

Erythrocyte membrane changes associated with nutrition and aging--the role of plasmalogens.

Fatty aldehyde dimethylacetals (DMA) derived from human plasma and red cell plasmalogens of 20 female and 20 male donors, aged 70 years and over, and of 17 younger ones (12 male, 5 female), were measured as part of total phospholipid fatty acid methyl esters and DMA. There were no statistically significant changes in the hexadecanal DMA fractions of erythrocyte membranes with respect to donor age. In contrast, small degrees of correlation, though statistically significant, indicate a stochastic decline with donor age of erythrocyte octadecanal DMA and of plasma-derived hexadecanal DMA and octadecanal DMA levels. It is concluded that in the context of age-related changes not only the plasmalogen content of biomembranes has to be considered. Because of the sensitivity of plasmalogens to autoxidation, effects of oxidative damage and defense on membrane architecture, the degree of plasmalogen domain formation with its implication on membrane functions and the mechanisms regulating membrane turnover have to be also assessed.

[Geriatric day clinics and rehabilitation]. / Geriatrische Tageskliniken und Rehabilitation.

If the present development of our population is not to result in a continued increase in care-requiring elderly people, the building and expansion of geriatric rehabilitation institutions is a matter of urgency. Numerous studies, some of which carried out in our own country, show how successful geriatric rehabilitation can be. Prerequisites are, apart from appropriately equipped facilities, the proper selection of those requiring care, adequate numbers of properly qualified personnel, and early initiation of any treatment needed. Thus, 70 to 80% of those originally scheduled for admission to an old persons' nursing home can be enabled to live more or less independently at home. Apart from geriatric hospitals, geriatric day clinics offer optimal possibilities for rehabilitation. They combine therapeutic effectiveness and economy with the advantage that, during treatment, the elderly person is not completely taken out of his familiar surroundings, which results in an improvement in his motivation to get well again quickly. At the same time, complicating diseases, such as, for example, diabetes mellitus, can be treated under conditions closely similar to those of the patient's subsequent day-to-day situation. In this sense, geriatric day clinics are not only desirable, but urgently needed institutions.

The effect of different fat supplemented diets on the erythrocyte ghosts and plasma lipid composition of geriatric subjects.

The responses of the lipid composition of erythrocyte ghosts and plasma phospholipid fatty acids of 20 female donors, aged older than 70 years, to different margarine and butter supplemented diets were investigated. On a low level of daily caloric intake (1900 kcal) there were no changes in phospholipid and cholesterol content of the red cell membranes, but statistically significant changes were found in erythrocyte and plasma phospholipid fatty acid patterns. These results demonstrate the influence of the fatty acid composition of the dietary fats with special reference to saturated, trans-isomeric monoene, and polyunsaturated acids.

[Rehabilitative treatment of cerebral apoplectic insults in advanced age and evaluating its effectiveness--results of a model project]. / Zur rehabilitativen Behandlung von zerebralen apoplektischen Insulten im höheren Lebensalter und ihrer Effizienzbeurteilung--Ergebnisse eines Modellprojekts.

This report is of a two year study of stroke rehabilitation. Given certain conditions with specialized personnel and equipment the rehabilitation of elderly stroke patients can be managed co-operatively in hospitals and old age care centres. The rehabilitation of stroke affected is based on the support of multidisciplinary diagnosis and interdisciplinary teamwork between physicians, physiotherapists, occupational therapists, speech therapists, psychologists and social workers. Each patient requires an individual treatment program. In this study were 72 patients ranging in age from 42-87 years, average age 73 years. They had been judged as progressively degenerative and helpless following their stroke and consequently regarded as patients for a nursing home. Following special rehabilitation treatment 75% (54 patients) had improved enough that it was possible for them to return to their homes. Only 12.5% (9 patients) had to remain in a nursing home. 6.6% (4 patients) transferred to an old people's home. 6.9% (9 patients) were readmitted to hospital because of additional serious complications. The average duration of rehabilitative treatment was 72.3 days. The degree of hemiplegia and the patients ability to lead their own active daily independent life was reviewed before and after rehabilitation and used as control. 76.6% showed an improvement in their motor function. 61.1% returned to their own independent daily life as measured by ADL-Indices. (a. Barthel Index, b. ADL-Index-Katz-, c. Patient Classification for Long Term Care-Jones-, d. Crichton Royal Behavioural Rating Scale-Robinson-.).(ABSTRACT TRUNCATED AT 250 WORDS)

[Influence of piracetam on the aggregation of platelets (author's transl)]. / Der Einfluss von Piracetam auf die Thrombozytenaggregation]

The aggregation of platelets were measured by 51 persons. Each person were medicated with 0, 3, 6, 9, 12 gr. of Piracetam. It was shown that the aggregation of platelets does not change by measuring the spontaneous aggregation as by measuring the ADP - induced aggregation of platelets.

[The attitude of stationary hospital patients towards the old people home and the nursing home (author's transl)]. / Die Einstellung stationärer Krankenhauspatienten zum Alten- bzw. Altenpflegehein.

Changes in our health and hospital policy towards shorter stays in hospital as well as changes in our social and family structures have led to a lot of problems in geriatrics. It is complicated to insure a necessary continuing home-treatment or a supply of daily necessities which are often necessary with advancing age after acute sicknesses. This has resulted in that many of the old peoples' or nursing home places are filled directly from the hospital. During investigations of 496 patients of an internal clinic we found that a rather high number of geriatric patients accepted a change into an old peoples or nursing home in contrast to investigations conducted outside the clinic. But the hospital patients complained about the same points in these institutions as the non-hospitalized. Therefore hospital personnel (doctors, sisters, nurses, therapeuts and social workers) ought to try all possibilities for rehabilitation inside and outside the usual stationary institutions (Reha-clinic, day-clinic) to insure the reintegration of old people in familiar or neighbourly surroundings. If this is not possible, the patients should be given enough time and opportunity to adjust themselves to the new life situation and to make independent decisions.

[An alternative in the therapy of primary hyperlipemias: etofibrate in depot preparations]. / Alternative in der Therapie primärer Hyperlipidämien: Etofibrat in Retardform.

In a randomised blind study with 404 patients 1 capsule Etofibrate per day (500 mg) in sustained release dosage form was tested in comparison to other lipid-lowering drugs. The trial extended to eight weeks and was performed in eight clinics and in four practices for internal medicine. Serum-cholesterol and serum-triglycerides were controlled at the beginning and at the end of the observation period. The result was a significant decrease of the cholesterol-level up to 22% and a decrease of the triglyceride-level up to 43%. Also the patients pretreated with other drugs showed a furthermore improvement of the former therapy. Side effects were very rare and it was never necessary to stop the treatment.

[Oral antidiabetics of the sulfonylurea group and their problems in therapy]. / Orale Antidiabetika aus der Gruppe der Sulfonylharnstoffderivate und ihre Problematik in der Therapie.

By the abolition of biguanids as oral antidiabetics the importance of derivatives of sulfonylcarbamids became prominent in the treatment of diabetic elderly patients. Because of the properties of that group, there are a number of problems by the therapy with these derivatives. There is the mostly existing multimorbidity in geriatric patients with the risk of incompatibilities of drugs in cause of multitherapy and there is the influence of morbid states on the pharmacokinetics. Some of the various questions will be shortly described in this article. There are then given also practical advices for the relations with the derivatives of sulfonylcarbamids in treating diabetic patients.

[New sulfonamide-trimethoprim combination, Supristol. Results of a joint therapeutic trial (author's transl)]. / Neue Sulfonamid-Trimethoprim-Kombination Supristol. Ergebnisse einer gemeinschaftlichen therapeutischen Prüfung.

The efficacy of a new low dosage trimethoprim-sulfamoxole combination (Supristol) was tested in a joint therapeutic study in 6 medical clinics or departments and in a general practice. A good therapeutic result (healing) was achieved in about 80% of the 143 patients included in the trial. The preparation was well tolerated. Symptoms of intolerance appeared in only 2% of the cases. It is assumed that the low dosage of the preparation influences the tolerance favorably without affecting the efficacy.

[Behaviour of oxytetracycline and doxycycline serum levels under forced diuresis in severe bromcarbamide intoxication (author's transl)]. / Verhalten der Serumspiegel von Oxytetracyclin und Doxycyclin unter der forcierten Diurese bei schweren Schlafmittelvergiftungen.

A dose of 500 or 1000 ml respectively was infused at hourly intervals over 12 or 24 hours respectively, using a standardised infusion schedule. It was found that this enormous increase in renal function did not cause any changes in the behaviour of the serum levels of oxytetracycline and doxycycline as compared to normal renal excretion. This result comes hardly as a surprise in the case of doxycycline due to its high degree of protein binding, it is, however, unexpected for oxytetracycline.