[Skill retention using extraglottic airways in out-of-hospital emergencies: efficacy and long-term results of simulator-based medical education : A prospective follow-up study]. / Routineerhalt beim Umgang mit extraglottischen Atemwegen im Rettungsdienst: Effektivität und Nachhaltigkeit einer simulatorbasierten Ausbildung : Eine prospektive 2­zeitige Simulatorstudie.

OBJECTIVE: For emergency medicine personnel (EMP), there is little evidence concerning the adequate timing for refresher courses to maintain routine in the application of extraglottic airways. The aim of this study was to evaluate the efficacy and long-term results of a simulator-based education concept teaching the basic airway management skills with extraglottic airways for EMP and also to draw conclusions concerning the adequate time interval for refresher courses. METHODS: By use of an explorative, prospective simulator-study with nonphysician EMP, airway management skills using the Larynxmaske Supreme® (LMA­S) after an introduction lecture were examined. The application of an endotracheal tube (ETT) served as control. Time for preparation of the airway devices, insertion success, and resulting apnea time were assessed immediately after the first introduction lecture (t1) and unannounced 9-12 months thereafter (t2). RESULTS: Comparison of the times for preparation of the LMA­S at t1 and t2 demonstrated similar results. After the introduction lecture, all paramedics were able to insert the LMA­S successfully after maximal 2 attempts; 9-12 months later success rates with the LMA­S were unchanged. Apnea time during airway management was shorter with the LMA­S compared to the ETT (p < 0.01). Times needed for preparation of the airway devices were similar. CONCLUSION: The results of this simulator study indicate that a standardized introduction lecture is appropriate to ensure long-lasting procedural skills up to 12 months, so that subsequent refresher courses in basic airway management with the LMA­S once a year may be adequate. A simulator-based education in basic airway management skills with extraglottic airways is recommended for facilitation of further clinical education according to the current guidelines.

The effect of a cervical collar on the seal pressure of the LMA Supreme™: a prospective, crossover trial.

For personnel inexperienced in airway management, supraglottic airway devices may be the first choice in an emergency. Changing head position is known to reduce the seal pressure of a laryngeal mask airway. The aim of this study was to investigate whether the use of a cervical collar improves the stability of airways secured with the LMA Supreme™ (The Laryngeal Mask Company Limited, Mahé, Seychelles). In this crossover trial, the primary endpoint was the difference in the seal pressure of the LMA Supreme in anaesthetised patients in maximum passive extension of the neck, with and without a cervical collar. The median (IQR [range]) seal pressure was 18 (13.8-22.1 [0-30]) cmH(2) O in maximum passive extension without a cervical collar. With a cervical collar in place, the seal pressure increased to 28 (22.8-30 [17-30]) cmH(2) O (p<0.001). In the neutral head position, the seal pressure was 22 (17.6-24.5 [12-30]) cmH(2) O without and 27 (22-30 [12-30]) cmH(2) O with a cervical collar in place (p<0.001). We found that a cervical collar stabilises the airway with an LMA Supreme in place and we recommend this combination for (pre-hospital) emergency cases.

Parathormone levels and Vitamin D metabolism in female patients with various grades of fecal elastase 1 deficiency.

BACKGROUND: There are still too few conclusive reports about conspicuous parathormone (PTH) and Vitamin D metabolism in patients with fecal elastase 1 deficiency or any connection of the calcium metabolism to the severity of exocrine pancreas insufficiency. METHODS: Between March 1998 and September 2002, we investigated on 240 female patients with fecal elastase 1 deficiency at an average age of approx. 56.4 years and suffering from meteorism and weight loss as well as on age matched 80 healthy female controls. Serum levels of PTH, total calcium, D subset3-vitamins, calcitriol and calcefediol, as well as the concentration of fecal elastase 1 were determined in patients and controls. RESULTS: In 240 female patients with deficiency of fecal elastase 1 only two patients show milder cases of new diagnosed primary hyperparathyroidism. Calcitriol was markedly decreased (14.3 +/- 6.1 and 20.7 +/- 9.4 pg/ml) compared to controls (41.8 +/- 8.3 pg / ml) ( p < 0.01). Calcefediol was not significantly different within the various elastase-groups (p = 0.07). Nevertheless, vitamin D subset3 and fecal elastase 1 in patients correlated significantly (p < 0.01) and, compared to controls, both were extremely low (means in patients. Both D subset3-vitamins in patients were significantly lower when elastase 1 in feces was under 200 microg/g compared to the others (for calcitriol p < 0.05, for calcefediol p < 0.05). CONCLUSION: In female patients elastase 1 in feces confirm the grade of vitamin D supply, and thus show a vitamin D subset3-deficiency, depending on the loss of stool content. There seems to be a connection here between the loss of exocrine function and may be even the characteristic of sterol-binding of elastase 1 in the pancreas, which seems to be relevant for vitamin D-supply.

Alterations of vitamin D3 metabolism in young women with various grades of chronic pancreatitis.

BACKGROUND: There are still too few conclusive reports about conspicuous vitamin D-deficiency in young female patients with chronic pancreatitis, or any connection of the deficiency to the severity of the disease. Therefore the aim of this study was to examine marker of vitamin D3 metabolism in female patients with episode of biliary pancreatitis to determine if increased severity of the disease would correlate with impaired vitamin D3 metabolism. METHODS: Between 1996 and 2003, we investigated 53 premenopausal patients with an average age of approximately 33 years suffering from an episode of chronic pancreatitis, as well as 30 female healthy controls with an average age of 32.4 years. The severity of chronic pancreatitis in patients was determined via endoscopic retrograde cholangiopancreaticography (ERCP) and assigned to 1 of 3 grades based on the Cambridge classification. Additional parameter assessed were demographics, smoking, consumption of alcohol and CD-transferrin, fasting metabolic parameters, biochemical markers of vitamin D3 metabolism and fecal elastase 1. None of the patients received hormone replacement therapy, Vitamin D or Calcium-supplementation. RESULTS: The serum levels of 1,25-dihydroxyvitamin D [1,25(OH2)D] were significantly reduced compared to female healthy controls. Fecal elastase 1 correlated with this classification of severity of chronic pancreatitis (p < 0.01). Furthermore, fecal elastase 1 of patients correlated the same way with both D-vitamins (p <0.01). The level of both D3 vitamins in patients were significantly lowered when the content of fecal elastase 1 was under 200 microg/g compared to the others [for 1,25-(OH2)D3 p < 0.01; 25-OH- D3 p < 0.01]. CONCLUSION: Premenopausal patients with chronic pancreatitis are at risk of developing decreased levels of 1,25(OH2)D3. This fact may contribute to a negative calcium balance and alteration of bone metabolism. Therefore, ERCP and fecal elastase 1 verify the severity grade of a chronic pancreatitis, and thus show a vitamin D3 deficiency in young women, depending on the progress of disease.

Vitamin D3 in patients with various grades of chronic pancreatitis, according to morphological and functional criteria of the pancreas.

There are still too few conclusive reports about conspicuous vitamin D deficiency in patients with chronic pancreatitis, or any connection of the deficiency to the severity of the disease. Between October 1999 and September 2000, we investigated 42 patients at an average age of 53 years, suffering from chronic pancreatits, as well as 20 healthy male controls at an average age of 49 years. Serum levels of D3 vitamins, 1,25-(OH)2-vitamin D3 and 25-(OH)-vitamin D3, as well as the concentration of fecal elastase 1 were determined in patients and controls. Furthermore, the severity of chronic pancreatitis in patients was determined via endoscopic retrograde cholangiopancreatography (ERCP) into 3 grades, based on the Cambridge classification. Elastase 1 in feces revealed sensitivities of 14%, 87%, and 95% for Cambridge-grades I, II, and III, respectively, and correlated significantly with this classification of severity of chronic pancreatitis (P < 0.01). In patients with Cambridge-grade II and III 1,25-(OH)2-D3 was markedly decreased (26.7 +/- 7.7 pg/ml and 27.6 +/- 9.0 pg/ml) compared to those with Cambridge-grade I (38.0 +/- 10.5 pg/ml; between I and II P = 0.027, between I and III P = 0.033). 25-(OH)-D-3 did not differ significantly within the various Cambridge-grade groups (P = 0.07). Nevertheless, vitamin D3 and fecal elastase 1 in patients correlated significantly (P < 0.01) and, compared to controls, both were extremely low (means in patients: fecal elastase 1 140.7 +/- 75.7 microg/g, 1,25-(OH)2-D3 29.9 +/- 9.5 pg/ml, 25-(OH)-D3 26.7 +/- 9.7 nmol/liter; controls: fecal elastase 1 694.9 +/- 138.6 microg/g, 1,25-(OH)2-D3 67.5 +/- 4.3 pg/ml, 25-(OH)-D3 69.5 +/- 13.5 nmol/liter). The amounts of both D3 vitamins in patients were significantly lower when the content of fecal elastase 1 was under 200 microg/g compared to the others [for 1,25-(OH)2-D3 P < 0.01, for 25-(OH)-D3 P < 0.05]. Therefore, ERCP and fecal elastase 1 verify the severity grade of a chronic pancreatitis, and thus show a vitamin D3 deficiency, depending on the progress of the disease. There seems to be a connection between inflammatory pancreas destruction (Cambridge classification), exocrine insufficiency (fecal elastase 1), and perhaps even the characteristics of sterol-binding of pancreatic elastase 1, which seems to be relevant for vitamin D supply.

Alterations of bone mineral density and bone metabolism in patients with various grades of chronic pancreatitis.

The aim of this study was to examine bone mineral density (BMD) and bone metabolism in patients with chronic pancreatitis to determine if increased severity of the disease would correlate with increased bone loss. Between October 1999 and September 2000, we investigated 42 patients with an average age of approximately 53 years suffering from chronic pancreatitis, as well as 20 healthy male controls with an average age of 49 years. Dual energy x-ray absorptiometry (DEXA) was performed on patients and controls, and serum levels of parathyroid hormone (PTH), osteocalcin (OC), carboxy-terminal propeptide of type I procollagen (CICP), bone-specific alkaline phosphatase (BAP), 1,25(OH)(2) vitamin D(3) and 25(OH) vitamin D(3), as well as fecal elastase 1 were also determined. The severity of chronic pancreatitis in patients was determined via endoscopic retrograde cholangiopancreatography (ERCP) and assigned to 1 of 3 grades based on the Cambridge classification. BMD of patients with chronic pancreatitis was markedly decreased compared to controls (means in patients: DEXA lumbar vertebra anterior/posterior (LV ap) 96.8% +/- 4.2%, DEXA Ward's triangle (WARD) 92.2% +/- 5.2%; controls: DEXA LV ap 98.7% +/- 3.7%, DEXA WARD 97.1% +/- 3.1%; P <.05 and P <.0001) and correlated with the various Cambridge-grades (DEXA LV ap and DEXA WARD, P <.01). Fecal elastase 1 showed sensitivities of 14%, 87%, and 95% for the Cambridge-grades I, II, and III, respectively, and correlated with this classification of severity of chronic pancreatitis (P <.01). Furthermore, fecal elastase 1 of patients correlated the same way with both D(3)-vitamins (P <.01), as well as with parameters of BMD (P <.01). If fecal elastase 1 in patients was below 200 micro g/g, then the BMD and vitamin D(3) values were also significantly decreased compared to those with fecal elastase 1 above 200 micro g/g. In patients with Cambridge grades II and III 1,25(OH)(2)D(3) was markedly decreased (26.7 +/- 7.7 pg/mL and 27.6 +/- 9.0 pg/mL) compared to those with Cambridge grade I (38.0 +/- 10.5 pg/mL; between I and II, P =.027; between I and III, P =.033). 25(OH)D(3) was not significantly different within the various Cambridge groups (P =.07). Compared to controls, both D(3) vitamins, as well as fecal elastase 1, were extremely low (means in patients: fecal elastase 1, 140.7 +/- 75.7 micro g/g; 1,25(OH)(2)D(3), 29.9 +/- 9.5 pg/mL; 25(OH)D(3), 26.7 +/- 9.7 nmol/L; controls: fecal elastase 1, 694.9 +/- 138.6 micro g/g; 1,25(OH)(2)D(3), 67.5 +/- 4.3 pg/mL; 25(OH)D(3), 69.5 +/- 13.5 nmol/L). A significant correlation was observed between increased severity of chronic pancreatitis based on both endoscopic retrograde cholangiopancreatography and levels of fecal elastase 1, with decreased circulating levels of vitmain D(3) and decreased BMD. This supports a connection between the inflammatory destruction of the pancreas (Cambridge classification), exocrine pancreatic insufficiency (fecal elastase 1), altered levels of vitamin D metabolites, and loss of skeletal mass.