Unscheduled return visits by patients to a german emergency department are a high risk group for initial wrong diagnosis.

The aim was to classify patients who returned unscheduled to an emergency department within 7 days. We categorized the patients' cases arbitrarily according to the underlying cause of the return. The main causes for returning unscheduled were: "patient related" (24,2%), "illness related" (35,4%), "physician related" (18,3%), "system related" (3,8%) and "other" (21,7%). We also analyzed missed diagnoses, as the literature describes this special patient population as a high risk group. 15,4% of all return cases had a wrong diagnosis. No typical risk constellation/symptom could be found. Vital signs or blood values were within normal limits as well.

Surface vs. aortic flush cooling during cardiac arrest in pigs.

BACKGROUND: To investigate the feasibility and efficacy of earlier induction of hypothermia already during the 'no-flow' period of cardiac arrest with non-invasive surface cooling or invasive aortic flush cooling. METHODS: This was a prospective randomized experimental study that included 14 pigs, Large White breed (30-38 kg), with ventricular fibrillation cardiac arrest plus blanket surface and an invasive cold saline flush cooling. The endpoint was a decline in brain temperature (T(br)) at 35 min after cardiac arrest. RESULTS: With surface cooling, T(br) decreased from 38.7+/-0.2 degrees C to 37.4+/-0.8 degrees C (P=0.02) and with invasive cooling T(br) decreased from 38.8+/-0.13 degrees C to 19.0+/-2.8 degrees C within 216+/-23 s (P=0.02) and increased back to 33.0+/-0.6 degrees C at 35 min of cardiac arrest (P=0.02 vs. T(br) at 15 min, P=0.002 vs. T(br) at 35 min in the surface cooling groups). CONCLUSION: Invasive cooling by aortic flush with cold saline rapidly induces deep cerebral hypothermia, whereas non-invasive surface cooling only marginally decreases brain temperature.

[Physician staffing and shift work schedules : Concepts for emergency and intensive care medicine]. / Ärztliche Personalbesetzung im Schichtdienst : Konzepte für die Notfall- und Intensivmedizin.

Human resource development is a key factor for a successful management of Intensive Care Units (ICU) and Emergency Departments (ED). It comprises the processes of recruiting and retaining employees. The present article offers strategies how the optimal manning level in ICUs and EDs can be determined and highlights the importance of active management of well being in acute care units. The manning level can be determined by using the work place method which is the common method for ICUs. For the EDs a method based on the specific times which are needed for patient care in relation to the intensity of care is more appropriate. This method needs to integrate the patient number per hour, the time needed per patient, and the defined service level particularly with respect to the time to be seen by a physician. For detailed staff calculation, complex mathematical models are needed (e.g. Erlang formula). The resulting manning level needs then to be distributed on the various shifts. Additional resources are needed for observation units and additional tasks like management tasks etc. Retainment of employees is only possible when the working field remains attractive over many years. While a structured and competence based education is of utmost importance in the beginning of a carrier, attractive rooster plans and the compatibility between work and private life, becomes more important when the specialisation has been achieved.

[Aspects of intensive care medicine in emergency medicine]. / Intensivmedizinische Aspekte in der Notfallmedizin.

Emergency medicine and intensive care medicine have many similarities. In this review, we will first discuss the terminology of emergency medicine in a hospital in terms of a uniform designation as a department for emergency medicine or emergency department. Emergency medicine and intensive care medicine are a location-independent concept of patient care in the sense of the recognition, treatment and diagnosis of acute health disorders. Emergency medicine covers the entire range of disease severity, while intensive care medicine focuses on organ replacement and organ preservation, uses highly specialized technology for this purpose and treats only the seriously ill. The treatment of seriously ill patients in the emergency departments requires special intensive care medical knowledge both by the physicians and nursing staff. In the medical field, the curriculum for the European emergency medicine specialist takes into account all aspects necessary for the diagnosis and treatment of critically ill patients. For the nursing sector, Germany has had its own recognized specialty training program in emergency medicine for several years. However, the treatment of critically ill patients in emergency departments also requires that the emergency departments be adequately equipped. In this regard, there is an urgent need for statutory quality criteria that are concrete and structured. We know from the literature that intensive care competence in emergency departments reduces the admission rate to intensive care units and the mortality of all emergency patients. The concept of intensive care units in the emergency department is gaining popularity in the USA and should also be evaluated for implementation in the German-speaking countries.

[Postcardiac arrest treatment guide]. / Praxisleitfaden für die Postreanimationsbehandlung.

BACKGROUND: Treatment after cardiac arrest has become more complex and interdisciplinary over the last few years. Thus, the clinically active intensive and emergency care physician not only has to carry out the immediate care and acute diagnostics, but also has to prognosticate the neurological outcome. AIM: The different, most important steps are presented by leading experts in the area, taking into account the interdisciplinarity and the currently valid guidelines. MATERIALS AND METHODS: Attention was paid to a concise, practice-oriented presentation. RESULTS AND DISCUSSION: The practical guide contains all important steps from the acute care to the neurological prognosis generation that are relevant for the clinically active intensive care physician.

The influence of chronic prearrest health conditions on mortality and functional neurological recovery in cardiac arrest survivors.

PURPOSE: To study the impact of chronic prearrest health conditions on mortality and neurological recovery in patients after witnessed cardiac arrest and primary successful resuscitation. PATIENTS AND METHODS: The study was set in the community of Vienna, Austria. Data concerning cardiopulmonary resuscitation of adult patients who survived a witnessed cardiac arrest were collected according to an internationally recommended protocol (Utstein-Style). Chronic prearrest health conditions and New York Heart Association (NYHA) functional classes were evaluated. All patients were followed up for 6 months after the event or death. Adverse outcome was defined as death or severe neurological impairment. A forward stepwise logistic regression model was applied to assess the impact of pre-arrest morbidity on unfavorable outcome, expressed as odds ratio (OR) with 95% confidence intervals (CI). RESULTS: Of 411 patients, 269 (66%) had one or more of the following pre-arrest diseases: coronary heart disease (45%), hypertension (26%), congestive heart failure (20%), diabetes mellitus (14%), chronic pulmonary disease (6%), and cerebrovascular disease (5%). In 22% a NYHA class of III or IV was present before cardiac arrest. At 6-month follow-up, 161 (40%) of the patients were alive with favorable neurological recovery; overall mortality was 57% (n = 233). Increasing NYHA classes (OR 1.4 per NYHA class increase; CI 1.1 to 1.7) and increasing age were independent predictors of adverse outcome (OR 1.03 per 10-year increase; CI 1.01 to 1.05), as were durations of cardiac arrest (OR 1.10 per 5-minute increase; CI 1.07 to 1.12) and the presence of ventricular fibrillation or tachycardia (OR 0.3; CI 0.2 to 0.5). The remaining health conditions, as listed above, were not independently associated with outcome. CONCLUSIONS: A large proportion of patients with cardiac arrest had chronic diseases before the event. The presence of impaired functional performance in patients with structural heart disease increased unfavorable outcome within 6 months in primary cardiac arrest survivors. However, the impact of chronic prearrest conditions on outcome seems to be very small, and should not influence decisions whether to withhold or withdraw therapy.

Gut damage during hemorrhagic shock: effects on survival of oral or enteral interleukin-6.

It has been reported that oral interleukin (IL)-6, without deleterious systemic side effects, prevents bacteremia and gut epithelial apoptosis after hemorrhagic shock (HS) in rodents. The goal of this study was to explore potential benefit of oral or enteral IL-6 on the gut and, consequently, on survival in a long-term outcome model of HS in rats. In Study A, 20 rats (control and IL-6, n = 10 per group) were anesthetized by spontaneous breathing of halothane and N2O. The left femoral vein and artery were cannulated. HS was initiated with withdrawal of 3 mL of blood per 100 g body weight over 15 min, and mean arterial pressure was maintained at 40 to 50 mmHg for another 75 min (total HS 90 min) by blood withdrawal or infusion of Ringer's solution. At HS 90 min, resuscitation included reinfusion of shed blood and additional Ringer's solution to restore normotension for 30 min. After awakening at resuscitation time 30 min, the rats received either 300 units IL-6 or the same volume of vehicle (controls) injected into the stomach via a feeding cannula. In Study B, 20 rats (control and IL-6, n = 10 per group), fasted overnight, were prepared and treated as in Study A, except that HS was initiated with withdrawal of 2 mL blood per 100 g over 10 min, and mean arterial pressure was maintained at 35-40 mmHg. IL-6 rats received 3,000 units IL-6 in 5 mL of normal saline injected directly into the ileum lumen 20 min after induction of shock and again at resuscitation time 60 min. Control rats received normal saline alone. In both studies, survival was observed to 72 h. In Study A, 7 of 10 rats in the control group and 5 of 10 in the IL-6 group survived to 72 h (NS). Macroscopic assessment of gut injury was not different between the two groups. In Study B, 6 of 10 rats survived to 72 h in each group. Frequency of bacteria growth in liver tissue of 72 h survivors was not different between the two groups. IL-6, administered into the stomach or directly injected into the small intestine lumen, did not protect the gut from ischemic injury, nor did it improve survival following severe HS in rats.

The association between blood lactate concentration on admission, duration of cardiac arrest, and functional neurological recovery in patients resuscitated from ventricular fibrillation.

OBJECTIVE: To assess the association between arterial lactate concentration on admission and the duration of human ventricular fibrillation cardiac arrest, and to what degree the arterial lactate concentration on admission is an early predictor of functional neurological recovery in human cardiac arrest survivors. DESIGN: Cohort study. Arterial lactate concentrations and out-of-hospital data concerning cardiac arrest and cardiopulmonary resuscitation were collected retrospectively according to a standardized protocol. Functional neurological recovery was assessed prospectively at regular intervals for 6 months. SETTING: Emergency department of an urban tertiary care hospital. PATIENTS: A total of 167 primary survivors of witnessed out-of-hospital ventricular fibrillation cardiac arrest. MEASUREMENTS: The association between arterial lactate concentration on admission, the duration of cardiac arrest, and functional neurological recovery was assessed. Further, we assessed whether admission concentrations of arterial lactate and duration of cardiac arrest can predict unfavorable functional neurological recovery. Functional neurological recovery was measured in cerebral performance categories (CPC). No or minimal functional impairment (CPC 1 and 2) was defined as favorable outcome; the remaining categories (CPC 3, 4 and 5) were defined as unfavorable functional neurological recovery. RESULTS: In 167 patients, a weak association between total duration of cardiac arrest and admission levels of lactate (r = 0.49, P < 0.001) could be shown. With increasing admission concentrations of arterial lactate functional neurological recovery was more likely to be unfavorable (OR 1.15 per mmol/l increase, 95% CI 1.04-1.27). Nevertheless, only at very high levels of lactate (16.3 mmol/l) could unfavorable neurological recovery be detected with 100% specificity, yielding a very low sensitivity of 16%. CONCLUSIONS: The arterial admission lactate concentration after out-of-hospital ventricular fibrillation cardiac arrest is a weak measure of the duration of ischemia. High admission lactate levels are associated with severe neurological impairment. However, this parameter has poor prognostic value for individual estimation of the severity of subsequent functional neurological impairment.

Percutaneous cardiopulmonary bypass for therapy resistant cardiac arrest from digoxin overdose.

A 79-year 65 kg male called the ambulance service 4 h after ingestion of 100 tablets of digoxin 0.1 mg complaining of nausea and vomiting. The ECG showed an idioventricular escape rhythm with a heart rate of 30/min. After 0.5 mg atropine, heart rate increased to 80/min. Soon after admission to the emergency department, the patient developed electromechanical dissociation. Due to persistent cardiac arrest, percutaneous cardiopulmonary bypass was started, and the ECG rhythm changed to ventricular fibrillation. Several attempts to terminate ventricular fibrillation by electrical defibrillation failed. Fifty-eight minutes after cardiac arrest, antidigoxin-Fab was administered and 1 h 25 min after cardiac arrest, ventricular fibrillation was terminated by the tenth electrical defibrillation attempt. Initially, the patient's overall status improved over the next 2 days, but then he developed a severe adult respiratory distress syndrome and died of unresponsive septic shock 12 days after ingestion of digoxin. This case demonstrates that percutaneous cardiopulmonary bypass may provide support in patients with cardiac arrest due to massive digoxin overdose. This temporary support can maintain adequate tissue perfusion during the time required for drug neutralization in order to achieve successful defibrillation. Percutaneous cardiopulmonary bypass should be considered in patients with severe, but temporary cardiac dysfunction due to a life-threatening drug overdose.

Effects of manual high-impulse CPR on myocardial perfusion during cardiac arrest in pigs.

The aim of the study was to compare the effect of a 30 and 50% duty cycle on coronary perfusion pressure (CPP) and end tidal carbon dioxide (ETCO2) and to determine whether a duty cycle of 30% can be achieved manually. After 3 min of ventricular fibrillation cardiac arrest, pigs were resuscitated in two groups with changing duty cycles every 3 min: group A starting with 50 and then 30%; and group B starting with 30 and then 50%. After administration of epinephrine, duty cycles in group A were 50 and then 30%, in group B initially 30% and then 50% Before administration of epinephrine, no significant differences in CPP between the 30 and 50% duty cycles were found; after epinephrine CPP increased with both duty cycles. ETCO2 did not vary before epinephrine; after epinephrine, there were statistically significant differences but there is doubt regarding the clinical relevance of these differences. Survival was 4/6 in group A and 3/5 in group B (NS). It is possible to perform a manual duty cycle of 30%. However, our data do not support the use of a 30% duty cycle during cardiopulmonary resuscitation (CPR).

Fructose-1,6-bisphosphate and MK-801 by aortic arch flush for cerebral preservation during exsanguination cardiac arrest of 20 min in dogs. An exploratory study.

In our exsanguination cardiac arrest (CA) outcome model in dogs we are systematically exploring suspended animation (SA), i.e. preservation of brain and heart immediately after the onset of CA to enable transport and resuscitative surgery during CA, followed by delayed resuscitation. We have shown in dogs that inducing moderate cerebral hypothermia with an aortic arch flush of 500 ml normal saline solution at 4 degrees C, at start of CA 20 min no-flow, leads to normal functional outcome. We hypothesized that, using the same model, but with the saline flush at 24 degrees C inducing minimal cerebral hypothermia (which would be more readily available in the field), adding either fructose-1,6-bisphosphate (FBP, a more efficient energy substrate) or MK-801 (an N-methyl-D-aspartate (NMDA) receptor blocker) would also achieve normal functional outcome. Dogs (range 19-30 kg) were exsanguinated over 5 min to CA of 20 min no-flow, and resuscitated by closed-chest cardiopulmonary bypass (CPB). They received assisted circulation to 2 h, mild systemic hypothermia (34 degrees C) post-CA to 12 h, controlled ventilation to 20 h, and intensive care to 72 h. At CA 2 min, the dogs received an aortic arch flush of 500 ml saline at 24 degrees C by a balloon-tipped catheter, inserted through the femoral artery (control group, n=6). In the FBP group (n=5), FBP (total 1440 or 4090 mg/kg) was given by flush and with reperfusion. In the MK-801 group (n=5), MK-801 (2, 4, or 8 mg/kg) was given by flush and with reperfusion. Outcome was assessed in terms of overall performance categories (OPC 1, normal; 2, moderate disability; 3, severe disability; 4, coma; 5, brain death or death), neurologic deficit scores (NDS 0-10%, normal; 100%, brain death), and brain histologic damage scores (HDS, total HDS 0, no damage; >100, extensive damage; 1064, maximal damage). In the control group, one dog achieved OPC 2, one OPC 3, and four OPC 4; in the FBP group, two dogs achieved OPC 3, and three OPC 4; in the MK-801 group, two dogs achieved OPC 3, and three OPC 4 (P=1.0). Median NDS were 62% (range 8-67) in the control group; 55% (range 34-66) in the FBP group; and 50% (range 26-59) in the MK-801 group (P=0.2). Median total HDS were 130 (range 56-140) in the control group; 96 (range 64-104) in the FBP group; and 80 (range 34-122) in the MK-801 group (P=0.2). There was no difference in regional HDS between groups. We conclude that neither FBP nor MK-801 by aortic arch flush at the start of CA, plus an additional i.v. infusion of the same drug during reperfusion, can provide cerebral preservation during CA 20 min no-flow. Other drugs and drug-combinations should be tested with this model in search for a breakthrough effect.

Thiopental and phenytoin by aortic arch flush for cerebral preservation during exsanguination cardiac arrest of 20 minutes in dogs. An exploratory study.

We are systematically exploring in our exsanguination cardiac arrest (CA) outcome model in dogs suspended animation (SA), i.e. immediate preservation of brain and heart for resuscitative surgery during CA, with delayed resuscitation. We have shown in dogs that inducing moderate cerebral hypothermia with an aortic arch flush of 500 ml normal saline solution of 4 degrees C, at start of CA 20 min no-flow, leads to normal functional outcome. We hypothesized that, using the same model, adding thiopental (or even better thiopental plus phenytoin) to the flush at ambient temperature (24 degrees C), which would be more readily available in the field, will also achieve normal functional outcome. Thirty dogs (20-28 kg) were exsanguinated over 5 min to CA of 20 min no-flow, and resuscitated by closed-chest cardiopulmonary bypass. They received assisted circulation to 2 h, 34 degrees C post-CA to 12 h, controlled ventilation to 20 h, and intensive care to 72 h. At CA 2 min, the dogs received an aortic arch flush of 500 ml saline at 24 degrees C by a balloon-tipped catheter, inserted through the femoral artery (control group 1, n=14). In group 2 (n=9), thiopental (variable total doses of 15-120 mg/kg) was added to the flush and given with reperfusion. In group 3 (n=7), thiopental (15 or 45 mg/kg) plus phenytoin (10, 20, or 30 mg/kg) was given by flush and with reperfusion. Outcome was assessed in terms of overall performance categories (OPC 1, normal; 2, moderate disability; 3, severe disability; 4, coma; 5, brain death), neurologic deficit scores (NDS 0-10%, normal; 100%, brain death), and histologic deficit scores (HDS, total and regional). The flush reduced tympanic temperature to about 36 degrees C in all groups. In control group 1, one dog achieved OPC 1, three OPC 2, six OPC 3, and four OPC 4. In thiopental group 2, two dogs achieved OPC 1, two OPC 3, and five OPC 4. In thiopental/phenytoin group 3, one dog achieved OPC 1, two OPC 3, and four OPC 4 (p=0.5). Median NDS were 36% (IQR 22-62%) in group 1; 51% (IQR 22-56%) in group 2; and 55% (IQR 38-59%) in group 3 (p=0.7). Median total HDS were 67 (IQR 56-127) in group 1; 60 (IQR 52-138) in group 2; and 76 (IQR 48-132) in group 3 (p=1.0). Thiopental and thiopental/phenytoin dogs achieved significantly lower HDS only in the putamen. Thiopental in large doses caused side effects. We conclude that neither thiopental alone nor thiopental plus phenytoin by flush, with or without additional intravenous infusion, can consistently provide 'clinically significant' cerebral preservation for 20 min no-flow. Other drugs and drug-combinations should be tested with this model in search for a breakthrough effect.

Adenosine by aortic flush fails to augment the brain preservation effect of mild hypothermia during exsanguination cardiac arrest in dogs - an exploratory study.

Most trauma cases with rapid exsanguination to cardiac arrest (CA) in the field, as well as many cases of normovolemic sudden cardiac death are 'unresuscitable' by standard cardiopulmonary-cerebral resuscitation (CPCR). We are presenting a dog model for exploring pharmacological strategies for the rapid induction by aortic arch flush of suspended animation (SA), i.e. preservation of cerebral viability for 15 min or longer. This can be extended by profound hypothermic circulatory arrest of at least 60 min, induced and reversed with (portable) cardiopulmonary bypass (CPB). SA is meant to buy time for transport and repair during pulselessness, to be followed by delayed resuscitation to survival without brain damage. This model with exsanguination over 5 min to CA of 15-min no-flow, is to evaluate rapid SA induction by aortic flush of normal saline solution (NSS) at room temperature (24 degrees C) at 2-min no-flow. This previously achieved normal functional recovery, but with histologic brain damage. We hypothesized that the addition of adenosine would achieve recovery with no histologic damage, because adenosine delays energy failure and helps repair brain injury. This dog model included reversal of 15-min no-flow with closed-chest CPB, controlled ventilation to 20 h, and intensive care to 72 h. Outcome was evaluated by overall performance, neurologic deficit, and brain histologic damage. At 2 min of CA, 500 ml of NSS at 24 degrees C was flushed (over 1 min) into the brain and heart via an aortic balloon catheter. Controls (n=5) received no drug. The adenosine group (n=5) received 2-chloro-adenosine (long acting adenosine analogue), 30 mg in the flush solution, and, after reperfusion, adenosine i.v. over 12 h (210 microg/kg per min for 3 h, 140 microg/kg per min for 9 h). The 24 degrees C flush reduced tympanic membrane temperature (T(ty)) within 2 min of CA from 37.5 to approximately 36.0 degrees C in both groups. At 72 h, final overall performance category (OPC) 1 (normal) was achieved by all ten dogs of the two groups. Final neurologic deficit scores (NDS; 0-10% normal, 100% brain death) were 5+/-3% in the control group versus 6+/-5% in the adenosine group (NS). Total brain histologic damage scores (HDS) at 72 h were 74+/-9 (64-80) in the control group versus 68+/-19 (40-88) in the adenosine group (NS). In both groups, ischemic neurons were as prevalent in the basal ganglia and neocortex as in the cerebellum and hippocampus. The mild hypothermic aortic flush protocol is feasible in dogs. The adenosine strategy used does not abolish the mild histologic brain damage.

Mandibular replacement after resection for tumor.

The ideal natural or prosthetic mandibular replacement should be adjustable at the time of surgery, completely stable, free from tissue reaction or rejection, rapidly incorporated into surrounding tissue, and unlimited in lifespan. A brief review of clinically utilized mandibular replacements is discussed in relation to the ideals. At this time the replacement most adequately satisfying these principles is autogenous cancellous bone and marrow supported by a titanium mesh trough. This article describes the details of external mandibular fixation and the reconstructive procedure including preoperative preparation and common postoperative complications. Modifications of the prosthesis and surgical technique are suggested in order to decrease the chances of postoperative exposure, a complication in any type of mandibular reconstruction.

Primary osteoma of the sphenoid sinus.

Osteomas of the nose and paranasal sinuses are rather common benign tumors arising in the head and neck area. The sphenoid sinus is involved in various inflammatory and neoplastic conditions; however, an osteoma arising from the sphenoid sinus proper has not been reported in the available literature. This paper reviews, in detail, osteomas of the paranasal sinuses and their incidence, and a case of a sphenoid sinus osteoma is presented with radiological and pathological findings.

Rapid induction of mild cerebral hypothermia by cold aortic flush achieves normal recovery in a dog outcome model with 20-minute exsanguination cardiac arrest.

OBJECTIVES: Resuscitation attempts in trauma victims who suffer cardiac arrest (CA) from exsanguination almost always fail. The authors hypothesized that an aortic arch flush with cold normal saline solution (NSS) at the start of exsanguination CA can preserve cerebral viability during 20-minute no-flow. METHODS: Twelve dogs were exsanguinated over 5 minutes to CA of 20-minute no-flow, resuscitated by cardiopulmonary bypass, followed by post-CA mild hypothermia (34 degrees C) continued to 12 hours, controlled ventilation to 20 hours, and intensive care to 72 hours. At CA 2 minutes, the dogs received a 500-mL flush of NSS at either 24 degrees C (group 1, n = 6) or 4 degrees C (group 2, n = 6), using a balloon-tipped catheter inserted via the femoral artery into the descending thoracic aorta. RESULTS: The flush at 24 degrees C (group 1) decreased tympanic membrane temperature [mean (+/-SD)] from 37.5 degrees C (+/-0.1) to 35.7 degrees C (+/-0.2); the flush at 4 degrees C (group 2) to 34.0 degrees C (+/-1.1) (p = 0.005). In group 1, one dog achieved overall performance category (OPC) 2 (moderate disability), one OPC 3 (severe disability), and four OPC 4 (coma). In group 2, four dogs achieved OPC 1 (normal), one OPC 2, and one OPC 3 (p = 0.008). Neurologic deficit scores (0-10% normal, 100% brain death) [median (25th-75th percentile)] were 62% (40-66) in group 1 and 5% (0-19) in group 2 (p = 0.01). Total brain histologic damage scores were 130 (62-137) in group 1 and 24 (10-55) in group 2 (p = 0.008). CONCLUSIONS: Aortic arch flush of 4 degrees C at the start of CA of 20 minutes rapidly induces mild cerebral hypothermia and can lead to normal functional recovery with minimal histologic brain damage. The same model with aortic arch flush of 24 degrees C results in survival with brain damage in all dogs, which makes it suitable for testing other (e.g., pharmacologic) preservation potentials.

[Recollections of ventilated patients after a stay in the intensive care unit]. / Erinnerungsreste beatmeter Patienten nach Aufenthalt an der Intensivstation.

UNLABELLED: A review of the literature reveals only scarce data and observations concerning the recollections of patients treated in a intensive care unit, although intraoperative awareness under general anaesthesia has been extensively reported. In the present study we investigated the recollections of patients who had undergone artificial ventilation in intensive care units. METHODS: Fifty patients who had undergone mechanical ventilation in intensive care units at the University Hospital of Vienna were retrospectively interviewed in regard of their experience during the treatment. A score was used to quantify discomfort. RESULTS: All patients remembered having been treated at the intensive care unit. The most unpleasant experience was tracheal suctioning which was remembered by 60%. The next most unpleasant experience was extubation; 52% remembered this intervention. Eighty-four per cent of patients remembered the medical staff, 90% of them had confidence in them, 86% remembered the nursing staff and 91% had confidence in them. CONCLUSION: In spite of unpleasant memories of intensive care treatment, of which tracheal suctioning was perceived as most unpleasant, the majority of patients expressed a positive evaluation of their treatment at the intensive care unit.

Intraoral keloid: complication of forehead flap.

Intraoral keloids are rare de novo, but can occur on transplanted skin. A case in which an unusual complication of forehead flap reconstruction resulted in the formation of a large keloid in the oral cavity is presented. Therapy is discussed.

[Radiologic healing phenomena in chronic polyarthritis treated with methotrexate or sodium aurothiomalate]. / Radiologische Heilungsphänomene bei chronischer Polyarthritis unter Behandlung mit Methotrexat oder Natriumaurothiomalat.

PROBLEM: Do radiographs of hands and forefeet obtained from patients with rheumatoid arthritis present with healing phenomena? What is their importance relative to progressive changes? METHODS: Dorsopalmar/-plantar radiographs of hands and forefeet of 43 patients with early rheumatoid arthritis (median disease duration 1.7 years, anatomical Steinbrocker's age < or = 2, patients selected from a prospective study, treatment with methotrexate vs gold-sodiumthiomalate) were obtained at months 0, 6, 12, 24 and 36. Radiographs were evaluated without knowing the mode of treatment at 34 sites according to their time sequence for the following variables: a modified Larsen index, numbers of erosive and of radiologically active joints, and the numbers of joints being improved vs. deteriorated in relation to the preceding x-ray. RESULTS: The radiologic progression could be measured by both a score derived from the modified Larsen index as well as by the numbers of erosive joints with the result of an increasingly crescent, but flattening curve. The number of erosive joints was more sensitive to progression than the score derived from Larsen index. The number of joints deteriorating, compared with the preceding x-ray, decreased from month 6 to month 36 from 16.1% to 7.1% resp. At the same time, 90% of patients increasingly developed radiologic improvement in 2.9% zu 9.3% of joints, including diminution in size and recortication of erosions and particular cysts with a "filling in" by trabecular bone and recovery of a bony outline. There were no relevant differences between therapy groups. CONCLUSIONS: Progression in early rheumatoid arthritis is best measured by the number of joints with erosions. Reparative signs show up with increasing frequency during the course of the disease. After 3 years of treatment the numbers of joints exhibiting improvement predominate those with deterioration. The data support the concept of early aggressive therapy of rheumatoid arthritis and suggest the inclusion of reparative phenomena into the criteria for improvement of this disease.

Time course of serum neuron-specific enolase. A predictor of neurological outcome in patients resuscitated from cardiac arrest.

BACKGROUND AND PURPOSE: The prediction of neurological outcome in comatose cardiac arrest survivors has enormous ethical and socioeconomic implications. The purpose of the present study was to investigate the prognostic relevance of the time course of serum neuron-specific enolase (NSE) as a biochemical marker of hypoxic brain damage. METHODS: Serial analysis of serum NSE levels was performed in 56 patients resuscitated from witnessed, nontraumatic, normothermic, in- or out-of-hospital cardiac arrest. The neurological outcome was evaluated with the use of the cerebral performance category (CPC) within 6 months after restoration of spontaneous circulation (ROSC). The Mann-Whitney U test was used to compare patients with good (CPC 1 to 2) and bad (CPC 3 to 4) neurological outcome. The diagnostic performance at different time points after ROSC was described in terms of areas under receiver operating characteristic curves according to standard methods. RESULTS: Patients with a bad neurological outcome (CPC 3 to 4) had significantly higher NSE levels than those with a good neurological outcome at 12 (P=0.004), 24 (P=0.04), 48 (P<0.001), and 72 hours (P<0.001) after ROSC. The maximum NSE level measured within 72 hours after ROSC was also significantly higher in patients with a bad neurological outcome (P<0.001). The NSE value at 72 hours after ROSC was the best predictor of neurological outcome (area under the curve=0.92+/-0.04). In addition, we also found a significant difference in the time course of NSE concentrations during the first 3 days after ROSC. CONCLUSIONS: Serum NSE levels are valuable adjunctive parameters for assessing neurological outcome after cardiac arrest.