[Advance directives in the prehospital setting -- emergency physicians' attitudes]. / Patientenverfügungen in der präklinischen Notfallmedizin: Eine Befragung von Notärzten.

OBJECTIVE: The German physician based emergency medical system (EMS) might confront physicians with advance directives in the field. A multi-question survey was used to evaluate emergency physicians' experience with advance directives in the prehospital setting and to assess their attitudes towards forms and statements of advance directives. METHODS: A questionnaire was mailed to the members of the Association of Emergency Physicians of Northern Germany ("AGNN"), an interest group of emergency physicians, in 2001. RESULTS: 511 emergency physicians (50,4 % of the AGNN members) filled in the questionnaire completely and sent it back for evaluation. 75 % of the participants were working as emergency physicians at present, 72 % had emergency experiences of more than 5 years. One third had previously dealt with advance directives in the prehospital setting. 77 % of these physicians thought advance directives generally helpful. Nevertheless 88 % based their management on the context of the individual circumstances (e. g. emergency conditions, underlying diseases, expected prognosis), only 7 % said they would always exactly follow the statements of the directive. In the view of the emergency physicians the advance directive should contain information on cardiopulmonary resuscitation (CPR: 88 %), intensive care-treatment (75 %) and preclinical emergency treatment (55 %). Information on underlying diseases (87 %) and a legal substitute (84 %) should be contained as well. As formal requirements, 47 % of the physicians wanted the family doctor to be involved, 49 % desired a notary authenticity confirmation, additionally or solely. Pragmatically, the advance directive should be kept with the personal documents (84 %). A regular reconfirmation was deemed necessary (twice to once a year: 64 %). The current legal situation was regarded as unclear by 81 % of the emergency physicians, 85 % favored a unique, officially authorized type of directive. CONCLUSION: The high number of returned questionnaires shows the importance of the topic "advance directives" for emergency physicians. Despite some practical and legal problems, a big majority of the experienced emergency physicians in this survey thought the advance directives in the prehospital setting to be helpful. A clear statement on resuscitation as well as simplification of the many existing types of directives are the most essential requirements demanded by the emergency physicians. A solution could be the creation of an extra "emergency advance directive".

[New pathways in undergraduate medical education - first experiences with the cross section speciality emergency and intensive care medicine]. / Neue Wege der studentischen Lehre - Erste Erfahrungen im Querschnittsbereich Notfall- und Intensivmedizin.

OBJECTIVE: On October 1 (st) 2003 Emergency Medicine was recognised for the first time as an independent cross section speciality in the new German "Approbationsordnung fuer Aerzte" (Medical Licensing Regulations). These amendments were made not only to increase the amount of small group teaching sessions but also to encourage a multidisciplinary and rather practical approach to the related topics. This article portrays the realisation of these objectives in form of a multidisciplinary module, as it has been established at University of Göttingen Medical School since the summer semester of 2004. We present the new curriculum, calculate the associated personnel resources and demonstrate the results of the structured evaluation given by the participating students. METHODS: We linked the fields of emergency and intensive care medicine by splitting them up into submodules which the students had to run through according to a set rota. 162 students were allocated to 27 small groups. Every student received a total of 38.5 hours of teaching, with the workshops coming to 46.8 %. The workshops comprised of nine sessions, three in Emergency Medicine, four in Intensive Care Medicine and two at human patient simulators. In addition we scheduled a seminar and an accompanying lecture. The final examination was performed as an Objective Structured Clinical Evaluation (OSCE). RESULTS: The realisation of the new module required a total of 1290 working hours for medical staff and 130 for our student aids. Compared to all other modules of Goettingen University Medical School the module here presented obtained the highest overall evaluation score by the medical students. Lessons with a high amount of practical involvement (i. e. Emergency Medicine and simulator-based workshops) were significantly better evaluated than rather formal teaching techniques, such as the lectures and the seminar. According to the students' self-assessment the simulator-based workshops were seen particularly valuable for the facilitation of knowledge transfer into clinical practice. CONCLUSION: The determined realisation of the new German Medical Licensing Regulations requires considerable time resources. However, its evaluation by the medical students is strikingly positive.

Do intracellular, extracellular or urinary magnesium concentrations predict renal retention of magnesium in critically ill patients?

BACKGROUND AND OBJECTIVE: Magnesium disorders are common in hospitalized patients. In patients with low or normal magnesium, the intravenous magnesium loading test has been demonstrated to be a sensitive test to assess magnesium deficiency in critically ill patients. However, it is more time consuming and more difficult than the measurement of intracellular or extracellular magnesium concentrations. This study evaluated whether erythrocyte, plasma and urinary magnesium concentrations predict renal magnesium retention measured by th magnesium loading test. METHODS: One-hundred-and-three intensive care patients (36 females, 67 males) in a tertiary care centre and 41 healthy subjects (13 females, 28 males) took part in this prospective study. Intracellular, total plasma, ionize extracellular and urinary magnesium concentrations were measured and also magnesium retention by intravenous magnesium loading test. RESULTS: Total plasma magnesium concentration was poorly correlated with magnesium retention (r = 0.36 r2 = 0.13) and was the only parameter that significantly predicted magnesium retention in intensive care patients (P < 0.01). However, only 10% of the magnesium retention data were linked to the total plasma magnesium concentration. CONCLUSIONS: Total plasma magnesium concentration predicts magnesium retention in critically ill intensive care patients but not intracellular and urinary magnesium concentrations. Only a small proportion of the magnesium retention was due to the total plasma magnesium concentration.

[Spontaneous breathing and stable hemodynamics during severe accidental hypothermia (22 degrees C)]. / Erhaltene Spontanatmung und stabile Hämodynamik trotz schwerer akzidentieller Hypothermie (22 C).

We present a case of severe accidental hypothermia (core temperature 22 degrees C) after a suicide attempt. The initial symptoms and the pre-hospital and hospital treatment are discussed. Additionally, different rewarming strategies for patients with severe accidental hypothermia are compared.

[Evaluation of the disability of ventilated patients]. / Untersuchung zur Befindlichkeit von beatmeten Patienten.

OBJECTIVE: It is very important to investigate the patient's disability and pain. Interviews of intubated and tracheotomised patients were neglected because of inadaequate measuring methods. This is the first prospective study that evaluates the disability and pain of intubated and tracheotomised patients. METHODS: Disability, Hospital Anxiety and Depression Scale, Visuelle Analogue Scale, Glasgow Coma Scale and structured questions were used to investigate the disability and pain of ventilated patients. 26 patients of an interdisciplinary operative intensive care unit took part in the study. Sociodemographic parameters, ventilation, sedation and pain were evaluated. Doctors and nurses were asked to assess the patient's pain and disability. RESULTS: 17 intubated and 9 tracheotomised patients were included in the study. Mean intensity of pain was 30.3 (SD = 31.4), anxiety 40.8 (SD = 31.4), disability 30.0 (SD = 11.5) and disability caused by ventilation 61.9 (SD = 28.5). 46.2 % of the patients had a pathological subscale of anxiety and 50 % of depression in the Hospital Anxiety and Depression Scale. Nurses assessed the patient's disability and pain better than the doctors. CONCLUSION: A high disability has to be taken in account in the therapy of intubated and tracheotomised patients.

High-dose midazolam and the attenuation of the contractile response to vasoconstrictors in coronary artery segments.

BACKGROUND AND OBJECTIVE: Benzodiazepines may cause hypotension and are reported to interfere with smooth vascular muscle activity. The aim was to elucidate the influence of three different benzodiazepines on the vascular reactivity of coronary arteries. METHODS: Using the model of isolated vessels, we studied the impact of midazolam (0.15, 1.5, 15 microg mL(-1)), diazepam (0.1, 1.0, 10 microg mL(-1)) and flunitrazepam (0.01, 0.1, 1.0 microg mL(-1)) on the contractile responses to histamine (2 x 10(-5) mol L(-1)) and serotonin (3 x 10(-5) mol L(-1)) in isolated intact and denuded coronary arteries. RESULTS: Midazolam significantly attenuated the contractile response when administered in high concentrations (15 microg mL(-1)). This effect was more pronounced in intact than in denuded preparations (histamine: -22.7 versus -7.3%, P = 0.0079; serotonin: -47.1 versus -15.9%, P < 0.0001). Diazepam and flunitrazepam exerted no significant effects on the vascular tone of coronary arteries. CONCLUSIONS: Midazolam, but not diazepam or flunitrazepam, attenuates the contractile responses to vasoconstrictors in concentrations beyond those used in clinical practice. This effect is in part mediated by endothelial factors.

[To resuscitate or not? The emergency physician's decision in the prehospital setting]. / Reanimieren oder nicht? Die notärztliche Entscheidung im Rettungsdienst.

OBJECTIVE: To identify factors affecting the decision to withhold resuscitative attempts or to terminate cardiopulmonary resuscitation (CPR) in the prehospital setting. METHODS: In a physician-based emergency medical system (EMS) standardised interviews with the emergency physicians were performed within 24 hours after unsuccessful or withheld CPR-efforts. RESULTS: Over a period of one year 170 prehospital cardiac arrests were evaluated. 47 patients (28 %) were declared dead on arrival by the emergency physician. The decision to withhold CPR was based on obvious clinical signs of death (32 patients) or the diagnosis of cardiac arrest due to severe trauma (8 patients). In 4 cases the terminal state of a fatal illness was the emergency physician's criterion not to initiate resuscitative efforts. In 3 patients an extended response time (more than 10 minutes) was mentioned, in combination with a primary rhythm of either asystole or electromechanical dissociation and additional information given by the family doctor. In 123 patients CPR was attempted. In 72 cases (59 %) resuscitative efforts were terminated as no return and stabilisation of spontaneous circulation was achieved. In 58 patients the decision to stop CPR was based on the evidence of cardiac death. Additional criteria for the termination of the resuscitation attempt were the duration of CPR, an extended response time, pre-existing diseases, age, pupillary status, missing brain stem reflexes, the reason of cardiac arrest, information given by the family or the family doctor and secondarily evolving signs of death. In 14 patients the emergency physicians reported that their decision to terminate CPR was primarily based on these co-factors, the evidence of cardiac death was not explicitly mentioned in these cases. CONCLUSION: In the pre-hospital setting the decision to withhold or to withdraw CPR is mostly based on reliable criteria such as obvious clinical signs of death, fatal trauma or evidence of cardiac death. Nevertheless, in a small but considerable number of cases exceptions to this rule are made by emergency physicians.

Can manipulation of the ratios of essential fatty acids slow the rapid rate of postmenopausal bone loss?

The rapid rate of postmenopausal bone loss is mediated by the inflammatory cytokines interleukin-1, interleukin-6, and tumor necrosis factor alpha. Dietary supplementation with fish oil, flaxseeds, and flaxseed oil in animals and healthy humans significantly reduces cytokine production while concomitantly increasing calcium absorption, bone calcium, and bone density. Possibilities may exist for the therapeutic use of the omega-3 fatty acids, as supplements or in the diet, to blunt the increase of the inflammatory bone resorbing cytokines produced in the early postmenopausal years, in order to slow the rapid rate of postmenopausal bone loss. Evidence also points to the possible benefit of gamma-linolenic acid in preserving bone density.

[Symptom control in palliative medicine]. / Symptomkontrolle in der Palliativmedizin.

Palliative medicine has as its goal improving the quality of life of patients with incurable diseases and their family members. According to the WHO, alleviating pain and other physical symptoms, as well as addressing psycho-social and spiritual problems have the highest priority. The role of medicine and the physician is inseparably linked to psycho-social and nursing resources in a multi-disciplinary team. Advanced stages of cancer are particularly characterized by symptoms which can cause lasting impairment of normal life. In addition to pain, patients suffer from other, often extremely distressing physical symptoms such as constipation, nausea and vomiting, gastrointestinal obstruction and difficulty in breathing. The first priority is to determine the causes of the individual symptoms, since therapeutic decisions are based on the specific pathophysiological mechanisms. Effective symptom management presupposes exact knowledge of the pharmacokinetics. The often difficult decision between causal and symptomatic therapy options must - whenever possible - be made together with the patient and frequently in interdisciplinary medical consultation. Tumor pain therapy follows the guidelines of the World Health Organization. Crucial are long-term therapy and dose titration of the analgesics, stepped progression between the groups of medication, and specific therapy approaches for neuropathic pain components. The significance of constipation with its variety of possible complications is often underestimated in the context of the tumor patient. Effective prophylaxis and cause-based therapy do improve the nutritional care and can help to prevent the transition to an ileus. New findings concerning the role of neurotransmitters in triggering nausea and vomiting have opened up specific methods of attack. Dyspnoea therapy places high demands on the medical team, since nursing measures must effectively supplement the more limited medical possibilities.

Cost-effectiveness of anaesthesia.

Cost-effectiveness analyses of anaesthesia regimens will become more and more important in the future because of increasing pressure to reduce the cost of health care. Inhalational and intravenous techniques are vying for the position of being the most cost-effective form of general anaesthesia. However, erroneous or misleading results are a considerable risk if the boundary conditions of the analyses are not chosen carefully. Recent comparative studies on this topic are analyzed with regard to their results and to the premises under which they were conducted.

[Basics of drug therapy of cancer pain]. / Grundlagen der medikamentösen Tumorschmerztherapie.

Industrial countries experience a significant increase of cancer prevalence. Despite recent advances in the treatment of various types of cancer still most of the patients cannot be cured. Especially the advanced incurable stages of cancer, however, often are accompanied by severe pain. Therefore, the high demand for a sufficient pain management and symptom control seems obvious. Throughout the last decades new drugs and techniques for the management of cancer pain have been developed. Most cancer patients should experience sufficient pain-management if existing recommendations for the pharmacological treatment of cancer pain (e.g. WHO-guidelines) are followed consequently. If, nevertheless, intractable pain or ongoing disabling symptoms continue despite proper therapy, every doctor should feel himself obliged to consult an expert in palliative medicine, in order not to tolerate avoidable suffering of his patient.

[Treatment of constipation and different laxative requirements in palliative medicine]. / Obstipationsbehandlung und differenzierter Laxanzieneinsatz in der Palliativmedizin.

The significance of constipation with its variety of possible complications is often underestimated in the context of the tumour patient's complaints although difficulties in stool management are more common in patients with advanced cancer than in those with other terminal diseases. Without treatment constipated patients will suffer from nausea and emesesis and will possibly develop small bowel paralysis. About half of all patients admitted to specialist palliative care units report constipation, but about 75% of the patients will require laxatives. Unlike for pain, no generally accepted and widely disseminated management guidelines are available. Effective prophylaxis and cause-based therapy do improve the alimentary condition and can help to prevent the transition to ileus situations. Effective symptom management presupposes exact knowledge of the pharmacokinetics.

Influence of opioids on the vascular tone of isolated porcine coronary artery segments.

BACKGROUND: It was the aim of this study to elucidate the influence of opioids on coronary vascular tone using the model of isolated porcine coronary artery segments. METHODS: We studied the effects of fentanyl (0.01, 0.1, 1.0 microg ml(-1)), alfentanil (0.1, 1.0, 10 microg ml(-1)), and sufentanil (0.01, 0.1, 1.0 microg ml(-1)) on the contractile response to three vasoconstrictors, acetylcholine, histamine and serotonin. RESULTS: Fentanyl (0.1, 1.0 microg x ml(-1)) dose-dependently attenuated the contractile response to acetylcholine, but not to histamine and serotonin. There were no differences in fentanyl's vasorelaxing potency between rings with intact and denuded endothelium. Alfentanil and sufentanil did not exert any significant influence on any of the vasoconstrictors tested. CONCLUSION: It is concluded that, in isolated porcine coronary artery rings, fentanyl at high concentrations has an attenuating effect on acetylcholine-induced contractions, which is independent of endothelial function, whereas alfentanil and sufentanil do not influence coronary vascular tone.

Do muscle relaxants influence vascular tone in isolated coronary artery segments?

The aim of this study was to elucidate the influence of four neuromuscular blocking substances on coronary vascular tone using the model of isolated porcine coronary artery segments. We studied the effects of four muscle relaxants, atracurium, pancuronium, rocuronium, and vecuronium (0.1, 1, and 10 microg mL-1 each), on the contractile response to three vasoconstrictors: acetylcholine, histamine, and serotonin. None of the neuromuscular blocking agents under investigation exerted a significant influence on the vasoconstricting effects of these mediators except for pancuronium, which dose-dependently attenuated acetylcholine-mediated contractions (-10.8% attenuation for 10 microg mL-1 pancuronium, P < 0.05). There was no difference between vessels with intact endothelium and denuded preparations. It is concluded that high-dose pancuronium exerts an antimuscarinic effect in vascular smooth muscle. The other neuromuscular agents studied do not alter vascular reactivity of isolated porcine coronary arteries.

Propofol and thiopental attenuate the contractile response to vasoconstrictors in human and porcine coronary artery segments.

The effects of propofol and thiopental on three vasoconstrictors, acetylcholine, histamine, and serotonin were studied in isolated porcine and human coronary artery rings. Propofol and thiopental attenuated the contractile response to all mediators in a dose-dependent manner. This dilating effect was fairly weak using low concentrations (propofol 1 microg mL-1 and 10 microg mL-1, thiopental 5 microg mL-1 and 10 microg mL-1). In the presence of high concentrations (propofol 100 microg mL-1, thiopental 50 microg mL-1) marked relaxation was observed (propofol -32% up to -49%, P < 0,05; thiopental -23% up to -67%, P < 0.05). These dilating effects were seen both in intact and denuded rings, the differences were not significant. Human coronary artery segments were relaxed by thiopental (-22% to -76%) and propofol (-11% to -67%) to a similar extent. Our data indicate that propofol and thiopental relax isolated coronary segments in a dose-dependent manner, and that there is no evidence that these effects are dependent of endothelial factors.

[Euthanasia in Europe--ten countries with special consideration of the Netherlands and Germany]. / Sterbehilfe in Europa. Eine Bestandsaufnahme am Beispiel von zehn Ländern unter besonderer Berücksichtigung der Niederlande und Deutschlands.

This article presents an overview of the current situation of euthanasia in Europe. Emphasis is given to the positions discussed in the Netherlands and in Germany. The current situation, the development of the legal positions, and the resulting debate are established by analysing English and German anesthesiological and medical-ethical journals. It has to be noted that many physicians are not satisfied with the terminology of euthanasia. The traditional concepts of euthanasia do not cover the aspect of accompanying terminally ill persons until they have died. The differentiation of active, passive, and indirect euthanasia does not correspond to the practical handling of the problem. Many physicians are in need of an open discussion of euthanasia-related issues. The way euthanasia is practiced in the Netherlands has strongly influenced the further development of the debate in Europe. Even though the Dutch model is rejected by the jurisdications of virtually all other countries, and official statements of medical corporations stick to the disapproval of active euthanasia, studies examining the attitudes towards euthanasia and the treatment of it in daily routine show that active interventions to shorten life are performed to different degrees outside of the Netherlands as well.