[Benefit of the extended-release methylphenidate formulations: a comparative study in childhood]. / Apports des formes de méthylphénidate à libération prolongée: étude comparative chez l'enfant.

UNLABELLED: Methylphenidate (MPH) is a potential therapeutic tool for Attention Deficit with Hyperactivity Disorders (ADHD). In addition to the immediate-release formulation, Ritalin, two extended-release formulations, Ritalin LA and Concerta are available and allow a once-daily administration. We compared the respective benefits of both formulations for the patients and their family in terms of efficacy, handling and tolerance. PATIENTS AND METHODS: This prospective study was based on 30 children aged 6 to 15 years. All patients had a confirmed ADHD and were efficiently treated with Ritalin. The children were consecutively treated with Ritalin LA and Concerta, with a comparable MPH daily dosage, during 2 months for each molecule. The 3 drugs were evaluated individually and comparatively through a battery of questionnaires submitted to the parents and the teachers of each child. RESULTS: Extended-release MPH efficacy was comparable to the immediate-release formulation, Ritalin. For both of them, the once-daily administration appeared beneficial. Concerta was finally prescribed in 18 children, Ritalin LA in 8 cases and Ritalin in 4 cases. In each case the medical choice was consistent with the parents preference. Concerta was appreciated for its persisting efficacy in late afternoon during homework. Concerta and Ritalin LA did not induce significant adverse effects, especially regarding alimentation and sleep. CONCLUSIONS: MPH therapy in ADHD carries an excellent risk/benefit ratio without addictive induced behaviours. The extended-release MPH formulations provide an improvement for the patients in keeping with Ritalin efficacy through a once-daily administration. Regardless of its formulation, MPH indications and guidelines must be respected.

[Diagnostic strategies for ischemic strokes in childhood]. / Stratégie diagnostique dans les accidents vasculaires cérébraux ischémiques de l'enfant.

Ischemic strokes represent a rare condition in childhood, mostly revealed by a motor deficit. In the pediatric age, strokes are different than in adulthood where atherosclerosis is the major cause. The etiologies of stroke in childhood are rather multiple and each of them is rare. In nearly half of the pediatric cases no cause can be found and usually no recurrence occurs. The aim of this presentation is to propose a diagnosis strategy for ischemic strokes in children. An extensive search should be performed in every children presenting a stroke episode even if the initial outcome appears favorable. Such investigations could improve our understanding and therapeutic strategies of stroke in childhood, a condition where the cognitive and functional prognosis can be severely compromised.

[Diagnostic strategies for ischemic strokes in childhood]. / Stratégie diagnostique dans les accidents vasculaires cérébraux ischémiques de l'enfant.

Ischemic strokes represent a rare condition in childhood, mostly revealed by a motor deficit. In the pediatric age, strokes are different than in adulthood where atherosclerosis is the major cause. The etiologies of stroke in childhood are rather multiple and each of them is rare. In nearly half of the pediatric cases no cause can be found and usually no recurrence occurs. The aim of this presentation is to propose a diagnosis strategy for ischemic strokes in children. An extensive search should be performed in every children presenting a stroke episode even if the initial outcome appears favorable. Such investigations could improve our understanding and therapeutic strategies of stroke in childhood, a condition where the cognitive and functional prognosis can be severely compromised.

Ischemia and aging brain. Studies on glucose and energy metabolism in rat cerebral cortex.

Age has been considered to be a crucial risk factor for brain ischemic insults and their mortality. Brain ischemia has been found to cause severe abnormalities in glucose metabolism, energy metabolism and related metabolism, thus damaging the structure and function of brain cells. To study the effect of age and ischemia on brain glucose and energy metabolism, investigations were performed on one-and two-year-old male Wistar rats, the latter of which can be designated as aged. In both age groups, ischemia resulted in a depletion of glucose, OAA, ATP AND CRP, a diminution of Pyr, Citr and alpha-Keto and an accumulation of FDP, Lact, Succ, ADP and AMP in brain cortex. During ischemia, differences between the two age groups became most obvious in the concentrations of Glu, FDP, DHAP, Lact, Succ, Mal, ADP and AMP. In general, the metabolic changes in both age groups point to an increased glycolytic flux which may be less accelerated in the aged group, to an inhibition of the starting reactions of the tricarboxylic acid cycle more severe in aged animals, to a preponderance of anaplerotic reactions in this oxidative system more pronounced in the two-year-old group and to a loss of AMP in the same age group. The age-related metabolic variations measured may indicate that with age the biological plasticity of the brain may be reduced to meet emergency conditions.

Catheter embolization following median sternotomy.

A case of intraoperative internal jugular vein catheter embolization in a patient undergoing median sternotomy for open-heart surgery is described. This complication suggests that right sided cannulation of the internal jugular vein is to be preferred in all patients having a median sternotomy in order to avoid the risk of intersection by median sternotomy.

Serum aluminium levels of intensive care patients treated with two different antacids for prevention of stress ulceration.

We studied the serum aluminum levels of 30 intensive care patients receiving six daily doses of magaldrate (Riopan) or aluminium hydroxide (Trigastril). In both groups we found a significant rise of the serum aluminium concentration (p less than 0.01) following administration of the antacid solutions. Examination on day 9 and 15 the magaldrate group showed significantly (p less than 0.05) lower aluminium levels than the aluminium hydroxide group. An increase up to the critical serum aluminium level of 100 ng/ml occurred in none of the patients that all had normal or slightly impaired renal function. Therefore routine measurements of serum aluminium levels in patients without renal impairment are not considered necessary following antacid therapy. However, we recommend the use of antacids with an aluminium absorption rate as low as possible.

[Cognitive function of geriatric ophthalmology patients after local and general anesthesia]. / Untersuchung der kognitiven Funktion bei geriatrischen ophthalmologischen Patienten nach Lokal-bzw. Allgemeinanästhesie.

Since there will be an increase in the number of geriatric patients who undergo surgery and anesthesia over the next few years, studies comparing the effects of general and local anesthesia on cognitive functioning in elderly persons are mandatory. One hundred eleven ophthalmological patients, all over the age of 64 years, were assessed preoperatively, on the first and on the fourth postoperative day using a battery of standardized cognitive tests. Of the initial sample, 47 patients undergoing local and 54 undergoing general anesthesia completed the assessment. The performance of the patients in six tests did not change perioperatively. In both anesthesia groups, two tests revealed a cognitive deficit postoperatively, which only became evident on the first postoperative day. The two other tests showed a significant difference between the two anesthesia groups on the first postoperative day. The performance of patients with general anesthesia decreased transiently and returned to the initial levels within 3 days. We conclude from our results that postoperative cognitive deficits may occur in geriatric patients. However, general anesthesia poses no more risk to cognitive function than local anesthesia.

Hazards of high dose barbiturate therapy in head-injury patients.

Despite of controversial findings, High-Dose-Barbiturate Therapy is advocated by many authors for treatment of postischemic/anoxic encephalopathy and head trauma with elevated intracranial pressure. The adverse effects to thiopentone are analyzed in a retrospective study including 30 patients treated by high-dose thiopentone for raised intracranial pressure after severe head injury. The pathophysiology and occurrence of clinical complications in many systems of the organism are illustrated. The specific prevention measures and the extended monitoring of barbiturate-treated patients are described. Considering the high incidence of clinical complications the indication for HDBT has to be reevaluated.

[AIDS and anesthesia]. / AIDS und Anästhesie.

AIDS will become a bigger and bigger problem in future, especially for medical staff who will be increasingly in contact with infected patients. The epidemiology of HIV infection (blood, vaginal secretion, sperm) and the threat of this infection require particularly strict observance of hygienic measures. Unqualified handling of infected material such as HIV-contaminated injection needles or pointed objects represent a major risk of HIV infection for medical personnel. Despite the high degree of safety in the preparation of banked blood we cannot completely guarantee that only absolutely safe HIV-free blood will be transfused. Hence, indication for transfusion must be very strictly limited. Autologous transfusion as a safe alternative to homologous transfusion should be employed more frequently. Seroconversion rate after needle-point injury is now stated to be one per cent. According to Goebel et al. in AIFO 5:227 (1988) four nurses carried out mouth-to-mouth resuscitation in an AIDS patient who had jumped from the third floor of a building in attempted suicide. Despite considerable blood contact the HIV antibody tests remained negative even now after 18 months.

[Air embolism; a complication during neurosurgery in the sitting position (author's transl)]. / Luftembolie; Eine Komplikation bei neurochirurgischen Eingriffen in sitzender Position.

Neurosurgery in the sitting position not only puts a strain on the cardiopulmonary system, but also carries the risk of venous air embolism. Special monitoring procedures as well as prophylactic measures greatly contribute towards the safety of the patient. The pathogenesis, pathophysiology and the symptoms of venous air embolism are reviewed, and various monitoring methods are discussed, with special reference to their reliability, sensitivity and practicability. The analysis shows that the Doppler ultrasound method, continuous capnography during the duration of the operation, intra-arterial measurement of blood pressure, recording of the central venous pressure and of electrocardiographic changes are essential means of routine monitoring. Suspected air embolism must be promptly dealt with not only by ligation of the severed vein but also by attempts at aspiration of the air bubbles via the atrial catheter. The latter, therefore, plays an important role both as a diagnostic parameter and a therapeutic agent. Although the suggested prophylactic measures do not absolutely protect against complications they will markedly reduce the incidence of venous air embolism.

[Micropore filters for preventing venous air embolism during infusions (author's transl)]. / Untersuchungen zur Prophylaxe venöser Luftembolien durch den Einsatz von 0,2 micrometer Infusionsfiltern.

The use of automatic pumps in intensive care medicine does not preclude the risk of accidental air embolism. The repeated introduction of small air bubbles into the infusion system in the course of additional medication may have a cumulative effect resulting in the blocking of the pulmonary capillary system. The use of 0.22 micrometer filters for eliminating air prevents this complication of infusion therapy. The efficacy of the microfilter Ultipor type FAE-020 (marketed by Pall Biomedizin GmbH) in preventing the introduction of air was tested in 50 specimens with 650 single injections and 10 slow drip infusions by means of the ultrasound Doppler technique. The filters reliably stopped the introduction of air into the circulation.

[Internal jugular vein catheter--success rate and complications with reference to educational status]. / Der Vena jugularis interna Katheter--Erfolgsrate und Komplikationen unter Berücksichtigung des Ausbildungsstandes.

In a prospective study the success and complications of internal jugular vein catheterization in relation to the degree of experience were investigated. The internal jugular vein catheter were placed in 200 patients by experienced anaesthetists and by anaesthetists not experienced in this procedure as well. In the case of physicians trained in this procedure, the success rate was 98 percent, whereas in the case of inexperienced collegues, the success rate was 83 percent with a high number of attempted punctures. In addition to the increased rate of haematoma, during the learning period, the incidence of accidental arterial punction was 18 percent resulting in a temporary Horners-syndrome in one patient. In the group of experienced anaesthetists the accidental arterial puncture occurred only in 3 percent without any haematome. In one patient the procedure was interrupted because of temporary AV-Block (3rd degree). The complications of internal jugular vein cannulation are reviewed and the methods to avoid them are presented.

[A child with a full stomach has to be anaesthesized]. / Ein nicht nüchternes Kind kommt zur Narkose.

In the present paper the problem of giving anaesthesia to a child with a full stomach is discussed using a case report. Children are not by nature more in danger of aspiration than grown-ups. Even the higher risk of aspiration in children with a full stomach, which seems plausible, is not proven in all published studies on this subject. Since there is a more or less large amount of residual gastric secrete even 6 - 10 hours after the accident, due to stress or opioids, and prophylaxis against aspiration must be taken in any case, narcosis for the emergency treatment of these children can be applied immediately at the same risk. Rapid sequence induction is the world-wide standard as prophylaxis against aspiration today. Should aspiration happen, bronchoscopic draining is the main measure. Artificial ventilation is not a cogent measure, if the airway is free as far as the visible segmental bronchus and there are no disruptions in the respiratory exchange.

[Positioning trauma in anesthesia and surgical intensive care medicine (2)]. / Lagerungsschäden in Anästhesie und operativer Intensivmedizin (Teil 2).

Specific modes of positioning are essential for successful surgery. These are again critically assessed in this final part of our review. Technically correct execution can minimize the risk of damage caused by positioning, although the possibility of damage still exists. First of all, the position on the fracture table is discussed. Great care must be taken concerning the perineal post and leg holder. In the lateral decubitus position, the correct positioning of head and spine as well as that of the lower arm are of great importance. When using the Trendelenburg and reverse Trendelenburg position, the effect on the cardiopulmonary system and the intracranial pressure must to be taken into consideration. Prone position and its modifications (i.e. tuck position) demand diligent care concerning the positioning of the head. There must be absolutely no bulbus compression and the abdominal wall should not be under pressure. While employing the sitting position, the patient should be adequately monitored so that venous air embolism can be recognized and treated as soon as possible. Because of the increased occurrence of grave complications, the sitting position should be used only if this is absolutely necessary.

[Pericardial tamponade: a rare but severe complication of a vena cava catheter. Case report]. / Herzbeuteltamponade: Eine seltene aber schwerwiegende Komplikation eines Cava-Katheters. Ein Fallbericht.

A case of catheter-induced cardiac tamponade followed by successfully treated cardiac arrest is reported in a 5-month old infant with oesophageal atresia. The complication occurred after a delay of 16 h following catheter placement and was diagnosed by ultra-sound technique. Treatment consisted of direct pericardial puncture. Cardiac tamponade is an unusual, but potentially fatal complication and is always due to incorrect catheter tip position.

[Acute angioneurotic edema due to ACE inhibitors]. / Akutes Angioneurotisches Odem auf ACE-Hemmer.

Acute angioneurotic edema due to angiotensin converting enzyme (ACE) inhibitors usually develops shortly after therapy has been started. In this case, hypopharyngeal edema occurred with a delay of nine days. It required endotracheal intubation and could only be differentiated from an inflammatory process by examination under general anesthesia. The mechanism of action of ACE inhibitors, the pathogenesis of angioneurotic edema, its therapy outside as well as in the hospital, and the case described are being discussed. It is concluded that severe reactions induced by ACE inhibitors must be expected even after considerable time of therapy.