Evaluation of a physical activity promotion program in primary care.

BACKGROUND: Physical inactivity increases the risk of many chronic disorders. It is not clear which strategies are the most appropriate to enable people to adopt a more active lifestyle. Randomized controlled trials have found that brief advice from GPs supported by written material had a significant positive effect on patient's physical activity. The pilot project 'Move for Health and the Environment' translated this evidence into a program suitable for the real-life situation of busy practices. The aim of this study was to evaluate the change in physical activity level of the participating patients 1 year after the intervention. METHODS: Patients aged 16-65 years completed a screening questionnaire before consultation with their physician. Insufficiently active patients were offered an information leaflet and a voucher for a physical activity counselling session. One year later, all inactive patients and a random selection of the active were re-contacted and invited to answer identical questions. RESULTS: A total of 1239 (73.9%) returned the follow-up questionnaire. In all, 37.3% of the formerly inactive patients met the threshold of sufficient activity at follow-up, whereas 20.3% of the previously active no longer did. Formerly inactive patients reported an increase of 58.8 minutes/week of moderate and 34.6 minutes/week of vigorous activity and spending more time walking and cycling. Formerly active patients reported less time spent in moderate activities. CONCLUSIONS: Systematic counselling in primary care encouraged insufficiently active patients to adopt a more active lifestyle. Yet it became evident that active patients also need counselling to maintain their activity levels.

[Epidural cooling. Neuroprotective treatment of thoracoabdominal aortic aneurysms]. / Epidurale Kühlung. Neuroprotektive Versorgung thorakoabdominaler Aortenaneurysmen.

The risk of paraplegia and paraparesis during thoracoabdominal aneurysm surgery still represents a major threat. In 1993, Cambria and coworkers applied for the first time a method of regional spinal cord hypothermia by epidural cooling and significantly diminished the rate of neurological deficits. In this article the first clinical application of this neuroprotective method in Germany will be reported. This neuroprotective method was used in seven patients who underwent elective thoracoabdominal aortic aneurysm repair. The spinal cord was cooled with ice-cold saline via an epidural catheter during surgical repair. Cerebrospinal fluid pressure was measured on-line via a spinal catheter and controlled using active cerebrospinal fluid drainage. Of these seven patients, four showed no postoperative neurological deficit and were released from hospital. The other three patients died in the intra-operative or post-operative phase due to complications other than spinal cord injury arising from pre-existing comorbid conditions. The described method of epidural cooling represents a preliminary experimental method, which might reduce spinal cord injury during surgical repair of thoracoabdominal aneurysms.

Patient and physician acceptance of a campaign approach to promoting physical activity: the "Move for Health" project.

QUESTIONS UNDER STUDY: Physical inactivity increases the risk of many chronic disorders. There is clear evidence that primary care-based interventions to promote physical activity may be effective under controlled research conditions. Yet little is known how this evidence translates into routine primary care practice. The pilot project "Move for Health" tested recruitment of family physicians for a primary prevention project and evaluated the feasibility of systematic assessment and discussion of patients' physical activity taking daily practice routine into account. METHOD: Patients aged 16-65 years completed a screening questionnaire during 8 two-week campaigns in 2004-5. Physicians evaluated and discussed questionnaire responses and offered a physical activity information leaflet and/or a voucher for a special physical activity counselling session to all inactive patients. Participating practices were interviewed to assess their experience of the project. RESULTS: 40 primary care physicians were motivated to participate. Recruitment was most effective through personal contacts of the project team's colleagues. 67% of the patients completed the screening questionnaire and 92% of these questionnaires were discussed during consultation. 83% of patients accepted the leaflet or the voucher, but only a minority of patients attended the special counselling session. With increasing age and readiness for behavioural change patients were more likely to attend the counselling session. CONCLUSIONS: A campaign approach consisting of systematic screening and brief counselling of insufficiently active patients in general practice is feasible. Participating practices considered the amount of work associated with the project to be manageable and 1-3 counselling campaigns per year to be feasible if the project runs for several years.

[Sevoflurane: metabolism and toxicity]. / Sevofluran: Metabolismus und Toxizität.

The new inhalational anesthetic sevoflurane is biotransformed by approximately 5%. Serum fluoride concentrations resulting from transformation mainly depend on rate of hepatic defluorination, total amount of anesthetic given and the solubility of the volatile anesthetic, as expressed by its blood gas partition coefficient. Enflurane is metabolized by 5-11%. However subsequent peak fluoride levels are lower than after sevoflurane which is a consequence of its lower rate of hepatic defluorination. To date numerous studies have examined the nephrotoxic potential of the sevoflurane degradation product fluoride. However, fluoride-related toxicity was not observed, neither in clinical or in animal studies, nor after prolonged administration or in patients with preexisting renal disease. New insights into intrarenal metabolisation of volatile anesthetics may well explain absence of nephrotoxicity after sevoflurane. The threshold of fluoride nephrotoxicity of 50 mumol/l, which has been empirically found after methoxyflurane, and which is still listed in many medical textbooks, can not be assumed a marker of nephrotoxicity after isoflurane, enflurane or sevoflurane. Therefore also, the elevated serum fluoride concentrations, as regularly obtained after anesthesia with sevoflurane are devoid of clinical significance. In addition, exposure to sevoflurane or its metabolites is not associated with hepatic toxicity.

[New inhalation anesthetics]. / Neue Inhalationsanästhetika.

Recently, two new halogenated volatile anaesthetics, sevoflurane and desflurane, have been approved for clinical use in Germany. Their low solubility in blood is the most important common property, and this represents the most obvious difference from the inhalational anaesthetics currently used. Extensive clinical and experimental evaluations have confirmed the superior pharmacokinetic properties predicted. Both sevoflurane and desflurane provide more rapid emergence from anaesthesia, permit easier titration of the anaesthetic dose during maintenance and offer more rapid recovery from anaesthesia. For sevoflurane, there are additional advantages: a pleasant odor, negligible airway irritation, and excellent pharmacodynamic characteristics that even provide cardiovascular stability comparable to isoflurane. A certain disadvantage and source of potential nephrotoxicity result from the metabolism of sevoflurane (2-5%) to anorganic fluoride and degradation to compound A in carbon dioxide absorbents. The extensive clinical data reported to date have revealed no evidence that sevoflurane has adverse renal effects. New insight into the pathomechanism of nephrotoxicity associated with either production of fluoride or compound A may well support clinical experience. Desflurane strongly resists in vivo metabolism and because of this it appears to be devoid of toxicity. Nevertheless, potential side-effects may result from degradation in dry absorbents and subsequent release of CO, from its extreme pungency and irritating airway effects. Thus, desflurane is not recommended for induction of anaesthesia, especially in children. The tendency for desflurane transiently to stimulate sympathetic activity, especially at concentrations above 1.0 MAC, limits its application in patients with cardiac disease.

[Fluoride-induced nephrotoxicity: factor fiction?]. / Fluoridinduzierte Nephrotoxizität: Fakt oder Fiktion?

In the 1960s, the widespread use of the inhalational anaesthetic methoxyflurane was associated with a significant occurrence of postoperative renal dysfunction. This was attributed to hepatic biotransformation of methoxyflurane and subsequent release of inorganic fluoride ions into the circulation. Based upon the clinical experience with methoxyflurane, serum fluoride concentrations exceeding 50 mumol/l were considered to be nephrotoxic. Without further reevaluation, this 50 mumol/l threshold was subsequently applied to other fluorinated anaesthetics as well. Enflurane and even isoflurane may, when used during prolonged operations, also yield anorganic fluoride levels in excess of 50 mumol/l. Nevertheless, no cases of renal dysfunction attributable to prolonged use of these anesthetics have been reported. About 4% of the new inhalational anaesthetic sevoflurane is metabolized, and fluoride concentrations exceeding those after enflurane are frequently measured. Numerous studies have examined the nephrotoxic potential of sevoflurane degradation products. However, fluoride-related toxicity has been observed neither in animal nor in clinical studies, including prolonged administration and patients with pre-existing renal disease. New insights into the intrarenal metabolisation of volatile anaesthetics may well explain the absence of nephrotoxicity after sevoflurane. The threshold for fluoride nephrotoxicity of 50 mumol/l, still given in many medical text-books, can no longer be applied as an indicator of nephrotoxicity after isoflurane, enflurane or sevoflurane. Therefore, the elevated serum fluoride concentrations consistently recorded following anaesthesia with sevoflurane are devoid of clinical significance.

Renal function and serum fluoride concentrations in patients with stable renal insufficiency after anesthesia with sevoflurane or enflurane.

Sevoflurane is metabolized to hexa-fluoro-isopropanol and inorganic fluoride by the human liver. Its use as an anesthetic may lead to peak plasma fluoride concentrations exceeding those seen after enflurane. Although there is no nephrotoxicity after sevoflurane anesthesia in humans with normal kidneys, those with chronically impaired renal function might be at increased risk because of increased fluoride load due to prolonged elimination half-life. In this study, measures of renal function after sevoflurane anesthesia were compared to those after enflurane in patients with chronically impaired renal function. Forty-one elective surgical patients with a stable preoperative serum creatinine concentration > or = 1.5 mg/dL were randomly allocated to receive sevoflurane (n = 21) or enflurane (n = 20) at a fresh gas inflow rate of 4 L/min for maintenance of anesthesia. Serum fluoride concentrations were measured by ion-selective electrode. Renal function (creatinine, urea, sodium, osmolality) was assessed in serum and urine preoperatively and for up to 7 days postoperatively. Peak serum inorganic fluoride concentrations were significantly higher after sevoflurane than after enflurane anesthesia (25.0 +/- 2.2 vs 13.3 +/- 1.1 microM; mean +/- SEM). Laboratory measures of renal function Laboratory measures of renal function remained stable throughout the postoperative period in both groups. No patient suffered a permanent deterioration of preexisting renal insufficiency and none required dialysis. Thus, neither sevoflurane nor enflurane deteriorated postoperative renal function in these patients with preexisting renal insufficiency. There is no evidence that fluoride released by metabolism of sevoflurane metabolism worsened renal function in these patients with stable, permanent serum creatinine concentrations more than 1.5 mg/dL.(ABSTRACT TRUNCATED AT 250 WORDS)