[Perioperative bleeding in a Jehovah's Witness]. / Perioperative Blutung bei einem Zeugen Jehovas.

Perioperative bleeding in Jehovah's Witnesses leaves physicians with difficult medical and ethical decisions. We report the case of a 45-year-old man, who refused to accept red blood cell concentrates by a patient directive. A postoperative bleeding occurred after removal of a transplanted kidney. Despite critically low hemoglobin (3.1 g/dl) and hematocrit (9.5%) levels, the case was managed without red blood cell transfusions. The patient showed an amazingly quick recovery and was discharged from hospital after 24 days without any sequelae.

[Blood clots in erythrocyte concentrates during transfusion]. / Blutkoagel in Erythrozytenkonzentraten während der Transfusion.

BACKGROUND: The presence of multiple blood clots in leucocyte-depleted erythrocyte concentrates during a transfusion gave rise to an investigation to find the exact cause. MATERIALS AND METHODS: Determination of the various blood group systems was carried out using the gel centrifugation method and also the polymerase chain reaction (PCR) using sequence-specific primers. In addition the human leucocyte antigens (HLA) class 1 and class 2 markers were determined with molecular biological methods. RESULTS: The erythrocytes in the blood bags containing the blood clots showed a mixed-field agglutination in each blood group where the donor and recipient had different phenotypes. The HLA groups, however, could be solely attributed to the patient, since during the preparation of erythrocyte concentrates all leucocytes are removed and only very few residual cells containing DNA are present. CONCLUSIONS: To the best of our knowledge, this is the first detailed report on blood clots from patient blood in erythrocyte concentrates, which occurred during a transfusion. The retrograde filling of the blood bag with patient blood during the transfusion led to coagulation in the bag. Therefore, careful attention must be taken when dealing with stored blood and corresponding training must be regularly carried out.

Intestinal elimination of hydroxyethyl starch?

OBJECTIVE: Hydroxyethyl starch (HES) is mainly eliminated via the kidneys. Any information about extrarenal elimination obtained so far has been either incomplete or contradictory. The objective of this study was to quantify the intestinal excretion of infused HES with a mean molecular weight of 200,000 and a molar substitution of 0.5 (HES 200/0.5) and to compare the reappearance/recovery rate in urine and plasma. DESIGN: Prospective clinical study without control group. SETTING: The study was conducted at the Institute of Hypertension of the Society of Clinical Pharmacology, Vienna, Austria, which is an establishment for research in volunteers. PARTICIPANTS: The results of six out of seven healthy male volunteers were appropriate for analysis. One trial subject had to be excluded from the study because of severe protocol violation (mixing of stool and urine samples). INTERVENTIONS AND METHODS: Each volunteer was administered 500 ml of 10% HES 200/0.5 in a 0.9% NaCl solution intravenously within 1 h. A gut lavage with 6 l of a polysaccharide free solution was continuously administered from 3 h prior to until 2 h after the HES infusion to facilitate the collection of the samples and to exclude any source of error at analysis. HES was quantified with the hexokinase method. MEASUREMENTS AND RESULTS: Right from the beginning of the infusion until 10 h after its completion, the cumulative HES excretion with feces (principle parameter) and urine as well as selective plasma volume and HES plasma level were measured. Six and 14 h after the infusion had been completed, the recovery rates of HES in urine were about 30% and 40%, respectively, and in plasma about 23% and 8%, respectively. By contrast, not more than a kind of "background noise amount" of HES (about 0.2 %) could be recovered in feces ( mean value in % of the infused amount of the substance). Six and 14 h after the infusion had been completed, the total recovery rates of HES were 53% and 49%, respectively. CONCLUSION: In a physiologically unimpaired gut HES 200/0.5 is not, or only to an infinitesimal extent, eliminated via the intestine. The question if there is any alternative path to renal excretion for HES still remains to be answered. As the calculated reappearance/recovery rate of HES is only about 50 % of the administered dose, further investigations as to the final fate of HES appear necessary.

Enzyme immunoassay for the measurement of human tenascin-C on the Bayer Immuno 1 analyzer.

OBJECTIVES: To evaluate a new tenascin-C assay performed on the Bayer Immuno 1 system. DESIGN AND METHODS: The precision was measured using three levels of serum pools. Linearity was tested by diluting patient serum samples containing high tenascin-C concentrations, and the minimal detectable concentration determined by repetitive analysis of the zero calibrator. Preliminary reference intervals were determined by testing serum samples from 220 healthy individuals. Biovariability was estimated in a cohort of 20 apparently healthy subjects over 18 days. The levels of tenascin-C in patients with different liver diseases was tested. RESULTS: The detection limit was 2 ng/mL. At concentrations ranging from 325 to 1957 ng/mL the assay demonstrated within-run and between-run CVs ranging from 4% to 3.6% and 8.4% to 6.7%, respectively. Dilutions of sera were linear and parallel to the standard curve with recoveries ranging from 97% to 100%. The reference interval (central 95% interval) for tenascin-C in serum of healthy adults was 199-906 ng/mL. The variability study yielded an analytical variability, CV(A), of 1.8%; a within-subject variability, CV(I), of 11.7%; and a between-subject variability, CV(G), of 39.3%. Tenascin-C concentrations in sera of liver disease patients were significantly increased. CONCLUSIONS: The novel assay provides a rapid and reliable procedure for the determination of tenascin-C levels in human sera.

Neuromuscular control mechanisms and strategy in arm movements of attempted supranormal speed.

Rapid, goal-directed elbow flexion movements were examined under interacting conditions of inertial loading and resistance to movement initiation. The resistance ceased when movement began, resulting in quick release movements. Inertial load slowed the movement and lengthened the agonist and antagonist electromyographic (EMG) burst durations. The quick release resulted in larger accelerations but only minimal changes in peak velocity. Most aspects of the triphasic EMG pattern were little affected by the quick release, but the build up of agonist EMG and the corresponding rate of static force development differed markedly between load and quick release conditions. These and other data suggest that the specific pattern of agonist muscle activation is set according to neuromuscular constraints of the antagonist muscle and the expectation of movement dynamics.

[Hypertonic-hyperoncotic solutions: possibilities and limits]. / Hypertone-hyperonkotische Lösungen: Möglichkeiten und Grenzen.

Hypertonic-hyperoncotic solutions are a supplementary possibility in the acute treatment of hypovolemia. The main mechanism of action of this solution is, induced by the tonicity of the infusion (approximately 2400 mOsm/l), the transcapillary fluid shift from the intracellular and interstitial to the intravascular compartment. Additionally the fluidity of blood is improved (due to an increase in the diameter of the capillaries), the adherence of leucocytes to the endothelial wall is reduced, and the arteriolar vasomotion is restarted. Due to the available prehospital and clinical results it can be concluded, that hypertonic-hyperoncotic solutions offer advantages compared to conventional fluid therapy regimes: rapid stabilization of hemodynamics, reduction of posttraumatic volume deficiency, of posttraumatic edema and of posttraumatic complications and an improvement of the outcome of the patients. If the therapeutic recommendations are followed, such as a dose of 4 ml/kg body weight, infusion time of about 3-5 minutes and after the end of the infusion application of colloids or crystalloids in an amount as needed, no side effects will occur. Only immediately after the end of infusion sodium, chloride and osmolarity will slightly increase, however these parameters will normalize within the first posttraumatic day. Hypertonic-hyperoncotic solutions are trigger-solutions, as with the infusion of these types of solution it is possible to restore hemodynamics adequately and to prevent shock-induced complications.

Epitope-specific monoclonal antibodies against human C-terminal procollagen alpha1(III)-propeptide.

We have generated monoclonal antibodies against recombinant C-terminal human procollagen alpha1(III) propeptide (PIIICP), produced in E. coli in high yields. The monoclonal antibodies were screened for epitope specificity using recombinant truncated PIIICP. Several antibodies were identified which recognized different regions of the PIIICP molecule. The ability of the antibodies to detect PIIICP antigens in human cell line lysates and supernatants was demonstrated. As PIIICP antigens are a key marker of extracellular matrix metabolism, the monoclonal antibodies described here should be of value for clinical and basic research.

Pain treatment in the ICU: intravenous, regional or both?

Adequate treatment of pain in ICU patients should be an integral part of ICU management, as inadequately treated pain leads to a series of complications that may counteract the success of ICU treatment. For continuous intravenous use we recommend sufentanil in a dose of 0.75-1.0 microgram kg-1 h-1 in mechanically ventilated patients and in a dose of 0.25-0.35 microgram kg-1 h-1 in intubated and spontaneously breathing patients. On-demand analgesia, administered via the intravenous or epidural route, may be an alternative to a relatively fixed continuous infusion of an analgesic drug, and in some ICU patients the transdermal use of opioids can be an alternative to continuous intravenous drug application or PCA. Increased sizes of the patch (25, 50, 75, 100 cm2) provide sustained transdermal rates of approximately 25, 50, 75 and 100 micrograms h-1 of fentanyl over a period up to about 72 hours. Patients with trauma to the thorax, pelvic fracture, or after major surgical interventions will be better managed by regional application of analgesic drugs alone or in combination with a systemic analgesic drug infusion. To achieve the best results it is necessary to be well informed and trained in the method, to know the advantages and disadvantages, the correct and modified dosages of the drugs used, and the indications and contraindications.

[Thyroid gland surgery in pregnancy]. / Chirurgie der Schilddrüse in der Schwangerschaft.

Thyroid carcinoma is more frequent in younger women, but direct correlation with pregnancy is not proven. Preoperative management of suspect nodules reveals clear indications for immediate intervention. Out on 1471 thyroid operations, 340 female were in the group between 20 and 40 years. 53 carcinoma, i.e. 3.6%, in this subgroup had a potential concomittance of pregnancy and thyroid tumor. Although risk of obortion is very low in non-abdominal surgery, operations should be delayed post-partum except in cases of proven carcinoma.

[Nephrogenic adenoma after kidney transplantation]. / Nephrogenes Adenom nach Nierentransplantation.

We report five cases of nephrogenic adenoma that arose several years after cadaver kidney transplantation. Cystoscopy was performed in all patients because of gross haematuria and revealed multifocal tumorous lesions in all parts of the bladder. On admission to of hospital graft function was satisfactory in all patients. There were three female and two male patients. In all patients the therapeutic procedure consisted of transurethral resection. Only very small lesions were fulgurated. Postoperatively an indwelling catheter was left in place for 2-4 days, and after a check on kidney parameters and immunosuppressive therapy all patients were discharged. Postoperative management consisted in cystoscopy every 3 months in the first year and then every 6 months. Though the etiology of nephrogenic adenoma remains unclear, mechanical traumatization and recurrent urinary tract infection seem to be the most important factors in its development.

[Education of the medical student in first aid, emergency and disaster medicine--the Graz model]. / Die Ausbildung des Medizinstudenten in Erster Hilfe, Notfall- und Katastrophenmedizin--Modell Graz.

In Austria emergency and disaster medicine is a young interdisciplinary subject. It is only a borderline discipline encompassing different medical subjects and was subdivided into emergency medicine for medical doctors only and first-aid for lay people and emergency technicians. In fact, since emergency medicine without first-aid can't be successful, the Department of Anaesthesiology at the University of Graz let all students of the medical faculty have a comprehensive education in the treatment of injured of acutely ill patients. According to the three steps of the study lectures and practices, all parts of first-aid, emergency and disaster medicine were offered. In spite of the short time since this has been running, we found a good acceptance and we hope to increase the interest evinced by medical students in our training programme.

[Degree of substitution and volume expanding effect of various medium molecular weight hydroxyethyl starch solutions]. / Substitutionsgrad und volumenexpandierender Effekt unterschiedlicher mittelmolekularer Hydroxyäthylstärke (HAES)-Lösungen.

Hydroxyethylstarch (HES) is today one of the most frequently used artificial plasma substitutes in prehospital, as well as in clinical settings. However, there are no studies comparing the volume effect of different HES solutions. The goals of the present study therefore were to compare the volume effect of three HES solutions, which are similar with regard to mean molecular weight but different in concentration and degree of substitution. The obtained results enable guidelines for fluid resuscitation in hypovolemia to be laid down. In 30 patients fulfilling the ASA physical status classification I and II 500 ml of either 10% HES 200/0.5, 6% HES 200/0.5 or 6% HES 200/0.6-0.66 were infused within 30 min. The effect of each solution was evaluated using the mechanical oscillator technique (MOT). This technique measures precisely density changes of blood and plasma and allows-using standard formulae-calculation of blood and plasma volume changes. All 3 HES solutions showed similar effects in increasing plasma volume. Immediately after the end of infusion plasma volume was increased by about 800 ml with 10% HES and by about 650 ml with 6% HES 200/0.5. The volume expanding effect of 6% HES 200/0.6-0.66 amounted to 700 ml. The volume expanding effect of all starches decreased only slightly during the following two hours; an interesting detail observed was a second volume effect of HES (about 20% of the volume infused). We conclude that for the correlation of fluid deficits due to trauma, hemorrhage and shock HES solutions seem to be most effective artificial plasma substitutes.(ABSTRACT TRUNCATED AT 250 WORDS)

["Small volume resuscitation"--does it open new possibilities in the treatment of hypovolemic shock?]. / "Small volume resuscitation"--Eröffnen sich damit neue Möglichkeiten in der Behandlung des hypovolämischen Schocks?

Hypertonic-hyperoncotic solutions are a supplementation to conventional fluid regimens in the management of hypovolemia due to trauma, hemorrhage and shock. In this review the possible modes of action of these solutions are discussed and their efficacy both in experimental and clinical settings is presented. Possible side effects, such as hypernatremia and possible problems in the presence of increased intracranial pressure, following administration of hypertonic-hyperoncotic solutions are discussed, as well as the reaction of normovolemic patients to such infusions.

Rapid movement kinematic and electromyographic control characteristics in males and females.

Maximally fast, self-terminated elbow flexion movements were performed by 10 male and 10 female college-aged subjects to assess potential gender-related differences in kinematics and the triphasic electromyographic (EMG) pattern. The subjects were instructed to move their forearms as fast as possible through 90 degrees of elbow flexion range of motion and stop as sharply as possible at the terminal point. An electromagnet, set to 0, 40, and 70% of each subject's maximal isometric torque, provided resistance to movement initiation and resulted in quick release movements. Surface EMG was collected from the biceps b. and triceps b. muscles. Results indicated that the males had faster movements and accelerations under all conditions. EMG records indicated that the males had faster rates of EMG rise, particularly in the triceps b., and more tightly coupled reciprocal activation. The quick release afforded faster accelerations for both groups, yet only the males moved faster throughout the full range of motion. Following the quick release, the males differed from the females by increasing the triceps b. EMG amplitude. Hence, the males were able to shorten movement time in quick release movements by increasing triceps b. activation and, thus, braking ability. These results suggest that the females were more neurally constrained than the males with respect to rapid EMG activation of the triceps b., resulting in limits in the braking process.