Extracorporeal Membrane Oxygenation during Percutaneous Coronary Intervention in Patients with Coronary Heart Disease.

Extracorporeal membrane oxygenation (ECMO) has become an effective method in the treatment of adults and children with severe cardiac and pulmonary dysfunction that is resistant to conventional therapy. The aim of this article was to summarize an experience of ECMO usage for cardiac dysfunction, which develops in patients with coronary heart disease (CHD) during percutaneous transluminal coronary angioplasty. The study comprised a retrospective, single-center analysis of 23 patients with CHD (19 men and four women, average age 65.7 ± 12.3 years), who undertook the ECMO technique during percutaneous transluminal coronary angioplasty. A total of 13 (56.52%) patients died directly in the hospital, or 30 days after a discharge. Independent predictors of fatal outcomes were diabetes mellitus (odds ratio [OR] = 17.58; 95% confidence interval [CI] = 6.47-47.48; p = .00125), chronic renal failure (CRF) (OR = 20.81; 95% CI = 5.95-72.21; p = .00014), and damage to the right coronary artery (RCA) (OR = 25.51; 95% CI = 8.27-79.12; p = .00013). For deceased patients, the "no reflow" phenomenon was indicated in a larger percentage of cases (23.1% in the group of deceased, vs. 10% in the group of survivors). A routine connection to ECMO before the occurrence of cardiac events was significantly more often used in the group of survived patients (90% of cases) than in the deceased (p = .0000001). Diabetes mellitus, CRF, and damage to the RCA were independent predictors of mortality during percutaneous transluminal coronary angioplasty in patients with CHD. The routine use of ECMO in high-risk patients with percutaneous transluminal coronary angioplasty was a positive prognostic factor of patient survival.

Prehospital airway management using the laryngeal tube. An emergency department point of view.

BACKGROUND: Competence in airway management and maintenance of oxygenation and ventilation represent fundamental skills in emergency medicine. The successful use of laryngeal tubes (LT, LT-D, LTS II) to secure the airway in the prehospital setting has been published in the past. However, some complications can be associated with the use of a laryngeal tube. METHODS: In a nonconsecutive case series, problems and complications associated with the use of the laryngeal tube in prehospital emergency medicine as seen by independent observers in the emergency room are presented. RESULTS: Various problems and possible complications associated with the use of a laryngeal tube in eight case reports are reported: incorrect placement of the laryngeal tube in the trachea, displacement and/or incorrect placement of the laryngeal tube in the pharynx, tongue and pharyngeal swelling with subsequently difficult laryngoscopy, and inadequate ventilation due to unrecognized airway obstruction and tension pneumothorax. CONCLUSION: Although the laryngeal tube is considered to be an effective, safe, and rapidly appropriable supraglottic airway device, it is also associated with adverse effects. In order to prevent tongue swelling, after initial prehospital or in-hospital placement of laryngeal tube and cuff inflation, it is important to adjust and monitor the cuff pressure. Article in English.

[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.

Comprehensive two-dimensional gas chromatography with time-of-flight mass spectrometric detection for the determination of anabolic steroids and related compounds in nutritional supplements.

A simple and effective analytical method for the determination of anabolic steroids and related compounds in nutritional supplements is reported. Target compounds are extracted with ethyl acetate, crude extract is purified using dispersive solid-phase extraction (SPE) with primary secondary amine (PSA) as sorbent, and finally they are identified and quantified as underivatized compounds using two-dimensional gas chromatography with time-of-flight mass spectrometric detection (GCxGC-TOF MS). This method was validated for 25 steroids in two types of commercially available solid nutritional supplements: protein concentrate and creatine monohydrate. Repeatability expressed as the relative standard deviation of analyte concentration ranged from 4.1 to 20.5%. Recoveries between 70.0 and 122.6% were obtained for the target compounds except for oxymetholone in protein concentrate where the recovery was low as a result of strong interactions with PSA. Excellent linearity was obtained for six-point calibration with regression coefficients of 0.997-1.000 for all compounds. The limits of quantification ranged from 0.007 to 0.114 mg kg(-1). For a monitoring programme of 48 samples of nutritional supplements, three were positive. Nandrolone, testosterone, dehydroepiandrosterone (DHEA), 5alpha-androstan-3,17-dione, 19-norandrostendione and progesterone were found in positive samples at concentrations between 0.022 and 0.398 mg kg(-1).

Baby food production chain: pesticide residues in fresh apples and products.

During 3 years of a monitoring programme, 522 samples of fresh apples, six brands of fruit purées and various types of fruit baby food prepared from these materials were analysed. Each sample was examined for the presence of 86 GC amenable pesticide residues. The reporting limits of the procedure employed for sample analyses were in the range 0.003-0.01 mg kg(-1). Pesticide residues were detected in 59.5% of the samples of fresh apples. However, maximum residue levels (European Union MRLs) were exceeded only in 1.4% of samples. The levels of residues in 'positive' fruit purées were substantially lower, overall with residues detected in 33% of samples. Fruit baby food represented the commodity with the lowest incidence of residues being detected in only 16% of samples. The 0.01 mg kg(-1) MRL was exceeded in 9% of these products. Multiple residues were found in 25% of fresh apples and in 10% of fruit purées. None of fruit baby food samples contained more than a single residue. Organophosphorus insecticides and fungicides representing phtalimides, sulphamides and dicarboximides were the most frequently found residues. To obtain more knowledge on the fate of residues during fruit baby food production, processing experiments employing apples with incurred residues (fenitrothion, phosalone and tolylfluanid) were conducted. Washing of apples did not significantly reduce the content of pesticides. Steam boiling followed by removal of peels/stems was identified as the most efficient steps in terms of residues decrease (phosalone) or complete elimination (fenitrothion and tolylfluanid).

Association interaction and voltammetric determination of 1-aminopyrene and 1-hydroxypyrene at cyclodextrin and DNA based electrochemical sensors.

The aim of this work was voltammetric determination of 1-aminopyrene and 1-hydroxypyrene using carbon paste electrodes modified with cyclodextrin derivatives and double stranded deoxyribonucleic acid (dsDNA). The detection schemes based on a preconcentration and differential pulse voltammetric (DPV) determination at beta-cyclodextrin and gamma-cyclodextrin modified carbon paste electrode (beta-CD/CPE, gamma-CD/CPE), neutral beta-cyclodextrin polymer and carboxymethyl-beta-cyclodextrin polymer modified screen-printed electrode (beta-CDP/SPE, beta-CDPA/SPE) and dsDNA modified screen-printed electrode (DNA/SPE) are proposed for the trace determination of studied analytes within the concentration range from 2 x 10(-8) to 4 x 10(-7) mol dm(-3) and from 2 x 10(-7) to 4 x 10(-6) mol dm(-3) with the limits of quantification down to 10(-8) mol dm(-3). Depending on pH, 1-aminopyrene interacts with both surface attached CD and DNA by electrostatic bonds and supramolecular complexation while 1-hydroxypyrene associates with the CD hosts via complexation. The 1-aminopyrene interaction with dsDNA was confirmed by fluorimetric measurements in the solution phase using a competing DNA-TO-PRO-3 dye complex. In addition, the effect of temperature on this association was investigated using an electrically heated DNA-modified carbon paste electrode (DNA/CPE).

Iridium 192 high-dose-rate brachytherapy--a useful alternative therapy for localized prostate cancer?

We report on a novel protocol involving iridium 192 high-dose-rate brachytherapy and follow-up of up to 130 months in patients with prostatic carcinoma. Using regional anesthesia, five to seven hollow needles are placed within the prostate by perineal puncture under ultrasound guidance. A 9-Gy prostate dose is applied followed by 30 min of hyperthermia (since 1991). This treatment is repeated once after 7 days; 2 weeks later, 18 x 2-Gy external beam radiation (small-field prostate) is added as percutaneous dose saturation. Since 1984 we have treated 40 patients with this protocol. Local tumor control was achieved by means of prostatic biopsy at 18 months after therapy and determination of prostate-specific antigen (PSA) values in about 70% of the patients; after a mean follow-up period of more than 6 years (16-130 months), 80% of the patients show either no evidence of disease or stable disease. We therefore conclude that iridium 192 high-dose-rate brachytherapy is a useful alternative in the treatment of localized prostate cancer in patients who are not eligible for radical prostatectomy.

Locally advanced rectal cancer: resection and intraoperative radiotherapy using the flab method combined with preoperative or postoperative radiochemotherapy.

PURPOSE: Surgery often fails to achieve local control in advanced rectal cancer. Additional measures are necessary to prevent local recurrence. The aim of this study was to evaluate intraoperative radiation therapy (IORT) (flab technique) combined with preoperative or postoperative radiochemotherapy. PATIENTS/METHODS: IORT is performed using a flexible flab containing hollow plastic tubes that are connected to a multichannel afterloading device with a 370 Gbq-192-Ir source. Patients receive an intraoperative dose of 15 Gy. Target volumes were measured in a cadaver experiment. From 1989 to 1993, 38 patients were included in this study. Nineteen patients were staged as T3 tumors by preoperative endosonography (Group I) and 19 as T4 tumors (Group II). Patients in Group I underwent resection (abdominoperineal resection (APR), 16; anterior resection, 3) and IORT, followed by postoperative radiochemotherapy (50 Gy/5-fluorouracil), whereas patients in Group II received preoperative radiochemotherapy (40 Gy/5-fluorouracil) followed by resection (APR, 18; anterior resection, 1) and IORT. Mean follow-up was 25.5 months. RESULTS: Operative radicality in Group I was RO (13), R1 (3), and R2 (3), and in Group II it was RO (14), R1 (3), R2 (2). R2 resections were attributable to preoperative undetected distant metastases. Perioperative mortality was 0 percent in Group I and 10.5 percent (n = 2) in Group II. Postoperative morbidity was 53 percent (n = 10) in Group I and 84 percent (n = 16) in Group II with delayed sacral wound healing being the predominant problem. Stenosis of the ureter occurred in two patients (Group II). Late or persistent therapy-related complications were seen in two patients in Group I and in six patients in Group II. Local recurrence developed in three patients in Group I (15.8 percent) and in two patients in Group II (10.5 percent). Survival data do not reach statistical significance between the two groups because of small numbers but show a favorable trend for the preoperative radiochemotherapy group. When compared with a matched historical control group of patients receiving resection only, adjuvant/neoadjuvant radiotherapy with resection/IORT improves survival significantly. CONCLUSION: The flab method is a simple but especially practical technique for IORT in the pelvis. Adjuvant/neoadjuvant therapy combined with resection/IORT is associated with high morbidity but acceptable mortality. Preliminary survival data are encouraging and call for a controlled prospective randomized trial.

[The flab method of intraoperative radiotherapy]. / Die Flabmethode zur intraoperativen Bestrahlung.

PURPOSE: Improvement of the relapse rate by locally increasing the tumor dose. METHODS: To increase the dose in the tumor bed a method for intraoperative radiation therapy has been developed. The radiation is applied using a high-dose-rate afterloading system. Flexible plastic flabs are used as applicators. Each flab contains tubes for the alterloading source. The size of the applicator is chosen to correspond to the size of the target volume. In the dosage system we use the dwell times at all source positions are equal. The dwell time has been precalculated to give the reference dose at the reference position which is located at the surface of the flab in the center of the target volume. RESULTS: The dose distributions around the flab have been calculated as a function of the thickness of the flab. If the source is not placed on a regular grid within the applicator due to a non ideal positioning of the tubes within the applicator, the dose distribution is not altered too much, if the positioning error is not larger than +/- 2 mm. The influence of a curvature of the flab has been evaluated and methods to decrease the dose at critical organs are discussed. CONCLUSION: The flab methods for IORT is safe and easy and has been demonstrated for more than 150 cases. This method allows the increase in tumor dose even in regions which are not easily treated by electron IORT due to the rigid electron applicators. Because of the rapid dose fall off, the flab method can only be used for flat target volumes like the tumor bed.

Magnetic resonance imaging of spinal cord syndromes.

Thirty-four patients with intramedullary space-occupying lesions or cord compression syndromes were examined with a resistive and two different superconductive magnetic resonance (MR) imaging units. Studies were done primarily by the spin-echo (SE) technique and in the majority of patients different pulse sequences were used. Images with short echo-time (TE) and short recovery-time (TR) were best for demonstration of spinal cord anatomy, for depicting cystic portions in intramedullary tumours and for showing syringomyelia. Solid intramedullary tumours showed normal cord signal intensity. Images with prolonged TE and TR predominantly enhanced CSF signal intensity and, to a more considerable extent, solid intramedullary tumours. Thus, the diameter of the subarachnoid space and the presence of a solid intramedullary tumour, not concomitant with a significant enlargement of the spinal cord, could only be recognized on these prolonged SE images. Major advantages of MR in comparison to CT are that the spinal cord can be imaged in the sagittal plane and that beam hardening artifacts do not occur; in comparison to myelography the cord can be imaged directly by MR. Partial volume is a major limitation of MR, not only in the preferably applied sagittal plane. The choice of slice thickness adequate to the diameter of the lesion and straight positioning of the patient for sagittal single slice midline images are fundamental for reliable MR investigations. Another limitation to MR is that cortical bone gives no signal. The actual diameter of the spinal canal therefore cannot be correctly appreciated and consequently it was difficult or impossible to assess spinal stenosis.