Combination of inhaled nitric oxide and intravenous prostacyclin for successful treatment of severe pulmonary hypertension in a patient with acute respiratory distress syndrome.

OBJECTIVE: To investigate the combination of inhaled nitric oxide (iNO) and intravenously administered prostacyclin (i.v. PGI2) in a patient with severe pulmonary hypertension and acute respiratory distress syndrome (ARDS). DESIGN: Single case study. SETTING: Intensive care unit of a university hospital. METHODS: In an ARDS patient with severe pulmonary hypertension, gas exchange and hemodynamics were measured during combined treatment with iNO and i.v. PGI2. On two subsequent days, a protocol consisting of four 20-min periods was performed: baseline, 10 ppm iNO, 10 ppm iNO plus 4 ng kg-1 min-1, and 4 ng kg-1 min-1 PGI2 alone. At the end of each period hemodynamic and gas exchange data were obtained. RESULTS: The combination of iNO and i.v. PGI2 resulted in a marked decrease in pulmonary artery pressure and a concomitant increase in cardiac output which was more pronounced than the effect of either drug alone. During iNO, as well as during the combination of iNO and i.v. PGI2, oxygenation was improved, whereas during i.v. PGI2 alone oxygenation was worse than baseline. CONCLUSION: We conclude that the combination of iNO and i.v. PGI2 might be more useful than either drug alone when severe pulmonary hypertension leading to impaired right ventricular function is present in ARDS. A systematic study of this observation is warranted.

Organochlorine residues in human breast milk: analysis through a sentinel practice network.

STUDY OBJECTIVE: The study aimed to assess through a sentinel practice network the validity of data on levels of organochlorine residues in human milk along with personal, lifestyle, and exposure variables of breastfeeding women; to compare the results of this new approach with those of the Lower Saxony breast milk surveillance programme; and to test hypotheses on potential determinants of contamination levels. DESIGN: Eligible women were enrolled into this cross sectional study by a network of 51 paediatric practices when bringing their babies for a U3 infant screening examination (4th to 6th week after delivery). Lifestyle and exposure factors were obtained by questionnaire. All milk samples were analysed for hexachlorocyclohexane, hexachlorbenzole, DDT, dieldrin, polychlorinated biphenyls (PCB) and heptachlor; half the samples were also analysed for dioxin. Analytic statistics were computed using polychotomous logistic regression (PLR). SETTING: The study was conducted in Lower Saxony, Germany, from summer 1992 to summer 1993. PARTICIPANTS: Altogether 156 primiparous, breast feeding German women, aged 25-35 years, who had been born and had grown up in West Germany, were studied. MAIN RESULTS: Compared with the regular programme, participants in this study had their milk analysed sooner after delivery and were more likely to have grown up in rural areas, less likely to have been exposed to hazardous substances, less likely to have a diet of health food, and slightly less likely to be a smoker at the time of the study. Breast milk contamination levels were comparable in both studies, and in all but two cases well below the tolerable concentrations established by the Deutsche Forschungsgemeinschaft (German Research Fellowship). After adjustment for potential confounders using polychotomous logistic regression, there were statistically significant positive associations between breast milk contamination and age (PCB, test for trend: p = 0.006), average dietary fat intake per week (dioxin, p = 0.01), and proximity of residence to hazardous sites (dioxin, p < 0.05), and negative associations between residue levels and relative body weight at the time of the study (PCB; p < 0.0001) and difference in body weight (weight minus weight before the pregnancy; PCB, p = 0.0002), respectively. CONCLUSIONS: Sentinel practice networks are a feasible and low-biased approach to population based breast milk studies. The contamination levels and associations found are biologically plausible and comparable with the results of other studies. To reduce organochlorine residue levels in human milk in the short term, breast-feeding women should be advised not to try to reduce their weight until after lactation. Public promotion of a lower dietary fat intake may reduce the lifetime accumulation of organochlorine compounds in the human body fat tissue in the long term, resulting in lower concentrations in breast milk as well.

[Results of clinical trials with the cation exchange preparation campanyl in the therapy and metaphylaxis of calcium-containing urinary calculi (author's transl)]. / Ergebnisse klinischer Prüfungen des Kationenaustauscherpräparates Campanyl in der Therapie und Metaphylaxe calciumhaltiger Harnsteine.

The efficacy of the cation exchange preparation Campanyl (T1286) was tested in the treatment and metaphylaxis of calcium-containing urinary calculi. For this purpose, in vitro experiments, animal exeriments, orienting clinical studies in 79 patients, and a long term clinical trial in 42 patients over 12 months were undertaken; 22 of the latter patients are also still being treated with the cation exchange preparation, the observation period for 15 patients being 3 1/2 years and 2 1/2 years for 7 patients. As a result of these studies a lowering of the medium calcium excretion and a reduction of calculus discharge by more than half was achieved in the patients being treated with the cation exchanger, without restriction of calcium in the diet. There was not yet seen litholysis. Serious side effects or an influence on the serum electrolytes was not recorded with Campanyl (T1286).

[MORBUS: the Sentinel Practice Network. Report on a study in South Oldenbury]. / MORBUS: Beobachtungspraxen in Niedersachsen Bericht zur Erhebung in Süd-Oldenburg.

There has been considerable public concern that emissions from intensive livestock farming may have hazardous effects on human health, particularly on the respiratory system. From October 1991 to September 1992, data on consultations of asthmatic children (up to 8 years) were obtained by a network of 25 GP and paediatric practices in South Oldenburg, a region with one of the highest livestock densities in Germany. Comparable data from a similar network of 75 practices in 3 adjacent regions (Brunswick, Hanover, Verden) with average livestock density served as a reference. In South Oldenberg, 2084 consultations of 542 asthmatic children were observed, with asthma being the reason for visit in 734 of the contacts (36%). The boy-girl ratio was 2.1:1 among index patients and 1.9:1 among consultations. Consultation rate was 25.2 contacts by asthmatic children per 1,000 total consultations of children up to 8 years in South Oldenburg, compared to 17.8 per 1,000 in Hanover, 15.7 per 1,000 in Brunswick and 13.6 per 1,000 in Verden. Consultations due to asthma scored 11.2/1,000 in South Oldenburg, 10.8/1,000 in Hanover, 7.2/1,000 in Brunswick and 6.5/1,000 in Verden. Asthmatic patients in South Oldenburg were younger (mean age 38 vs. 42 months) than those observed in the reference regions. There were no regional patterns in sex ratio, severity of asthma, respiratory allergies or atopic dermatitis. As this is an ecological study design, inferences concerning the cause of the observed regional differences can only be weak. We therefore propose a case-control study in order to obtain exposure and health data on an individual level.

[Controversies of partial nephrectomy for renal cell carcinoma : survey in the German-speaking countries]. / Kontroversen der Nierenteilresektion bei Nierenzellkarzinom : Umfrage im deutschsprachigen Raum.

BACKGROUND: The goal of this study was to evaluate how partial nephrectomy is technically performed in Germany, Austria, and Switzerland. METHODS: A one-page anonymous questionnaire was designed to evaluate the indication, the technical procedure, and the follow-up of R1 situation after partial nephrectomy. Furthermore, the size of the hospitals and their catchment areas were recorded. The questionnaire was sent to 341 clinics and a statistical analysis was performed. RESULTS: The response rate was 69 %. Up to 99 % of the clinics also perform partial resection in T1b tumors. Of those responding, 58 % perform this surgery laparoscopically, and 83 % of the surgeries are performed in warm ischemia. For the follow-up, 29 % suggest imaging within the first 6 weeks. According to this survey, maximum care clinics perform laparoscopic nephrectomy more frequently (p = 0.003). CONCLUSION: The survey of 236 hospitals performing partial nephrectomy shows great variability in the indication, technique, and aftercare of organ-preserving renal tumor surgery. It also shows that a large proportion of tumors >4 cm undergo organ-preserving surgery, many of them minimally invasive. The diverse handling with positive instantaneous section and R1 results suggest the need for further studies concerning long-term follow-up after minimally invasive surgery with R1 situation and renal tumors > T1a.

[Multiple intracerebral lesions. Identification of the causative agent by 16S rDNA-PCR]. / Multiple bakterielle Hirnabszesse. Erregernachweis mittels 16S-rDNA-PCR.

Molecular biological methods such as polymerase chain reaction (PCR) enable microbiologists to detect bacteria even if antibiotic treatment has already been started. Based on this case report of a 39-year-old man with multiple intracerebral lesions, we describe a PCR method called 16S rDNA-PCR which can be used to identify panbacterial DNA by focussing on the universal gene sequences for the bacterial 16S part of the ribosome.

[Reduced parenteral calorie administration after severe multiple injuries]. / Reduzierte parenterale Kalorienzufuhr nach schweren Mehrfachverletzungen.

15 polytraumatized patients were treated within 5 posttraumatic days with reduced calorie and normal amino-acid supply (17 kcal/kg BW as carbohydrates and 1.0 g AA/kg BW). Changes in carbohydrate and protein metabolism were investigated. The fluid volume for parenteral nutrition did not exceed 2,000 ml/day. In spite of restricted carbohydrate dosage, we still needed 28IU of insulin daily to keep the blood glucose within a range of 8-10 mmol/l. Nitrogen balance ranged between -7 and -12 g per day. The unstable serum proteins transferrin, prealbumin, retinol-binding protein and the cholinesterases remained within normal values. Plasma AA showed the familiar pattern of the posttraumatic state with elevated levels of nearly all AA including BCAA although we were using a solution with a reduced BCAA content. The free fatty acids in serum reached values 40% above normal, the triglycerides remained within normal values. Infusion therapy can be considerably simplified by reducing carbohydrate dosage. The risk of intensifying existing metabolic disturbances declines. After five posttraumatic days a combined parenteral/enteral nutrition offering more calories was possible in 70% of our patients.

[A rare complication following the insertion of a bleier-secu-clip]. / Seltene Komplikation nach Bleier-Secu-Clip-Anwendung.

A case of bilateral torsion of the fallopian tubes, the right with a hydro-salpinx is reported. This occurred 8 months following tubal sterilization following by the Bleier Secu-clips in a case of acute abdominal pain following tubal sterilization the differential diagnosis of a torsion of the fallopian tube with swelling of the infracted tube must be considered in addition to a torsion of an ovarian cyst.

PIP: A case of bilateral torsion of the right fallopian tube with hydrosalpinx is reported. This occurred 8 months following tubal sterilization with Bleier Secu-clips. Where there is acute abdominal pain following tubal sterilization, the differential diagnosis of a torsion of the fallopian tube with swelling of the infracted tube must be considered in addition to a torsion of an ovarian cyst. (author's modified)

[Postoperative changes of plasma amino acids following abdominal and vaginal hysterectomy]. / Postoperative Veränderungen der Plasma-Aminosäuren bei abdominalen und vaginalen Hysterektomien.

This study on the metabolism of amino-acids following gynaecological operations confirms, that abdominal and vaginal hysterectomies cause a so-called post-aggression metabolism. The majority of the aminograms showed changes in the metabolism of nitrogen. The aminograms were carried out by the Stein-Moore chromatography. The administration of a 3% complete solution of aminoacids changed the metabolism of the short time enzyme proteins into an anabolic phase and therefore diminished complications such-as paralytic ileus impaired wound healing, infections, and edema.

[Urea and potassium losses and changes in amino acid concentration after aortocoronary bypass operations]. / Harnstoff- und Kaliumverluste sowie Anderungen der Aminosäuren-konzentration nach aortokoronaren Bypassoperationen.

Changes in urea nitrogen excretion, renal potassium losses, and changes of amino acid concentrations in plasma following aortocoronary bypass operations were observed in 10 patients. The observation time included the preoperative day, the day of operation, and 4 postoperative days. The patients were treated with a 5% glucose solution (800-1000 ml/m2). The additional spontaneous oral intake was estimated and reached approximately 600-800 kcal and 25-30 g protein on the 3rd and 4th postoperative day. The calculated urea nitrogen loss was between -8.2 g (operation day) and -11.2 g (4th postoperative day). The concentrations of serum amino acids in plasma were below normal preoperatively. It seems possible that this is due to longer preoperative fasting because only patients with normal body weight were admitted to operation. The amino acid concentrations fell significantly to lower than normal values during the postoperative period. There were massive renal losses of potassium of about 140 mEq/day on the day of operation and on the 1st postoperative day. High parenteral substitution was necessary to avoid severe falls in serum potassium levels and possible cardiac arrythmias.

[Plasma amino acids in gynecologic operations]. / Plasmaaminogamme bei gynäkologischen Operationen.

Complete solutions with amino-acids, carbohydrates and electrolytes are able to reduce the metabolic changes of so-called postaggression-metabolism (adaptation-disease). The infusions can be used routinely for basic-partial parenteral nutrition from the end of operation treatment to beginning of oral nutrition. It is not necessary to control many parameters. Realising this practice postaggression-metabolism in gynecologic patients will be normalised soon.

Posttraumatic hypocaloric parenteral nutrition--development and clinical application.

The use of hypocaloric parenteral nutrition (HPN) is very common in surgical medicine because it allows for a standardized peripheral venous supply of nutrients. HPN causes very little stress to the posttraumatically labile carbohydrate metabolism-this applies to the use of glucose as well as to sugar substitutes: For example, mean glucose concentrations in serum on glucose administration of 2-3 g/kg/day are between 5.5 and 8.4 mmol/l. The mean dose of amino acids of 1.0-1.2 g/kg/day commonly used in HPN leads to a 50-67% improvement in the N-balance compared to an exclusive water/electrolyte supply or the administration of 2 g of carbohydrates per kg and day. Even a high caloric nutritional therapy leads to no significantly improved N-balances on the first posttraumatic days. HPN is recommended after major surgery and severe trauma in order to better estimate the individual metabolic reaction to nutritional supply prior to any consumption-orientated parenteral nutrition. HPN is also important as an adjunct to early-phase enteral nutrition. Its value after moderate surgical interventions is questionable because studies have yet to confirm HPN's clinical efficacy. HPN should not be used after minor surgery or brief periods of fasting. A possible, but as yet uncertified indication for HPN is the longer-term nutrition of very obese patients.

[Pulse cytophotometric investigations concerning the biological behaviour of laryngeal carcinomas (author's transl)]. / Impulszytophotometrische Untersuchungen zum biologischen Verhalten von Larynxkarzinomen.

25 laryngeal carcinomas were investigated by pules cytophotometry, stained with ethidium bromide after pepsination. The karyograms were interpreted as DNA-distribution curves. In diploid populations the height of the 4c-peak was taken as a measure of proliferation rate. Aneuploidy and polyploidy were estimated by camparison with human diploid material . In our material we found 13 polyploid tumors (under them 6 aneuploid populations from 7 at all). After dividing the cases into two groups (1: with slow, 2: with rapid progression) the moiety of polyploid and aneuploid tumors and the height of the 4c-peak was significantly higher in group 2. The pulse cytophotometry gives reliable additional informations showing the great variability of biological characteristics of laryngeal carcinomas. Possibly this is a basis of a more differentiated therapy.

[Standardized postoperative parenteral nutrition with a complete solution containing glucose]. / Standardisierte postoperative parenterale Ernährung mit einer glucosehaltigen Komplettlösung.

15 cholecystectomized patients were treated with a newly developed solution containing 2% amino acids, 12.5% dextrose, and electrolytes during a period of 3 postoperative days. The solution with an osmolarity of 1.060 mosmol/l was administered by peripheral veins. Blood glucose concentration did not exceed 8.8 +/- 1.3 (S.D.). Application of insulin or additional potassium was not necessary. Glucose excretion ranged from 3.3 to 7.6 percent of the infused dose. Urinary nitrogen excretion was approximately 8.4 +/- 2.2 (S.D.) g/day. From this the nitrogen balance was calculated as -2.6 g/day. There were no systemic side effects of the solution; in some cases an irritation of peripheral veins was observed.

[Metabolic changes following aorto-coronary bypass operations (author's transl)]. / Stoffwechseländerungen nach aorto-coronaren Bypass-Operationen.

Metabolic changes following aorto-coronary bypass operations were observed in 10 patients. The observation time included the preoperative day, the day of operation, and 4 postoperative days. The patients were treated with a 5% dextrose solution for a period of 2 or 3 days. Additional oral feeding beginning on the 2nd or 3rd postoperative day was possible. This spontaneous calorie and nitrogen intake was estimated. There was an urea-nitrogen loss of 6.9 +/- 3.2 g (S.D.) on the day of operation and of 13.5 +/- 6.3 g (S.D.) the 4th postoperative day. From these values the nitrogen balance was calculated to be -8 g (operation day) and -11 g (4th p.o. day). Concentrations of the plasma pseudocholinesterases, the prealbumin, and the retinolbinding protein fell significantly to lower than normal values. Glucose utilisation was severely depressed on the day of operation. There were massive losses of potassium of about 140 +/- 41 mmol (S.D.) on the day of operation and the 1st postoperative day. Serum zinc levels were significantly below normal for 2 postoperative days combined with a high urinary excretion. The increase of free fatty acids in serum postoperatively was within normal values.

The influence of posttraumatic parenteral calorie and nitrogen supply upon the cumulative nitrogen balance.

The aim of the study was to describe the influence of posttraumatic calorie and nitrogen (N) supply upon the cumulative N-balance by analyzing the literature of the past 18 years. Three groups of patients were formed, in which nutritional therapy was performed following trauma of differing severity: (1) patients following moderate trauma-N-losses 10-15 g/day; (2) patients following severe trauma--N-losses 15-20 g/day; and (3) polytraumatised patients--N-losses more than 20 g/day. The data gained for the calorie and N-supplies as well as for the N-balances in each group of patients served as a basis for the calculation of regression analyses of higher order; in these the cumulative N-balance was regarded as a function of the calorie and the N-supply: NBcum = f (C, N) Whilst for the group of polytraumatized patients only statements for a nutrient supply of about 20-30 kcal/kg BW/day and 0.2-0.3 g N/kg BW/day are possible, due to the limited data available, general statements about the different influence of calorie and N-supply can be made for nutritional therapy after moderate and major trauma; the calculated functions reveal that the N-supply influences the N-balance decisively, whereas the calorie supply exerts only a slight N-sparing effect. The mathematically calculated optimum of the N-supply after severe trauma is 0.2 g/kg BW/day, corresponding to an amino acid supply of 1.25 g/kg BW/day.

Studies on the pharmacokinetics of fluorescein and its dilaurate ester under the conditions of the fluorescein dilaurate test.

Some aspects of the pharmacokinetics of fluorescein have been studied under the conditions of the fluorescein dilaurate test (Pancreolauryl-Test) in healthy volunteers. Dependence of fluorescein excretion on urine volume was investigated in a retrospective study in 370 patients. For intravenously administered fluorescein mean Cmax was 10.9 micrograms/ml with a mean elimination half-life of 286 min. For orally administered fluorescein sodium mean Cmax was 3.5 micrograms/ml with a tmax of 120 min and a t 1/2 of 267 min. Bioavailability of fluorescein by oral administration was 99%. By contrast, fluorescein from fluorescein dilaurate showed a 56% bioavailability under the conditions of the test with a Cmax of 1.8 micrograms/ml, a tmax of 270 min and a tt 1/2 of 246 min. Following enteral absorption of fluorescein hepatic extraction and enterohepatic circulation via the bile occurs, but although the concentrations of fluorescein in the bile may exceed those in the urine the absolute amount is likely to be small. In spite of the enterohepatic circulation fluorescein cleared from the urine within 24 h indicating that no delay between Part 1 and Part 2 of the test seems necessary. However, an adequate urine flow must be maintained throughout the test since a renal clearance/urine flow relationship exists, with fluorescein excretion being increased with increasing urine volume.