[Anesthesia for electroconvulsive therapy]. / Narkose zur Elektrokrampftherapie.

Electroconvulsive therapy is a well-established form of treatment for a broad spectrum of severe psychiatric disorders. The treatment, in which a generalized epileptic seizure is provoked by electrical stimulation of the brain, is performed with the patient under anesthesia and muscle relaxation. Therefore, sufficient knowledge of the physiological and pharmacological characteristics is an essential requirement for safe anesthesia. The following review is intended to provide some new aspects of the procedure and management of anesthesia.

[Specific aspects of pediatric emergencies in the prehospital setting]. / Spezielle pädiatrische Notfälle in der Prähospitalphase.

Life-threatening pediatric emergencies are relatively rare in the prehospital setting; therefore, the treating emergency physician may not always be familiar with and well trained in these situations. However, pediatric emergencies require early recognition and initiation of specific diagnostic and therapeutic interventions to prevent further complications. Treatment of pediatric emergencies follows current recommendations as detailed in published international guidelines. The aim of this review is to provide specific information with regard to respiratory, cardiac and neurological medical emergencies commnly encountered in children in the prehospital setting. It is not the aim of this review article to provide specific guidance with regard to a variety of surgical emergencies. Due to improved treatment modalities the emergency medical team may also be confronted with acutely ill children with very severe and complex underlying clinical syndromes (e.g. complex cardiac malformations and syndromic genetic disorders). This article also provides specific information with regard to treatment of this susceptible and vulnerable patient cohort.

Nuclear steady-state RNA from chicken immature red blood cells. Distribution of globin-coding and poly (A) sequences.

Nuclear steady-state RNA and polysomal RNA of chicken immature red blood cells were isolated and separated on formamide sucrose gradients. For comparison the distribution of 9 S globin mRNA was investigated by gradient centrifugation of 125I-labelled mRNA. The material was either pooled into two fractions (less than 20 S; greater than 20 S) and translated in an Ehrlich ascites cell-free system or each gradient fraction was analyzed by hybridization with [3H]-poly (U) or [3H]-labelled DNA complementary to purified 9 S globin mRNA (globin cDNA). In neither case could evidence be obtained for the existence of a high molecular weight RNA as a probable globin mRNA precursor. Further analysis was performed by electrophoresis of RNA on exponential polyacrylamide gels in formamide and subsequent hybridization with cDNA. The results are consistent with those of gradient centrifugation and demonstrate that the distribution of globin-coding sequences in nuclear steady state RNA corresponds to that of cytoplasmic 9 S globin mRNA.

The putative 15 S precursor of globin mRNA contains a poly (A) sequence.

[3H] Uridine or [3H] adenosine pulse-labelled nuclear RNA was isolated from chicken immature red blood cells and separated on denaturing formamide sucrose gradients. RNA of each gradient fraction was hybridized with unlabelled globin DNA complementary to mRNA (cDNA) and subsequently digested by RNAase A and RNAase T1. The experiments revealed two RNA species with globin coding sequences sedimenting 9 S and approx. 15 S, the latter probably representing a precursor of 9 S globin mRNA. A poly (A) sequence was demonstrated in this RNA by two different approaches. Nuclear RNA pulse-labelled with [3H] uridine was fractionated by chromatography on poly (U)-Sepharose. Part of the 15 S precursor was found in the poly(A)-containing RNA. In the second approach 15 S RNA pulse-labelled with [3H]adenosine was hybridized with globin cDNA, incubated with RNAase A and RNAase T1 and subjected to chromatography on hydroxyapatite. The hybrids were isolated and after separation of the strands degraded with DNAase I, RNAase A and RNAase T1. By this procedure poly(A) sequences of approximately 100 nucleotides could be isolated from the 15 S RNA with globin coding sequences. The poly(A) sequence was completely degraded by RNAase T2.

Inserts within the mRNA sequence on the 15 S globin mRNA precursor from chicken.

[3H]Uridine pulse-labelled nuclear RNA of chicken immature red blood cells contains two RNA species with globin coding sequences sedimenting at 9 S and 15 S, the latter representing most probably the precursor to 9 S globin mRNA. Whether the globin mRNA sequence on the 15 S precursor is interrupted by interspersed sequences was investigated by hybridization of labelled nuclear 15 S RNA with an excess of unlabelled globin complementary DNA. After degradation of nonhybridized RNA by RNAase A the enzyme was removed by proteinase K and a subsequent phenol extraction. The complementary DNA hybrids were melted and the complementary DNA degraded by DNAase I. For the separation of complementary DNA protected RNA polyacrylamide gel electrophoresis in formamide was used. Three RNA fragments with approximately 320, 200 and 120 nucleotides were found in the case of the 15 S RNA, whereas only one 650-700 nucleotide fragment was detected when the same procedure was carried out with nuclear 9 S RNA. This means, that the chicken 15 S globin mRNA precursor contains at least two inserts within the mRNA sequence, which originate presumably by transcription of a gene with intervening sequences.

[Pediatric emergencies: Knowledge of basic measures for the emergency physician]. / Notfälle im Kindesalter: Vom Notarzt zu beherrschende Basismaßnahmen.

Life-threatening pediatric emergencies are relatively rare in the prehospital setting. Thus, the treating emergency physician may not always be familiar with and well trained in these situations. However, pediatric emergencies require early recognition and initiation of specific diagnostic and therapeutic interventions to prevent further damage. The treatment of pediatric emergencies follows current recommendations as detailed in published international guidelines. The aim of this review is to familiarize the emergency physician with general aspects pertinent to this topic-most importantly anatomical and physiological characteristics in this cohort. Also, specific information with regard to analgesia and sedation, which may be warranted in the prehospital setting, will be provided.

Valve-preserving replacement of the ascending aorta: remodeling versus reimplantation.

OBJECTIVE: Aortic valve regurgitation in combination with dilatation of the ascending aorta and root requires a combined procedure to restore valve function and eliminate pathologic dilatation of the proximal aorta. Two techniques have been proposed for this purpose; the aortic root may be either remodeled with an especially configured vascular graft or replaced with reimplantation of the aortic valve within the graft. We have used both techniques depending on the individual pathologic condition of the aortic root. METHODS: Of 107 patients undergoing operation for proximal aortic disease between October 1995 and November 1997, 40 patients had morphologically intact aortic valve leaflets in conjunction with dilatation of the aortic root. Of these, 15 patients underwent an operation as a surgical emergency for acute aortic dissection type A. In 29 instances, root remodeling in conjunction with ascending aortic replacement was performed; 11 patients underwent radical replacement of the proximal aorta with reimplantation of the aortic valve. Partial or total arch replacement was performed additionally in 27 of these patients. Other concomitant procedures were coronary artery bypass grafts (n = 11) and mitral reconstruction (n = 1). RESULTS: Two patients died after repair of acute aortic dissection, for a total operative mortality rate of 5%. No patient died after elective surgery. Aortic valve function could be effectively restored with both techniques. No patient underwent reoperation on the proximal aorta; freedom from aortic regurgitation of grade II or more at 1 year is 88% with both techniques. CONCLUSIONS: Depending on individual root pathologic condition, both the remodeling and the reimplantation techniques appeared to have their individual merits. Both result in adequate restoration of aortic valve function and elimination of pathologic aortic dilatation.

Cloning and prokaryotic expression of a biologically active human placental aldose reductase.

cDNA clones coding for human aldose reductase (AR) were isolated by antibody screening of a placental lambda gt11 cDNA library. The cDNA comprises the entire coding region and has a total length of 1,394 bp. The sequence deduced from the open reading frame encodes a protein of 316 amino acids and its amino acid composition is identical to the placental protein 9 (PP9), whose isolation and characterization were described by Bohn et al. (1982). The amino acid sequence of the placental human AR shows high homology to the rat AR; both proteins belong to the same protein superfamily as human liver AR, frog lens rho-crystallin, and bovine lung prostaglandin F synthase. Northern blot hybridization analysis revealed a size for the AR mRNA of approximately 1,500 bases. In addition to the full-length cDNA, one lambda gt11 clone was isolated which carries a putative intron of 597 bp at nucleotide position 754, corresponding to amino acid position 247. Expression of the AR cDNA in Escherichia coli resulted in the synthesis of a protein with a molecular weight of approximately 35 kD which can be immunoprecipitated specifically with antiserum raised against PP9. Despite the absence of a typical signal sequence, the human aldose reductase is partially translocated into the periplasm of the E. coli cells, where it is present in an enzymatically active form.

Cloning and expression of a cDNA encoding human placental protein 11, a putative serine protease with diagnostic significance as a tumor marker.

The placental protein 11 (PP11) can act as a tumor marker because of its specific association with various forms of cancer. A lambda gt11 cDNA library prepared from human placenta was screened with a polyclonal anti-PP11 antiserum. Out of 10(6) independent clones, only one clone reacted with the anti-PP11 antiserum. The isolated cDNA coded only for the carboxy-terminal part of PP11 and was subsequently used to rescreen a lambda gt10 placental cDNA library. Two cDNA clones out of 10(6) screened were identified encoding the entire protein of 369 amino acids, including a typical hydrophobic signal sequence of 18 amino acids. Expression of the PP11 cDNA coding sequence in Escherichia coli resulted in the synthesis of a protein with the expected size which can be specifically immunoprecipitated with anti-PP11 antiserum. Fractionation experiments revealed that two forms of the protein are present in the bacterial cell: a higher-molecular-weight form of approximately 42 kD in the cytoplasm and a smaller-molecular-weight form of approximately 42 kD in the periplasm. This result indicates that PP11 can be synthesized in E. coli and is process by removal of the hydrophobic signal sequence. Both the placental and the processed recombinant PP11 protein exhibit a protease activity.

Cardiac output and liver blood flow in humans: effect of the volatile anesthetic halothane.

In 40 men with normal circulatory and liver function, from whom 10 were undergoing general anesthesia with halothane for minor orthopedic surgery, the relationship between hemodynamic parameters and total hepatic blood flow (HBF) was investigated. Cardiac output (CO) was measured noninvasively by means of the thoracic electrical bioimpedance method, systemic arterial blood pressure (BPsys, BPdia, mean arterial pressure) by an automated oscillometric device and HBF by indocyanine green clearance. In the subjects without halothane anesthesia no relationship was found between BP and HBF, but a significant correlation could be seen between CO and HBF, whereby the fraction of HBF decreased with increasing CO. In contrast, in the presence of halothane the systemic arterial blood pressure correlated with the HBF, indicating a loss of autoregulation of the liver circulation.

A multicenter comparison of isoflurane and propofol as adjuncts to remifentanil-based anesthesia.

STUDY OBJECTIVE: To compare recovery, hemodynamics, and side effects of remifentanil-based anesthesia with hypnotic concentrations of isoflurane or propofol. DESIGN: Multicenter, prospective, randomized, two-group study. SETTING: 15 university and 5 municipal hospitals. PATIENTS: 249 ASA physical status I, II, and III adult patients scheduled for elective gynecological laparoscopy, varicose vein, or arthroscopic surgery of at least 30 minutes' duration. INTERVENTIONS: Anesthesia was induced in the same manner in both groups: remifentanil-bolus (1 microg/kg), start of remifentanil-infusion (0. 5 microg/kg/min), followed by propofol as needed for induction. Five minutes after intubation, remifentanil was reduced to 0.25 microg/kg/min, and it was combined with either a propofol-infusion (0.1 mg/kg/min) or with isoflurane (0.6 vol% end-tidal) in O(2)/air. Adverse hemodynamic responses of heart rate and systolic blood pressure were recorded and treated according to a predefined protocol. With termination of surgery, anesthetic delivery was discontinued simultaneously without tapering, and recovery times were recorded. MEASUREMENTS AND MAIN RESULTS: No significant differences were observed between the remifentanil-isoflurane or remifentanil-propofol treatment regimens. Recovery times (means +/- SD) were similar for spontaneous ventilation (5.8 +/- 3.2 min vs. 6. 3 +/- 3.7 min), extubation (7.6 +/- 3.5 vs. 8.5 +/- 4.2 min), eye opening (6.8 +/- 3.2 vs. 7.5 +/- 3.8 min), and arrival to the postanesthesia care unit (16.5 +/- 7.0 vs.18.0 +/- 7.2 min). There were no significant differences in adverse hemodynamic responses, postoperative shivering, nausea, or vomiting between the groups. CONCLUSIONS: Emergence after remifentanil-based anesthesia with 0.6 vol% of isoflurane is at least as rapid as with 0.1 mg/kg/min propofol. Both isoflurane and propofol are suitable adjuncts to remifentanil, and the applied dosages are clinically equivalent with respect to emergence and recovery. Therefore, both combinations should be appropriate, particularly in settings in which rapid recovery from anesthesia is desirable, such as fast tracking and/or ambulatory surgery.

Selective gelatinase inhibition reduces apoptosis and pro-inflammatory immune cell responses in Campylobacter jejuni-infected gnotobiotic IL-10 deficient mice.

Increased levels of the matrix metalloproteinases-2 and -9 (also referred to gelatinase-A and -B, respectively) can be detected in intestinal inflammation. We have recently shown that selective gelatinase blockage by the synthetic compound RO28-2653 ameliorates acute murine ileitis and colitis. We here investigated whether RO28-2653 exerts anti-inflammatory effects in acute Campylobacter jejuni-induced enterocolitis of gnotobiotic IL-10(-/-) mice generated following antibiotic treatment. Mice were perorally infected with C. jejuni (day 0) and either treated with RO28-2653 (75 mg/kg body weight/day) or placebo from day 1 until day 6 post infection (p.i.) by gavage. Irrespective of the treatment, infected mice displayed comparable pathogen loads within the gastrointestinal tract. Following RO28-2653 administration, however, infected mice exhibited less severe symptoms such as bloody diarrhea as compared to placebo controls. Furthermore, less distinct apoptosis but higher numbers of proliferating cells could be detected in the colon of RO28-2653-treated as compared to placebo-treated mice at day 7 p.i. Remarkably, gelatinase blockage resulted in lower numbers of T- and B-lymphocytes as well as macrophages and monocytes in the colonic mucosa of C. jejuni-infected gnotobiotic IL-10(-/-) mice. Taken together, synthetic gelatinase inhibition exerts anti-inflammatory effects in experimental campylobacteriosis.

Campylobacter jejuni infection of infant mice: acute enterocolitis is followed by asymptomatic intestinal and extra-intestinal immune responses.

Campylobacter (C.) jejuni is among the leading bacterial agents causing enterocolitis worldwide. Despite the high prevalence of C. jejuni infections and its significant medical and economical consequences, intestinal pathogenesis is poorly understood. This is mainly due to the lack of appropriate animal models. In the age of 3 months, adult mice display strong colonization resistance (CR) against C. jejuni. Previous studies underlined the substantial role of the murine intestinal microbiota in maintaining CR. Due to the fact that the host-specific gut flora establishes after weaning, we investigated CR against C. jejuni in 3-week-old mice and studied intestinal and extra-intestinal immunopathogenesis as well as age dependent differences of the murine colon microbiota. In infant animals infected orally immediately after weaning C. jejuni strain B2 could stably colonize the gastrointestinal tract for more than 100 days. Within six days following infection, infant mice developed acute enterocolitis as indicated by bloody diarrhea, colonic shortening, and increased apoptotic cell numbers in the colon mucosa. Similar to human campylobacteriosis clinical disease manifestations were self-limited and disappeared within two weeks. Interestingly, long-term C. jejuni infection was accompanied by distinct intestinal immune and inflammatory responses as indicated by increased numbers of T- and B-lymphocytes, regulatory T-cells, neutrophils, as well as apoptotic cells in the colon mucosa. Strikingly, C. jejuni infection also induced a pronounced influx of immune cells into extra-intestinal sites such as liver, lung, and kidney. Furthermore, C. jejuni susceptible weaned mice harbored a different microbiota as compared to resistant adult animals. These results support the essential role of the microflora composition in CR against C. jejuni and demonstrate that infant mouse models resemble C. jejuni mediated immunopathogenesis including the characteristic self-limited enterocolitis in human campylobacteriosis. Furthermore, potential clinical and immunological sequelae of chronic C. jejuni carriers in humans can be further elucidated by investigation of long-term infected infant mice. The observed extraintestinal disease manifestations might help to unravel the mechanisms causing complications such as reactive arthritis or Guillain-Barré syndrome.

[Anaesthesiological aspects of electroconvulsive therapy]. / Anästhesiologische Aspekte bei Elektrokrampftherapie.

Electroconvulsive therapy (ECT) is used in the therapy of severe psychiatric disorders. The treatment, in which a generalized epileptic seizure is provoked by electrical stimulation of the brain, is performed under anaesthesia and muscle relaxation. Considering careful previous clinical examination and anaesthesiological and internal contraindications, ECT is a safe form of treatment. The following review is intended to familiarize with ECT and to provide advice for the anaesthesiological management.

[Placenta praevia totalis et increta. Cause of life-threatening haemorrhaging during a caesarean section]. / Placenta praevia totalis et increta. Ursache einer lebensbedrohlichen Blutung während einer Sectio caesarea.

Placenta increta is a rare but potentially life-threatening risk constellation after a previous caesarean section. We present the case of a 29-year-old gravida 2 para 1 patient, who developed dramatic haemorrhaging caused by this abnormal placentation, which could only be resolved by a postpartal hysterectomy. This demonstrates that in the case of a combination of the two most common predisposing factors, repeat caesarean section and placenta praevia, the possibility of a placenta increta should be considered and suitable precautions should be taken.

[Remifentanil-propofol versus fentanyl-midazolam combinations for intracranial surgery: influence of anaesthesia technique and intensive sedation on ventilation times and duration of stay in the ICU]. / Remifentanil-Propofol versus Fentanyl-Midazolam-Kombination bei intrakraniellen Eingriffen: Einfluss von Anästhesietechnik und Intensivanalgosedierung auf Beatmungszeiten und Dauer des Intensivaufenthalts.

INTRODUCTION: After neurosurgery patients often need to be sedated and ventilated in the intensive care unit (ICU). However, rapid postoperative recovery and neurological examination are particularly important for the early recognition of complications. In this retrospective study two different strategies of anaesthesia technique and ICU sedation (fentanyl-midazolam versus remifentanil-propofol) were compared. METHODS: Intraoperatively, patients received continuous infusions of either fentanyl (0.2-1.0 mg/h) and midazolam (2-10 mg/h) or remifentanil (0.2-0.5 microg/kg body weight/min) and propofol (3-6 mg/kg body weight/h). After arrival in the ICU fentanyl (0.03-0.2 mg/h) and midazolam (2-12 mg/h) or remifentanil (0.1-0.2 microg/kg body weight/min) and propofol (0.5-3 mg/kg body weight/h) were infused to reach a Ramsay score of 4. The times between termination of infusion and extubation and the length of stay in the ICU were examined. RESULTS: A total of 60 patients (n=30 each group) undergoing supratentorial brain tumour surgery were enrolled. The groups were comparable for age, weight, ASA status (American Society of Anesthesiologists) and duration of drug administration (remifentanil-propofol 528+/-382 min versus fentanyl-midazolam 548+/-360 min). Extubation times were significantly shorter after remifentanil-propofol (47 min) than after fentanyl-midazolam (481 min), and the length of stay in the ICU was also significantly reduced (1.8 days versus 3.7 days). As a result of prolonged unconsciousness and impaired neurological assessability, a brain CT scan was necessary in 3 patients after fentanyl-midazolam to exclude neurosurgical complications. CONCLUSION: This retrospective study demonstrates that remifentanil-propofol anaesthesia and ICU sedation are superior to the combination of fentanyl and midazolam in terms of ventilation time and length of ICU stay. Moreover, the use of fentanyl-midazolam may lead to unnecessary CT scans.

[Acute aortic dissection. Differential diagnosis of a thoracic emergency]. / Akute Aortendissektion. Differenzialdiagnose des thorakalen Notfalls.

Acute aortic dissection is an infrequent but important differential diagnosis of acute chest pain. The variability of presenting symptoms makes it difficult to diagnose correctly. Important clinical indicators - besides chest pain - are symptoms related to acute aortic insufficiency and/or pericardial tamponade, variable acute neurologic alterations, or signs of peripheral or visceral malperfusion. The spontaneous prognosis depends on the location and extent of the dissection, and left untreated dissection carries a high mortality. The key goal of preclinical treatment is stabilization with analgesia, mild sedation (opioids, benzodiazepines) and treatment of hypertension (beta-blockers) or hypotension (fluid administration). If the patient presents with a high probability of dissection, early transfer to a specialized center appears advisable. Initial clinical diagnostic studies include transthoracic echocardiogram and computed tomography. If the ascending aorta is involved (Stanford type A) immediate replacement of the proximal aorta is necessary. Isolated dissections of the descending aorta (type B) require aggressive blood pressure control, but can be managed conservatively in most cases. A high level of vigilance is necessary in all patients to detect and treat visceral ischemia.

Effect of propofol on seizure-like phenomena and electroencephalographic activity in children with epilepsy vs children with learning difficulties.

There is an ongoing debate as to whether propofol exhibits pro- or anticonvulsant effects, and whether it should be used in patients with epilepsy. We prospectively assessed the occurrence of seizure-like phenomena and the effects of intravenous propofol on the electroencephalogram (EEG) in 25 children with epilepsy (mean (SD) age: 101 (49) months) and 25 children with learning difficulties (mean (SD) age: 52 (40) months) undergoing elective sedation for MRI studies of the brain. No child demonstrated seizure-like phenomena of epileptic origin during and after propofol sedation. Immediately after stopping propofol, characteristic EEG changes in the epilepsy group consisted of increased beta wave activity (23/25 children), and suppression of pre-existing theta rhythms (11/16 children). In addition, 16 of 18 children with epilepsy and documented EEG seizure activity demonstrated suppression of spike-wave patterns after propofol sedation. In all 25 children with learning difficulties an increase in beta wave activity was seen. Suppression of theta rhythms occurred in 11 of 12 children at the end of the MRI study. In no child of either group was a primary occurrence or an increase in spike-wave patterns seen following propofol administration. The occurrence of beta wave activity (children with learning difficulties and epilepsy group) and suppression of spike-wave patterns (epilepsy group) were transient, and disappeared after 4 h. This study demonstrates characteristic, time-dependent EEG patterns induced by propofol in children with epilepsy and learning difficulties. Our data support the concept of propofol being a sedative-hypnotic agent with anticonvulsant properties as shown by depression of spike-wave patterns in children with epilepsy and by the absence of seizure-like phenomena of epileptic origin.