[Prediction of further hospital treatment for emergency patients by emergency medical service physicians]. / Notärztliche Einschätzung der klinischen Weiterversorgung von Notfallpatienten.

INTRODUCTION: Prehospital assessment of illness and injury severity with the National Advisory Committee for Aeronautics (NACA) score and hospital pre-arrival notification of a patient who is likely to need intensive care unit (ICU) or intermediate care unit (IMC) admission are both common in Germany's physician-staffed emergency medical services (EMS) system. AIM: This study aimed at comparing the prehospital evaluation of severity of disease or injuries by EMS physicians and the subsequent clinical treatment in unselected emergency department (ED) patients. MATERIAL AND METHODS: This study involved a prospective observational analysis of patients transported to the ED of an academic level I hospital escorted by an EMS physician over a period of 6 months (February-July 2011). The physician's qualification and the patient's NACA score were documented and the EMS physician was asked to predict whether the patient would need hospital admission and, if so, to the general ward, IMC or ICU. After the ED treatment, discharge or admission, outcome and length of hospital and ICU or IMC stay were documented. RESULTS: A total of 378 mostly non-trauma patients (88 %) treated by experienced EMS physicians could be enrolled. The number of patients discharged from the ED decreased, while the number of patients admitted to the ICU increased with higher NACA scores. Prehospital prediction of discharge or admission, IMC or ICU treatment by EMS physicians was accurate in 47 % of the patients. In 40 % of patients a lower level of care was sufficient while 12 % needed treatment on a higher level of care than that predicted by EMS physicians. Of the patients 39 % who were predicted to be discharged after ED treatment, were admitted to hospital and 48 % of patients predicted to be admitted to the IMC were admitted to the general ward. Patients predicted to be admitted to the ICU were admitted to the ICU in 75 %. Higher NACA scores were associated with increased mortality and a longer hospital IMC or ICU length of stay, but significant differences were only found between patients with NACA V versus VI scores or patients predicted to be treated on the IMC versus the ICU. CONCLUSIONS: Prehospital NACA scores indicate the need for inpatient treatment, but neither hospital discharge or admission nor need of IMC or ICU admission after initial ED treatment could be sufficiently predicted by EMS physicians. Thus, hospital prenotification in order to predispose IMC or ICU capacities does not seem to be useful in cases where an ED can reassess admitted EMS patients.

Characterization of lysosomal acid lipase mutations in the signal peptide and mature polypeptide region causing Wolman disease.

Wolman disease results from an inherited deficiency of lysosomal acid lipase (LAL; EC 3.1.1.13). This enzyme is essential for the hydrolysis of cholesteryl esters and triacylglycerols derived from endocytosed lipoproteins. Because of a complete absence of LAL activity, Wolman patients accumulate progressive amounts of cholesteryl esters and triacylglycerols in affected tissues. To investigate the nature of the genetic defects causing this disease, mutations in the LAL gene from three subjects of Moslem-Arab and Russian descent living in Israel were determined. Two homozygotes for a novel 1-bp deletion introducing a premature in-frame termination codon at amino acid position 106 (S106X) were identified. A third subject was a homozygote for a G-5R signal peptide substitution and a G60V missense mutation. The functional significance of these mutations was tested by in vitro expression of single and double mutants in Spodoptera frugiperda cells. Single mutants G60V and S106X and double mutant G-5R/G60V displayed a virtual absence of lipase activity in cell extracts and culture medium. Signal peptide mutant G-5R retained lipase activity in cell extracts and showed a drastically reduced enzyme activity in culture supernatant, indicating that the mutation may affect secretion of active enzyme from cells. These results support the notion that Wolman disease is a genetically heterogeneous disorder of lipid metabolism.

Abdominal aortic aneurysm repair after renal transplantation with extracorporeal bypass.

The successful resection of an abdominal aortic aneurysm is presented in a patient who had undergone kidney transplantation 4 years previously. Because the transplanted kidney is more sensitive to ischemia than a normal one, a femoro-femoral bypass with a pump oxygenator was used for perfusion of the transplanted kidney during crossclamping. During the clamping time of 40 minutes kidney perfusion was maintained with a perfusion pressure of 60 to 80 mmHg and the flow was 600 to 1000 ml/min. A collagen-seeded Dacron graft (diameter: 18 mm, length: 12 mm) was interposed. The postoperative course was uncomplicated. We believe that performing the femoro-femoral bypass with a pump oxygenator is an effective and simple method for kidney protection in such operations.

[Biomechanical effects of intra-articular ankle bone fractures on the ankle joint. An experimental study]. / Biomechanische Auswirkungen intraartikulärer Fersenbeinfrakturen auf das obere Sprunggelenk. Eine experimentelle Untersuchung.

Intraarticular heelbone fractures lead to cartilage damage by way of joint surface incongruence. This causes arthrosis of the lower ankle joint. The influence of a dislocated calcaneus fracture on the upper ankle joint was documented in an experimental study on eight cadaver legs. We performed an osteotomy of the calcaneus to imitate a typical fracture, placed a pressure film into the upper ankle joint and subjected the joint to axial pressure of 850 N. Changes in contact area and pressure pattern were measured in different flexion/extension positions of the foot. Results with respect to total contact area and high-pressure contact zone are discussed.

Rapid brain cooling in the free-running hamster Mesocricetus auratus.

A thermocouple reentrant tube was stereotaxically implanted in the rostral brain stem of the golden hamster, Mesocricetus auratus. Brain temperature was continuously recorded while the hamster was permitted volitional running on an activity wheel. There was an immediate decrease in brain temperature at the start of running activity, reaching a mean of 0.49 degrees C below the prerunning level. Spontaneous or forced cessation of running activity was associated with a rapid recovery of brain temperature. The time course of brain cooling during exercise greatly differed from the exponential decay of brain temperature in hyperthermic and dead animals. Air flow through the nose may contribute to the maintenance of a low brain temperature because nasal blockade promotes an increase in brain temperature. Below an ambient temperature of 33 degrees C, the resting hamster maintains its brain temperature below deep-body (abdominal) temperature. Vinyl acetate casts of the arterial and venous systems revealed several potential sites for heat exchange that might account for brain cooling under resting and exercising conditions.