Epistaxis in anticoagulated patients: Fewer hospital admissions and shorter hospital stays on rivaroxaban compared to phenprocoumon.

OBJECTIVES: Treatment of epistaxis in patients on anticoagulants is challenging and associated with higher admission rates and longer hospital stays compared with patients without anticoagulation. However, there is little information about epistaxis in patients taking new direct oral anticoagulants such as rivaroxaban compared with patients on traditional vitamin K antagonists such as phenprocoumon. DESIGN: Retrospective cohort study. SETTING: The study was conducted at the emergency department of the University Hospital Inselspital, Bern, Switzerland. PARTICIPANTS: All admissions to the emergency department of the University Hospital Inselspital, Bern, Switzerland from 1st July 2012 to 30th June 2016 with non-traumatic epistaxis on anticoagulant therapy with phenprocoumon or rivaroxaban were included. MAIN OUTCOME MEASURES: We compared clinical outcome parameters (admission rates, length of hospital stay and mortality) for both anticoagulant groups. RESULTS: We included 440 patients with epistaxis, 123 (28%) on rivaroxaban and 317 (72%) on phenprocoumon. Fewer hospital admissions and shorter hospital stays were found in patients under rivaroxaban (12 (10.4%) vs 57 (18.0%) patients, P=.033; 0.7±2.2 vs 1.5±3.7 days, P=.011) compared with phenprocoumon. Anterior epistaxis was more common in the rivaroxaban group in contrast to posterior epistaxis in patients on phenprocoumon (74 (60.2%) vs 139 (43.8%) patients, P=.002; 7 (5.7%) vs 39 (12.3%) patients, P=.042). CONCLUSIONS: Our data suggests that epistaxis on direct oral anticoagulation with rivaroxaban is associated with shorter hospital stays and fewer hospital admissions than epistaxis on vitamin K antagonist phenprocoumon.

Genetic algorithm for shift-uncertainty correction in 1-D NMR-based metabolite identifications and quantifications.

MOTIVATION: The analysis of metabolic processes is becoming increasingly important to our understanding of complex biological systems and disease states. Nuclear magnetic resonance spectroscopy (NMR) is a particularly relevant technology in this respect, since the NMR signals provide a quantitative measure of the metabolite concentrations. However, due to the complexity of the spectra typical of biological samples, the demands of clinical and high-throughput analysis will only be fully met by a system capable of reliable, automatic processing of the spectra. An initial step in this direction has been taken by Targeted Profiling (TP), employing a set of known and predicted metabolite signatures fitted against the signal. However, an accurate fitting procedure for (1)H NMR data is complicated by shift uncertainties in the peak systems caused by measurement imperfections. These uncertainties have a large impact on the accuracy of identification and quantification and currently require compensation by very time consuming manual interactions. Here, we present an approach, termed Extended Targeted Profiling (ETP), that estimates shift uncertainties based on a genetic algorithm (GA) combined with a least squares optimization (LSQO). The estimated shifts are used to correct the known metabolite signatures leading to significantly improved identification and quantification. In this way, use of the automated system significantly reduces the effort normally associated with manual processing and paves the way for reliable, high-throughput analysis of complex NMR spectra. RESULTS: The results indicate that using simultaneous shift uncertainty correction and least squares fitting significantly improves the identification and quantification results for (1)H NMR data in comparison to the standard targeted profiling approach and compares favorably with the results obtained by manual expert analysis. Preservation of the functional structure of the NMR spectra makes this approach more realistic than simple binning strategies.

Evaluation of a new point-of-care test for influenza A and B virus in travellers with influenza-like symptoms.

Point-of-care (POC) tests for influenza facilitate clinical case management, and might also be helpful in the care of travellers who are at special risk for influenza infection. To evaluate influenza POC testing in travellers, a new assay, the ImmunoCard STAT! Flu A and B, was used to investigate travellers presenting with influenza-like symptoms. Influenza virus infection was diagnosed in 27 (13%) of 203 patients by influenza virus-specific PCR and viral culture. The POC test had sensitivity and specificity values of 64% and 99% for influenza A, and 67% and 100% for influenza B, respectively. Combined sensitivity and specificity were 67% and 99%, respectively, yielding positive and negative predictive values of 95%, and positive and negative likelihood ratios of 117 and 0.34, respectively. The convenient application, excellent specificity and high positive likelihood ratio of the POC test allowed rapid identification of influenza cases. However, negative test results might require confirmation by other methods because of limitations in sensitivity. Overall, influenza POC testing appeared to be a useful tool for the management of travellers with influenza-like symptoms.

Bilateral lingual artery stenosis: A rare, late complication of chemoradiotherapy.

INTRODUCTION: Carotid artery stenosis following radiotherapy (RT) is a known risk factor for the development of cerebrovascular disease with a risk of subsequent stroke or transient ischaemic attack. In contrast, small vessel disease in the neck following RT has been more rarely described. CASE REPORT: The authors report the case of a 61-year-old man who developed partial lingual necrosis 4 years after surgery and postoperative chemoradiotherapy for squamous cell carcinoma of the floor of the mouth. Contrast-enhanced CT scan confirmed subtotal to total occlusion of both lingual arteries. Surgical debridement of the necrosis allowed complete cure of the lesions. DISCUSSION: Small vessel disease is a possible complication in patients treated by RT for head and neck cancer. Although the risk of these complications is not directly related to the total radiation dose, higher doses appear to accelerate the development of vascular lesions. Practitioners must be aware of the possibility of these complications, especially in patients surviving more than 5 years.

The effect of intrathecal baclofen on electrical muscle activity in spasticity.

The efficacy of intrathecally administered baclofen was demonstrated in three patients with different types of muscular hypertonia (supraspinal rigidity, spasms shortly after spinal trauma, spasms for many years induced by multiple sclerosis) using integrated electromyography. Reduction of muscular electrical activity was accompanied by clinical improvement during long-term infusion via an implanted pump. The three patients have been observed for more than 1 year, during which time the antispastic activity of intrathecally infused baclofen has remained stable. Intrathecal application of baclofen may be considered as a possible alternative to surgery.

[Serum endotoxin level in the course of open peritonitis treatment]. / Serum-Endotoxin-Spiegel während des Verlaufs der offenen Peritonitis-Behandlung.

In 27 patients with severe diffuse purulent or fecal peritonitis planned relaparotomies with peritoneal lavage or continuous dorsoventral lavage with open abdomen were performed after surgical treatment of the primary infection. During the course of the lavage treatment serum endotoxin was measured daily. The endotoxin-induced liberation of lysosomal proteases was studied by determining the elastase from polymorphonuclear leucocytes. 16 surviving patients showed decreasing endotoxin levels and decreasing elastase concentrations during the course of abdominal lavages. Planned peritoneal lavage and continuous dorso-ventral lavage seem to have the same potency in eliminating endotoxin from the infected peritoneal cavity. In letal courses endotoxinemia either persisted at high levels or even progressed inspite of lavage treatment.

Sensitivity and specificity of a new commercial enzyme-linked immunoassay kit for detecting Entamoeba histolytica IgG antibodies in serum samples.

The study presented here was conducted to evaluate the performance of the newly available RIDASCREEN Set (R-Biopharm AG, Darmstadt, Germany) for the detection of immunoglobulin G antibodies against Entamoeba histolytica. The sensitivity and specificity of this new enzyme-linked immunosorbent assay were evaluated using a panel of sera from 239 individuals. The assay was positive for 43 of 44 patients with invasive amebiasis, including all 18 patients with amebic liver abscess, while it was negative for 190 of 195 adult controls who were either healthy individuals or patients with other parasitic diseases. The kit was found to be highly specific (97.4%) and sensitive (97.7%) for detecting antibodies against E. histolytica in humans. Although antibody titers in patients with amebic liver abscess tend to be higher on average than in patients with invasive amebiasis, it is not possible to distinguish the two forms solely based on the results of this commercial test.

[Pathophysiology of thoracic injuries]. / Pathophysiologie der Thoraxverletzungen.

A systematic review of the pathophysiology of thoracic injuries has not yet been published. As an introduction all kinds of injuries of the chest are listed. The causes of the so called "acute thorax" are described. Furthermore three cardinal symptoms which occur after thoracic trauma are distinguished and explained: hemorrhagic shock, the combination of venous congestion and low cardiac output (which is very similar to cardiogenic shock) and hypoxia. A short description of the pathophysiology of the acute respiratory distress syndrome (ARDS) is given. The review ends with some remarks to the therapeutic management of chest injury and to the aftereffects of initial therapy.

[Airway pressure and transcutaneous O2 and CO2 partial pressure as monitoring measurements for high-frequency jet ventilation?]. / Atemwegsdruck und transkutane O2- und CO2-Partialdrücke als Monitorgrössen für die High Frequency Jet-Ventilation?

Two different methods of measuring airway pressures (n = 7), and the usefulness of transcutaneous pO2 and pCO2 measurement (n = 9) in monitoring High Frequency Jet Ventilation (HFJV), were investigated in critically ill patients. Airway pressures obtained by tip manometer from different points within trachea and mainstem bronchi during HFJV (f = 100/min, inspiratory time 40%, FIO2 0,4, minute volume 25.6 +/- 5.2 l) were nearly identical with pressures obtained from the integrated pressure line of HI-LO-JET endotracheal tubes (R = 0.9638). There was no difference between proximal and peripheral airway pressures. When using a PEEP-valve, rather high values of PEEP may occur due to gas trapping. There was sufficient correlation between transcutaneous and arterial pO2 (R = 0.7573) and poor correlation between transcutaneous and arterial pCO2 (R = 0.4987). paO2 values were 51.1% above, paCO2 values 33.4% below transcutaneous values. Transcutaneous measurement of pO2 and pCO2 is only an additional method in monitoring HFJV which can reveal rough trends but cannot replace blood gas analysis.

[High frequency jet ventilation in patients with acute respiratory failure. A comparison with conventional artificial respiration]. / Die High Frequency Jet-Ventilation bei Patienten mit akuter Ateminsuffizienz. Ein Vergleich mit konventioneller Beatmung.

The major advantage of High Frequency Jet Ventilation (HFJV) in the treatment of patients with ARDS was commonly seen in better oxygenation and lower airway pressures, compared to conventional ventilation. Furthermore, HFJV seemed to be successful even in those patients in whom conventional ventilation had failed. We compared HFJV (f = 100/min, inspiratory time 40% to 50%) to conventional ventilation (f = 10/min, PEEP 5 to 10 cm H2O). For mean airway pressure and FIO2 equal values were chosen in both ventilatory modes. With HFJV paO2 was significantly (P less than 0.01) lower (82.2 +/- 28.2 mmHg compared to 139.2 +/- 23.5 mmHg), intrapulmonary shunting higher (29.2 +/- 19.6% compared to 15.3 +/- 6.4%) than with CV. Ventilatory volume required for normocarbia under HFJV was 25.6 +/- 5.4 l/min approximately equal to 341 +/- 81.8 ml/kg B.W. Pulmonary artery pressure (PAP 25.0 +/- 5.0 mmHg compared to 19.9 +/- 4.7 mmHg), central venous pressure (10.5 +/- 4.2 mmHg compared to 8.8 +/- 3.0 mmHg), pulmonary capillary pressure (13.3 +/- 4.4 mmHg compared to 11.3 +/- 3.7 mmHg), pulmonary vascular resistance (131.4 +/- 55.0 dyn . s . cm-5 compared to 96.7 +/- 33.7 dyn . s . cm-5) and right cardiac work index (1.38 +/- 0.55 kg . m/m2 compared to 1.05 +/- 0.33 kg . m/m2) were significantly increased (P less than 0.01) under HFJV. The other haemodynamic variables showed no difference between the two ventilatory modes. HFJV was inferior to conventional artificial ventilation in all patients and caused severe hypoxia in several patients, leading to pulmonary vasoconstriction and increased work of the right heart.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of a new apparatus for determining sodium and potassium via ion-selective electrodes]. / Evaluierung eines neuen Gerätes zur Natrium- und Kaliumbestimmung mittels ionenselektiver Elektroden.

Evaluation of an apparatus for the direct measurement of sodium and potassium by means of ion-selective electrodes yielded very good results. This apparatus is notable for excellent linearity. It possesses a low detection threshold, the lowest identification limit being 4.43 mmol./l. for sodium and 0.21 mmol./l. for potassium. The sensitivity is high, since it is approximately 1.5 mmol./l. for sodium in whole blood and approximately 0.15 mmol./l. for potassium. On checking the accuracy of the instrument, a mean recovery of 100% was seen for both electrolytes. An examination of the precision of the instrument yielded, in serial determinations of sodium, variation coefficients between 0.2 and 0.4%, and in case of potassium, variation coefficients around 1%; even in respect of day-to-day precision, all variation coefficients were definitely below 5%. Hence, the overall precision of the apparatus can be rated as good. However, when using whole blood samples anticoagulated with sodium heparinate solution, it is necessary to take the dilution effect into account when arriving at the potassium value.

[Value of morphine derivatives administered by the peridural route per- and postoperatively]. / L'intérêt des dérivés morphiniques par voie péridurale en per et post-opératoire.

The existence of opiate receptors in the spinal cord led the authors to seek a clinical application. 1 - A peroperative injection of morphine was administered in 170 cases: 0.005 mg/kg of fentanyl in 105 cases and 0.05 mg/kg of morphine in 65 cases. In addition to usual surveillance (blood pressure, heart rate and central venous pressure), more extensive haemodynamic investigations were undertaken in 20 patients using a Swan-Ganz catheter. Blood concentrations (11 cases) and CSF concentrations (2 cases for each time of measurement) were determined in the case of fentanyl. In 20 patients (10 of whom had received fentanyl and 10 morphine) there was sophisticated cardio-respiratory surveillance postoperatively. 2 - 0.05 mg/kg or morphine (404 cases), 50 mg of pethidine (10 cases) and 0.1 mg of fentanyl (10 cases) were injected postoperatively. A comparison was made of the analgesia obtained. After three types of anaesthesia: epidural with bupivacaine with intubation (10 cases), halothane with intubation (10 cases) and neuroleptanaesthesia (10 cases), an injection was given of 0.05 mg/kg of morphine, with cardiorespiratory surveillance. Results were as follows: 1 - There were no significant variations in haemodynamic parameters peroperatively, indicative of adequate analgesia. Blood concentrations of fentanyl were as follows: 3.2 +/- 2.1 ng/ml after 10 minutes, 2 +/- 1.7 ng/ml after one hour, 1.4 +/- 1 ng/ml after two hours and 0.4 +/- 0.3 ng/ml after four hours. CSF concentrations were much higher; 34 ng/ml after one hour, 30 ng/ml after two and three hours and 25 ng/ml after four hours. No cardio-respiratory depression was seen after the peroperative injection of morphine. 2- The duration of analgesia following a postoperative injection of a morphine derivative was as follows: morphine 17.3 +/- 3.9 hours, pethidine 3.5 +/- 0.5 hours, and fentanyl 5.1 +/- 0.7 hours. The epidural injection of morphine after neuroleptoanaesthesia caused respiratory depression in two of the 10 cases, with a rise in pCO2 of 0.45 and 0.52 KPa. The results are discussed and compared with those of other authors. In conclusion, the authors emphasize the advantages of this method which makes it possible to obtain with smaller doses analgesia of longer duration than following a systemic injection of morphine, whilst at the same time decreasing the side effects.

[Epidural opiate analgesia (EOA), compatibility of opiates with tissue and CSF (author's transl)]. / Epidurale Opiatanalgesie Gewebe- und Liquorverträglichkeit der Opiate.

To estimate the compatibility of opiates with tissue we measured the pH of opiate solutions in comparison to local anaesthetics. Piritramide and opium solutions revealed very low pH values (3.96 and 3.38). Two patients, who underwent EOA for the last two and a half three weeks before their death showed, macroscopically and microscopically, no signs of effect on tissue. The examination of the compatibility of opiate solutions and local anaesthetics with CSF showed a deproteinisation of CSF after Piritramide and a rise of opacity after opium. Of the local anaesthetics tested, only Editocaine interferred by crystallizing of the substance. In conclusion, all opiates except piritramide and opium can be used in EOA. In our opinion bupivacaine but not editocaine can be used for spinal anesthesia. All opiates tested can be mixed either with bupivacaine or editocaine.

[Influence of different preinjections on unfavourable side-effects of succinylcholine-induced block (author's transl)]. / Einfluss unterschiedlicher Vorinjektionen auf unerwünschte Begleiterscheinungen des Succinylcholinblocks.

Pretreatment with a subparalytic dose of a nondepolarizing relaxant is used to prevent side-effects of the succinylcholine (Sch) dose needed for intubation. On the other hand small doses of Sch (self-taming) or lignocaine are recommended to avoid in part reversal of the Sch-induced block caused by nondepolarizing relaxant. 50 patients received different preinjections before Sch-induced relaxation: 2 mg alcuronium, n = 10; 1 mg pancuronium, n = 10; 0.1 mg/kg bw Sch, n = 10; 1 mg/kg bw lignocaine, n = 10; no pretreatment, n = 10. Injection of small doses of Sch or lignocaine prior to the Sch dose needed for intubation, offered no advantage in comparison to the conventional method of pretreatment with nondepolarizing relaxant, concerning intensity and duration of the relaxation, conditions for intubation and muscle fasciculations. After preinjection of Sch or lignocaine a similar rise of serum potassium was observed as without preinjection (0.4-0.5 mEq/l).

Desflurane inhibits platelet function in vitro similar to halothane.

BACKGROUND AND OBJECTIVE: The effects of the volatile anaesthetic desflurane on platelet activation in vitro were studied and compared to those of halothane. METHODS: Platelet-rich plasma was exposed to 2 MAC of desflurane or halothane, or air only and stimulated by platelet agonists ADP (2.5, 5 and 10 micromol L(-10) and collagen (10 microg m(L-1)). Platelet response was measured by Born aggregometry (maximum aggregation response, area under the curve) and flow cytometry (mean channel fluorescence, percentage of CD62P-positive cells, index of platelet activation for positive platelets). RESULTS: Aggregation response was significantly reduced in platelets exposed to desflurane or halothane; the inhibitory effect was more pronounced when the areas under the curve were analysed: values ranged from 37.5% to 73.3% of control samples for ADP stimulation and 77.1% to 79.8% for collagen stimulation. CD62P expression before and after stimulation with receptor agonists was not statistically different in platelets exposed to desflurane, halothane or air. CONCLUSIONS: By impairing platelet aggregation while not affecting alpha-degranulation desflurane has a differential effect on various aspects of platelet activation similar to halothane. Our results are compatible with the hypothesis of an impairment of platelet thromboxane receptor signalling by halothane. We suggest a similar mechanism for desflurane.

[A specific fully enzymatic method for creatinine: reference values in serum (author's transl)]. / Referenzwerte für Kreatinin im Serum, ermittelt mit einer spezifischen enzymatischen Methode.

Reference values for creatinine in serum were established using a fully enzymatic method, adapted to a discontinuous analyzer. Our reference group included 250 females and 215 males (blood donors, hospital staff and patients) aged 18-70 years. Up to 60 years, creatinine concentration did not depend on age, but there was a significant difference between the creatinine concentrations of women and men. We propose reference ranges for creatinine in serum (95% range) of 44-80 mu mol/l for women and of 44-97 mu mol/l for men.

[Enzymatic assay of creatinine in serum: comparison with Jaffé methods (author's transl)]. / Enzymatische Kreatinin-Bestimmung im Serum: Vergleich mit Jaffé-Methoden.

The creatinine concentrations in 337 sera were determined by enzymatic assay and by six different modifications of the Jaffé method. The enzymatic assay showed satisfactory precision and gave the same results as the assay after adsorption on Fuller's earth (Lloyd's reagent). All other methods using picrate gave falsely high values: the relative deviation from the enzymatic method had a median value between +20% and +50% for creatinine concentrations in the range 22-88 mu mol/l, and between +10% and 30% for creatinine concentrations in the range 89-177 mu mol/l. The study thus confirms the lack of specificity of all Jaffé methods, with the exception of the assay after adsorption on Fuller's earth.