Prospective documentation and analysis of the pre- and early clinical management in severe head injury in southern Bavaria at a population based level.

Treatment of patients suffering from severe head injury is so far restricted to general procedures, whereas specific pharmacological agents of neuroprotection including hypothermia have not been found to improve the outcome in clinical trials. Albeit effective, symptomatic measures of the preclinical rescue of patients (i.e. stabilization or reestablishment of the circulatory and respiratory system) or of the early clinical care (e.g. prompt diagnosis and treatment of an intracranial space occupying mass, maintenance of a competent circulatory and respiratory system, and others) by and large constitute the current treatment based on considerable organizational and logistical efforts. These and other components of the head injury treatment are certainly worthwhile of a systematic analysis as to their efficacy or remaining deficiencies, respectively. Deficits could be associated with delays of providing preclinical rescue procedures (e.g. until intubation of the patient or administration of fluid). Delays could also be associated in the hospital with the diagnostic establishment of intracranial lesions requiring prompt neurosurgical intervention. By support of the Federal Ministry of Education and Research and under the auspices of the Forschungsverbund Neurotraumatology, University of Munich, a prospective system analysis was carried out on major aspects of the pre- and early clinical management at a population based level in patients with traumatic brain injury. Documentation of pertinent data was made from August 1998 to July 1999 covering a catchment area of Southern Bavaria (5.6 mio inhabitants). Altogether 528 cases identified to suffer from severe head injury (GCS < or = 8 or deteriorating to that level within 48 hrs) were enrolled following admission to the hospital and establishment of the diagnosis. Further, patients dying on the scene or during transport to the hospital were also documented, particularly as to the frequency of severe head injury as underlying cause of mortality. The analysis included also cases with additional peripheral trauma (polytrauma). The efficacy of the logistics and organization of the management was studied by documentation of prognosis-relevant time intervals, as for example until arrival of the rescue squad at the scene of an accident, until intubation and administration of fluid, or upon hospital admission until establishment of the CT-diagnosis and commencement of surgery or transfer to the intensive care unit, respectively. The severity of cases studied in the present analysis is evident from a mortality of far above 40% of cases admitted to the hospital, which was increased by about 20% when including prehospital mortality. The outcome data notwithstanding, the emerging results demonstrate a high efficacy of the pre- and early clinical management, as indicated by a prompt arrival of the rescue squad at the scene, a competent prehospital and early clinical management and care, indicative of a low rate of avoidable complications. It is tentatively concluded on the basis of these findings that the patient prognosis is increasingly determined by the manifestations of primary brain damage vs. the development of secondary complications.

Heparin coating of vascular prostheses reduces thromboemboli.

BACKGROUND: Synthetic conduits made from currently available materials are suboptimal for use in small-diameter vascular reconstruction because of their high surface thrombogenicity, which leads to failure. METHODS: In this study control, heparin-irrigated, or heparin-bonded expanded polytetrafluoroethylene (ePTFE) grafts (4 mm long by 1 mm inner diameter) were implanted to reconstruct the iliac artery in male rats. The cremaster muscle was isolated as an island flap based on branches of the iliac artery downstream from the graft. Emboli were quantitated by using intravital fluorescent microscopy of the cremaster muscle's microcirculation. RESULTS: The mean number of emboli observed per animal during a 20-minute period was 91 for the control group, 84 for the heparin-irrigated group, and 22 for the tridodecylmethylammonium chloride (TDMAC)-heparin group. The mean area of each embolus was 1057 microns 2 for control, 940 microns 2 for heparin-irrigated, and 808 microns 2 for TDMAC-heparin-coated grafts (p < 0.05 for TDMAC-heparin versus control or heparin-irrigated). CONCLUSIONS: A TDMAC-heparin coating of ePTFE microvascular prostheses significantly reduces downstream microemboli.

Glycopeptide profiling of human urinary erythropoietin by matrix-assisted laser desorption/ionization mass spectrometry.

The site-specific glycan heterogeneity of human urinary erythropoietin was investigated by matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS). Owing to the small amount of protein available, a strategy combining optimal sensitivity and specificity was used. Erythropoietin was reduced, S-alkylated and digested with endoproteinase Lys C. The peptides were separated by reversed-phase high-performance liquid chromatography and the molecular masses of the peptides determined by MALDI-MS. The peptides were identified by comparing the experimental masses with the masses predicted from the cDNA derived amino acid sequence. Glycopeptides were identified from the mass spectra based on the peak pattern caused by the glycan heterogeneity. They were further characterized after treatment with neuraminidase and endoproteases. All N-glycosylation sites exhibited fucose-containing complex-type glycans. The N-glycosylation sites at Asn38 and Asn83 are mainly occupied by tetraantennary glycans, whereas Asn24 is occupied by a mixture of bi-, tri- and tetraantennary glycans. A molecular mass glycoprofile for each glycosylation site was established based on the relative peak intensities observed in the MALDI mass spectra of the desialylated glycopeptides.

[Biliary pancreatitis--a good indication for laparoscopic cholecystectomy]. / Biliäre Pankreatitis--eine gute Indikation zur laparoskopischen Cholezystektomie.

Recently the indication for laparoscopic cholecystectomy has been enlarged to include biliary pancreatitis. While a majority of reports recommend early open cholecystectomy for biliary pancreatitis the use of laparoscopic cholecystectomy in this disease has not yet been discussed. We retrospectively reviewed 52 patients with biliary pancreatitis being admitted to our ward in the last five years. Cholecystectomy was performed in 48 patients. Ten had undergone laparoscopic cholecystectomy. Postoperative complications occurred in 8 of the 48 patients (16.6%). Four patients (8.3%) died due to necrotizing pancreatitis or rupture of pseudocysts. We found a correlation between morbidity and mortality and the prognostic score as well as the presence of pseudocysts. We conclude that biliary pancreatitis is a good indication for laparoscopic cholecystectomy in patients with a low prognostic score. The presence of pseudocysts in our view is no contraindication for laparoscopy. Although it may increase postoperative morbidity. Choledocholithiasis has to be ruled out either by preoperative ERCP or during laparoscopy with intraoperative cholangiography.