The German version of the Critical-Care Pain Observation Tool for critically ill adults : A prospective validation study.

BACKGROUND: The implementation of the Critical-Care Pain Observation tool (CPOT) in intensive care units (ICU) has been associated with more frequent pain assessments, a reduced number of complications, and improved administration of analgesics and sedatives. So far no German translation exists. Translating this tool into foreign languages requires further validation testing. OBJECTIVE: The aim of this prospective observational validation study was to translate the original version of the CPOT according to scientific principles for translation and to establish the validity and reliability of the German translation of CPOT for critically ill adult patients. MATERIAL AND METHODS: A total of 292 cardiac surgery patients from 2 ICUs of 2 German university teaching hospitals were included (114 patients at center 1 and 178 patients at center 2). Of the included patients 22.6% were female and 76.4% were male with a mean age of 68.5 years ±9.3 SD. Pain was evaluated with the CPOT, the Bhavioral Pain Scale (BPS) and with the Numeric Rating scale (NRS) at three time points (1. intubated + sedated, 2. intubated + awake, 3. extubated + awake) at rest and during nociceptive stimulus (positioning). Assessments were made separately by trained physicians and nursing staff. RESULTS: Good results for interrater reliability and internal consistency could be demonstrated (weighted Cohen's kappa of 0.73, Cronbach's coefficient alpha of 0.8). Spearman correlation between CPOT and NRS was moderate but significant. The receiver operating characteristic (ROC) analysis to obtain optimal thresholds of CPOT to detect pain revealed different results during rest and stimulus and in intubated and extubated patients. CONCLUSION: The validated German CPOT translation is a reliable tool for pain assessment in cardiac ICU patients in the absence of patients' ability for self-reporting. The use of this German version of CPOT now allows a better international comparability of corresponding data in future studies.

Exercise training improves physical function and fitness in long-term paediatric brain tumour survivors treated with cranial irradiation.

AIMS: We examined the efficacy of exercise training for improving physical functioning and cardiopulmonary fitness in survivors of paediatric brain tumours (BTs) treated with cranial irradiation. METHODS: We conducted a controlled clinical trial with crossover of exercise training versus no training in the community in either a group or combined group/home setting. A volunteer sample of 28 children treated with cranial irradiation for brain tumours completed training (mean age = 11.53 years; mean time since diagnosis = 5.25 years). end-points were physical functioning assessed by four subtests from the Bruininks-Oseretsky Test of motor performance (BOT-2) and pro-rated work rate from a cycle ergometer. Linear mixed modelling was used to evaluate time, training, training setting, and carryover effects. RESULTS: Adherence to training was 84%. Performance on the BOT-2 was below average for all assessments. However, training resulted in improvement in bilateral coordination (F (1, 30) = 6.59, p = 0.02), irrespective of training setting and improved performance was maintained even approximately 12°weeks after training had ended (F (1, 24) = 9.60, p = 0.005). Training resulted in increased pro-rated work rate for participants in the group training setting only (F (1, 25) = 4.57, p = 0.04) and these participants maintained their improved work rate approximately 12°weeks after training had ended (F (1, 20) = 8.38, p = 0.01). CONCLUSION: Exercise training improves physical functioning and fitness in paediatric BT survivors. Exercise interventions that ameliorate adverse physical effects and promote health in long-term survivors are highly recommended in this vulnerable population. (ClinicalTrials.gov, NCT01944761).

Embryonal tumors in Canadian children less than 36 months of age: results from the Canadian Pediatric Brain Tumor Consortium (CPBTC).

Embryonal tumors are a heterogeneous group of central nervous system (CNS) tumors whose subgroups have varying incidence and outcome. Despite these differences, they are often grouped as a single entity for study purposes. To date, there are no Canadian multi-institutional studies examining the incidence and outcome of all embryonal subtypes. The current study is an observational study reviewing embryonal tumors in all patients less than 36 months of age diagnosed with a CNS tumor in Canada from 1990 to 2005. Embryonal tumors accounted for 26.9% of all CNS tumors. Medulloblastomas were the highest proportion of the embryonal tumors at 61.5%. Atypical teratoid/rhabdoid tumors (AT/RT) had the second highest proportion of embryonal tumors at 18%. The proportion of primitive neuroectodermal tumors (PNET) was 16%, with 2.6 and 1.9% for congenital medulloepithelioma and ependymoblastoma tumors, respectively. AT/RT and PNET were more common in younger age groups. Medulloblastoma became more prevalent with increasing age, with its highest prevalence in the 25 to 36 month age group. Survival rates for our Canadian population at 18 and 24 months were 0.74 and 0.68 for medulloblastoma, 0.64 and 0.60 for PNET, and 0.36 and 0.29 for AT/RT, respectively. Overall, our data are comparable with published international rates for embryonal tumors. These incidence and outcome figures can guide future research into these rare tumors.

PO-18 - Fibronectin EDA/EDB is expressed in adherent SCLC NCI-H69 cells and in pleural effusions of lung cancer patients: possible implication for drug resistance.

INTRODUCTION: Small cell lung cancer (SCLC) is an extremely aggressive tumour which metastasizes early. Even if chemotherapy can achieve an initial regression, relapses due to chemo-resistance are almost inevitable. Sethi et al (Nat Med. 1999;5:662-668) reported that matrix proteins are essentially involved in the development of drug resistance. SCLC cells in suspension culture secrete negligible amounts of matrix proteins AIM: For a more detailed study of the SCLC ability to produce matrix proteins we applied a recently introduced cell culture model of adherence selected SCLC (Salge et al. J Cancer Res Clin Oncol. 2001;127(2):139-411) and analysed pleural effusions form lung cancer patients. MATERIALS AND METHODS: Adherent cells were selected from the SCLC cell line NCI-H69 after exposure to cellular stress. Pleural effusion were obtained from lung cancer patients (SCLC and NSCLC) and from pleural effusions (PE) with congestive heart failure Protein expression was analysed by western blotting (WB) and flow cytometry using specific antibodies against the fibronectin extra domain A (FnEDA) and B (FnEDB) (Sirius, Italy), and for integrins alpha 1-5 and beta 1-3. Drug resistance was assessed with the metabolic stain MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium-bromid). RESULTS: SCLC suspension cells expressed negligible amounts of fibronectin. In contrast, adherent H69 cells, which showed a significantly reduced chemo-sensitivity against carboplatin and doxorubicin, strongly expressed FnEDA and to a lesser extent FnEDB. Furthermore, in adherent cells expression of various integrins was up-regulated, in particular integrins alpha5/beta3, representing potential binding sites for FnEDA/FnEDB. Analysis of pleural effusions clearly showed the presence of FnEDA/ FnEDB in those of lung cancer patients, whereas in benign pleural effusion almost no FnEDA/ FnEDB was found. CONCLUSIONS: Our data reveal the presence of Fn, and its splice variants FnEDA/EDB in particular, in adherent SCLC cells as well as in malignant PE. We assume that the splice variants FnEDA/ FnEDB are linked to cancer progression and chemo-resistance in this tumour type.

Does the use of the revised psychosocial assessment tool (PATrev) result in improved quality of life and reduced psychosocial risk in Canadian families with a child newly diagnosed with cancer?

OBJECTIVES: Early psychosocial screening may guide interventions and ameliorate the adverse psychosocial effects of childhood cancer. The revised psychosocial assessment tool provides risk information - Universal (typical distress), Targeted (additional specific distress), and Clinical (severe distress) - about the child with cancer and his or her family. This pilot study investigated the benefits of providing a summary of family psychosocial risk information to the medical team treating the newly diagnosed child (Experimental Group, EG). METHOD: We conducted a pilot randomized control trial with a sample of 67 parents, comparing the EG to the control group (CG) on parental perception of family psychosocial difficulties (revised psychosocial assessment tool risk levels), child behavior (behavior assessment scale for children-2), pediatric quality of life (PedsQL), and parental anxiety (state-anxiety scale of the state-trait anxiety inventory ), 2-4 weeks after diagnosis (Time 1) and 6 months later (Time 2). RESULTS: Compared to the CG, participants in the EG had significantly reduced targeted and clinical risk (p < 0.001), and improved pain related PedsQL at Time 2 (p < 0.05). Scores for PedsQL total and nearly all subscales improved over time in both groups (p < 0.05 to p < 0.001). No changes in behavior scores were noted. CONCLUSION: Preliminary findings suggest that providing a summary of the Psychosocial Assessment Tool to the treating team shortly after diagnosis may help reduce family wide psychosocial risk 6 months later and improve quality of life related to pain for children who are undergoing treatment for cancer.

External validity and reliability of the Psychosocial Assessment Tool (PAT) among Canadian parents of children newly diagnosed with cancer.

BACKGROUND: The Psychosocial Screening Tool (PAT) was developed and validated with a sample of caregivers of children newly diagnosed with cancer in the United States. This study aimed to assess cultural adaptation (Phase 1) and validity and reliability of the revised PAT (PATrev) with a Canadian sample (Phase 2). PROCEDURE: In Phase 1, a convenience sample of seven parents of children who were treated for cancer and six pediatric oncology healthcare experts participated. In Phase 2, 67 parents of children newly diagnosed with cancer from 4 Canadian pediatric cancer centers participated. To assess reliability and validity of the PATrev, parents completed behavioral (BASC-2) and quality of life (PedsQL) instruments about the child and an anxiety inventory (STAI) about themselves. RESULTS: The PAT required minor changes to be culturally adapted for the Canadian population. The PATrev had strong inter-rater (0.77) test-retest (0.75), and internal consistency reliability (0.85), as well as moderate to strong validity comparing PATrev child's problems and PedsQL total (-0.49), PedsQL anxiety (-0.47), BASC-2 internalizing (0.64), behavioral (0.63), and adaptive scores (-0.56). PATrev discriminative validity was confirmed with BASC-2 scores (AUR scores of 0.70-0.74). PATrev parental stressors were strongly correlated to STAI scores (0.53). Finally, agreement between PATrev child's problems and parental anxiety scores was moderate (0.47). CONCLUSION: This study supports the original PAT, demonstrates PATrev is a reliable and valid psychosocial screening tool, and provides unique evidence regarding early psychosocial risk in the family, which have important implications for guiding psychosocial practice.

The use and effectiveness of temozolomide in children with central nervous system tumours: a survey from the Canadian Paediatric Brain Tumour Consortium.

OBJECTIVE: To describe the use of temozolomide (tmz) in Canadian children treated for brain tumours and to evaluate survival and predictors of survival for children treated with this agent. METHODS: A survey was conducted within the Canadian Paediatric Brain Tumour Consortium (cpbtc), a group of tertiary care centres in pediatric neuro-oncology (n = 16) in Canada that are involved in the treatment of children with central nervous system tumours. RESULTS: In 10 of the 16 participating pediatric oncology centres of the cpbtc, 137 children with brain tumours were treated with tmz between January 2000 and March 2006. Although 33% of the children were enrolled into a clinical trial, 67% were treated outside open studies. Most patients (72%) received tmz treatment on recurrence of their brain tumour (first or subsequent). The most commonly administered regimen was single-agent tmz 150-200 mg/m(2) administered on 5 consecutive days every 28 days. The median duration of tmz treatment was 141 days (range: 4-1102 days). Response data were provided for 127 of the 137 patients, of whom 6 showed a complete response. Sixteen patients experienced a minor or partial response, 53 had stable disease, and 52 had progressive disease. Of 32 patients alive at last follow-up, 19 had a diagnosis of low-grade glioma. CONCLUSIONS: Temozolomide is used in a variety of pediatric brain tumours, often at the time of recurrence. The lack of insight into clear indications for this agent in pediatric brain tumours-used either alone or in combination therapy-may be a result of suboptimal design of phase i and ii studies and a lack of phase iii trials in the pediatric brain tumour population.

Prehospital emergency physicians' experiences with advance directives in Germany: a questionnaire-based multicenter study.

BACKGROUND: Palliative medical emergencies and end-of-life decisions resulting from the exacerbation of cancer account for approximately 3% of all out-of-hospital emergency applications in Germany. Therefore, prehospital emergency physicians (EP) may be confronted with advance directives and ethical and end-of-life decisions. The purpose of the study was to identify EPs' knowledge about ethical and end-of-life decisions and their legal education and experiences concerning advance directives. METHODS: Over a six-month period, we questioned all 150 EPs from three emergency medical services (Braunschweig, Göttingen und Kaiserslautern). An anonymous, self-administered questionnaire with a mixed-methods design was used. The main outcome measures included responses regarding experiences related to advance directives and end-of-life decisions in palliative care patients. For statistical assessment, EPs were divided into three categories: competent, skilled, and unskilled. RESULTS: A total of 104 EPs returned the questionnaire (response rate 69%). Eighty-nine percent of the respondents treated patients who had advance directives. The existence of an advance directive influenced the EP's therapy decision in about 77% of their encounters. Eighty-seven percent of the EPs reported the need for defined end-of-life care pathways and/or standard operating procedures. Eighty-two percent desired educational training concerning end-of-life decisions and the validity of advance directives. CONCLUSION: The prehospital emergency treatment of palliative care patients can be particularly challenging for any EP. A high percentage of the EPs in our study felt insecure in dealing with advance directives and ethical and end-of-life decisions in palliative care patients. Our results suggest that EPs may need more information and education about palliative medical care, legal issues and ethical and end-of-life decisions to provide adequate patient-oriented palliative care in prehospital emergency situations.

[Lazarus phenomenon. Spontaneous return of circulation after cardiac arrest and cessation of resuscitation attempts]. / Lazarus-Phänomen. Spontane Kreislauffunktion nach beendeten Reanimationsmassnahmen.

BACKGROUND: In the medical literature the Lazarus phenomenon is defined as the spontaneous return of circulation (SROC) after cessation of cardio-pulmonary resuscitation. Based on published literature recommendations concerning the treatment of patients after cessation of resuscitation and reasons for the Lazarus phenomenon are discussed. METHODS: A literature search in Medline, PubMed, Embase, Google Scholar and Google from 1982 to 2009 was carried out for the terms "Lazarus phenomenon", "cessation of cardiopulmonary resuscitation and return of spontaneous circulation (ROSC)", "spontaneous return of circulation (SROC)", "resuscitation and spontaneous defibrillation", "spontaneous recovery and cardiopulmonary resuscitation". Related secondary literature which was cited in the relevant articles was included as well as publications found in our personal literature base. RESULTS: More than 10,000 articles and comments could be recovered and of these 45 were considered to be medically relevant articles (letters to the Editor, abstracts, case reports and literature reviews). CONCLUSIONS: In the relevant medical literature, the Lazarus phenomenon is a rare occurrence. It seems to be a phenomenon which has often been described in non-medical literature but not published in medical literature. The pathophysiological mechanisms are poorly understood. In the literature several mechanisms are discussed which could be important for this phenomenon, e.g. autopositive end-expiratory pressure, hyperventilation and alkalosis, hyperkalemia, delayed action of drugs and unobserved minimal vital signs. In the literature it is recommended that patients should be passively monitored for at least 10 min after cessation of resuscitation. However, more scientific experimental investigations seem to be necessary to gain a better understanding of this phenomenon.

[Palliative medicine. Fifth pillar of anaesthesia departments]. / Palliativmedizin: Fünfte Säule anästhesiologischer Abteilungen?

Palliative medicine has progressed during recent years to an independent medical faculty within the German health system. Despite this development palliative care systems for out-of-hospital and in-hospital palliative care are still insufficient in Germany so that the development of necessary resources must be considered as not yet completed. To support the further national development palliative medicine can be temporarily or permanently coupled to existing departments, which can be advantageous for all concerned and last but not least be profitable to patients and their relatives. Possibilities for participation of anaesthesiologists in this area of medical care are discussed in the study reported here. Anaesthesiologists have always historically been represented in palliative medical departments, e.g. as pain specialists. In the following investigation the special possibilities of anaesthesia departments for supporting the education and development of in-hospital and out-of hospital palliative medical care departments are reported. Previous experience of co-operation between these two departments is well established. Departments of palliative medicine depend on a well working interdisciplinary co-operation between different medical disciplines (e.g. anaesthesiology, radiotherapy, surgery and oncology) and several medical professions (e.g. physicians, nurses, psychologists). The aim of palliative care therapy is to be responsible for the best possible therapy for cancer patients and to give support to their care-giving relatives. Due to the increasing establishment of palliative care procedures in Germany, departments of anaesthesiology should actively take part in the further development. Part of the responsibility of most anaesthesia departments is to practice pain management and critical care medicine, which are reasons why anaesthesiologists are predestined to be part of the system for palliative care patients and their relatives. Anaesthesia departments can be responsible for the organization of in-hospital and out-of-hospital palliative medicine and palliative care. The integration of anaesthesiological expertise into palliative medicine departments and vice versa can be a great opportunity for both medical departments and therefore represents a worthwhile engagement.

Treatment of palliative care emergencies by prehospital emergency physicians in Germany: an interview based investigation.

Palliative care medical emergencies as a consequence of advanced cancer account for approximately 3% of all prehospital emergency cases. Therefore, prehospital emergency physicians (EP) are confronted with 'end of life decisions'. No educational content exists concerning palliative medicine in emergency medicine curricula. Over the course of 6 months, we interviewed 150 EPs about their experiences in 'end of life decisions' using a specific questionnaire. The total response rate was 69% (n = 104). Most of the interviewed EPs (89%, n = 93) had been confronted with palliative care medical emergencies and expressed uncertainties in dealing with these difficult situations, especially in the area of psychosocial care of the patients (50%). The emergency treatment of palliative care patients can become a particular challenge for any EP. A large percentage of interviewed EPs felt uncertain about aspects of social care and in the assessment of decisions at the end of life. Further information and training are necessary to amenable EPs to provide adequate patient-oriented care to palliative care patients and their relatives in emergency situations.

Telomere maintenance and dysfunction predict recurrence in paediatric ependymoma.

We have recently described the enzymatic subunit of telomerase (hTERT) as an important prognostic marker for paediatric ependymoma. Because of the lack of good, representative pre-clinical models for ependymoma, we took advantage of our large cohort of ependymoma patients, some with multiple recurrences, to investigate telomere biology in these tumours. Our cohort consisted of 133 ependymomas from 83 paediatric patients and included 31 patients with recurrences. Clinical outcome was measured as overall survival, progression-free survival and response to therapy. In all 133 tumours, hTERT expression correlated with proliferative markers, including MIB-1 index (P<0.0001) and mitotic index (P=0.005), as well as overall tumour grade (P=0.001), but not with other markers of anaplasia. There was no correlation between telomere length and hTERT expression or survival. Surprisingly, prior radiation or chemotherapy neither induced sustained DNA damage nor affected telomere maintenance in recurrent tumours. There was an inverse correlation between hTERT expression and telomere dysfunction as measured by gamma H2AX expression (P=0.016). Combining gamma H2AX and hTERT expressions could segregate tumours into three different survival groups (log rank, P<0.0001) such that those patients whose tumours expressed hTERT and showed no evidence of DNA damage had the worst outcome. This study emphasises the importance of telomere biology as a prognostic tool and telomerase inhibition as a therapeutic target for paediatric ependymoma. Furthermore, we have demonstrated that analysing tumours as they progress in vivo is a viable approach to studying tumour biology in humans.

[Palliative care patients in an advanced state of disease. Cardiopulmonary resuscitation and determination of death]. / Palliativpatienten im weit fortgeschrittenen Krankheitsstadium. Notärztliche Reanimation und Todesfeststellung.

BACKGROUND: Prehospital emergency teams will be confronted with the specific needs of resuscitation in palliative patients in whom a return of spontaneous circulation (ROSC) could be found significantly less frequently than in other emergency situations. The present investigation aims to show medical and judicial problems related to cardiopulmonary resuscitation (CPR), external examination of the corpse and death certification. METHODS: Over a 12-month period all emergency cases involving physicians in an out-of-hospital resuscitation setting in cancer patients were retrospectively analysed for indications for emergency call, situation on-site and prehospital treatment by emergency physicians, external examination of the corpse and determination of death. RESULTS: For the period mentioned 164 (2.7% of the total) emergency calls by cancer patients or their relatives were identified. In the following study 43 patients (26.2%) could be included. In 20 cases (46.5%) the emergency physicians attempted to resuscitate the patient by performing CPR. In the majority of cases (36; 83.7%) death certification and external examination of the corpse were necessary at the scene. CONCLUSIONS: Due to a reduced rate of ROSC in palliative patients, death certification and external examination of the corpse are more often necessary than in other emergency situations. Therefore every emergency physician should be familiar with the ethics of resuscitation of patients in palliative care and with external examination of the corpse to do justice to patients and their caregivers.

[The Göttingen palliative emergency card: improvement of emergency medical care for ambulatory palliative care patients. The "yellow card for rescue services"]. / Göttinger Palliativkrisenbogen: Verbesserung der notfallmedizinischen Versorgung von ambulanten Palliativpatienten. Die "Gelbe Karte für den Rettungsdienst."

Currently more and more patients with cancer will be treated at home, especially at the final stage of their disease. Relatives and nursing services will therefore be confronted with acute emergency situations concerning these patients. The handling of these acute situations may be beyond the relatives' coping capacity. For that reason the pre-hospital emergency system (2.5% of all emergency calls) will be confronted with very specific needs of these patients. Emergency situations of palliative patients at home are more predictable than other circumstances. It is thus possible to achieve a practicable preparation for such emergency situations. An individual "emergency plan" should be created for these cases.. The plan may be processed in an emergency situation. It may then be possible to avoid emergency calls and make it possible for the patient to remain at home. This promotes the patient's quality of life and his/her predominant desire to stay at home after the emergency. An advance directive should be made which records the patient's wishes. Because of the complexity of an advance directive it is essential to indicated the patient's wishes in a short and quickly read form in case an emergency arises. This is one of the reasons for producing a short version like the "Göttingen palliative emergency card". In acute situations it is then possible quickly to make known the patient's wishes The patient may be given the possibility of remaining at home after an emergency situation has been dealt with successfully.

[Reduction in no flow time using a laryngeal tube: comparison to bag-mask ventilation]. / "No-flow-time"-Reduzierung durch Einsatz des Larynxtubus: Vergleich zur Beutel-Masken-Beatmung.

OBJECTIVE: In 2005 the European Resuscitation Council (ERC) published the new guidelines for Advanced Life Support (ALS). One of the aims was to reduce the no flow time (NFT), without chest compression in the first period of cardiac arrest. Furthermore the guidelines recommend that endotracheal intubation should only be carried out by personnel experienced in this procedure. METHODS: An attempt was made to evaluate whether the use of the laryngeal tube suction (LTS-D) for emergency airway management could contribute to reduce NFT compared to bag-mask ventilation (BMV). In a randomised prospective study 50 participants were asked to perform standardised simulated cardiac arrest management on a full-scale simulator following a one-day cardiac arrest training. Each participant was randomised into the LTS-D and the BMV group for airway management. At the end of each scenario an evaluation of the use of each ventilation procedure by the participants was made by means of a questionnaire. RESULTS: During the manikin scenario (430 s for LTS-D and 420 s for BMV) there was a significant difference in the overall NFT comparing the use of the LTS-D vs. BMV (105.8 s, range 94-124 s vs. 150.7 s, range 124-179 s; p<0.01). This corresponded during the whole scenario to a proportion of 24.6% (LTS-D) or 35.9% (BMV). Using the LTS-D all participants were able to ventilate the manikin successfully (tidal volume 500-600 ml). In a subjective evaluation of the different airway management procedures by the participants more than 90% expressed a positive opinion about the LTS-D with respect to ease of insertion and safety of ventilation. CONCLUSION: The use of the LTS-D on a manikin by emergency physicians after standardised cardiac arrest training significantly reduces the NFT in comparison to BMV. Therefore the LTS-D seems to be a good alternative to BMV during a simulated cardiac arrest scenario.

[Foudroyant meningococcal sepsis in emergency medicine. Medical treatment and post-exposure prophylaxis]. / Foudroyante Meningokokkensepsis im Notarztdienst. Handlungsempfehlungen und Expositionsprophylaxe.

A paediatric emergency case with a rescue helicopter, which was reported as unexpected cardiac arrest of a 4-year-old child will be described. Based on this case, the symptoms and therapy of meningococcal sepsis and Waterhouse-Friderichsen-Syndrome under emergency conditions will be discussed as well as aspects of post-exposure prophylaxis.

[Another case of "Lazarus phenomenon" during surgery? Spontaneous return of circulation in a patient with a pacemaker]. / Intraoperatives "Lazarus-Phänomen"? Spontane Kreislaufstabilisierung bei einem Patienten mit Herzschrittmacher.

A case is presented of spontaneous return of circulation after cardiac arrest in a patient with a pacemaker without intraoperative resuscitation. In the literature this kind of situation is called the Lazarus phenomenon. Cardiac arrest of the patient occurred during surgery and because of the poor prognosis no cardiopulmonary resuscitation was initiated. After 6 min of apnoea and cessation of circulation, the circulation restarted spontaneously and surgery was continued. Afterwards the patient was transferred to the intensive care unit but died 2 days later without regaining consciousness. The pathophysiological mechanisms for the Lazarus phenomenon are poorly understood but several mechanisms and multifactorial events are discussed in the literature.

[AnaConDa as last resort treatment. Case report of a chronic obstructive pulmonary disease]. / AnaConDa als Ultima-Ratio-Therapie. Fallbericht einer chronisch obstruktiven Lungenerkrankung.

Treatment of patients suffering from decompensated chronic pulmonary disease (COPD) not responding to pharmacological therapy is still a major challenge in intensive care medicine. Administration of volatile anaesthetics may be a therapy of last resort in these cases. We report on a 65-year-old woman suffering from exacerbated COPD, who could not be sufficiently ventilated despite comprehensive pharmacological therapy. In order to administer a volatile anaesthetic in the ICU, we employed the "Anaesthetic Conserving Device" (AnaConDa) consisting of a vaporizer chamber embedded in a charcoal filter system. With this device, every standard intensive care ventilator can be used to deliver volatile anaesthetics in a safe and economic manner. The AnaConDa converts the open breathing system of the intensive care ventilator into a de facto half-closed system. The very low pulmonary compliance of the patient increased dramatically after administration of 0.75 vol% halothane for 48 h (27 vs. 150 ml/mbar). Elimination of CO(2) was improved and weaning from controlled ventilation was achieved. After surgical removal of a pulmonary abscess and a total of 78 days of intensive care therapy, the patient was discharged in good health.

[Treatment of oncology patients in the final stadium of disease by prehospital emergency physicians]. / Notärztliche Betreuung von Tumorpatienten in der finalen Krankheitsphase.

BACKGROUND: Presently and even more in the near future more cancer patients will be treated at home especially in the final stage of their disease. For this reason the prehospital emergency system will be confronted with the specific needs of these patients. Palliative care is not part of the German model of post-graduate training regulations for emergency medicine and palliative care teams (PCT) are only involved in the treatment of cancer patients in emergency situations. METHODS: Over a 12-month period we retrospectively analysed all emergency cases that had been categorised as final cancer stage at 2 emergency sites (one air-based, the other ground-based) involving physicians in an out-of-hospital setting. We analysed all cases for indications of emergency call, prehospital treatment and involvement of a PCT in the treatment of symptoms. RESULTS: For this period we analysed 2,765 emergency documents and identified more than 2.5% as emergency calls by cancer patients or their relatives (the majority of patients had been in the final stage of the disease). Most emergency calls occurred at times when no general practitioner was on duty and acute dyspnoea (42.7%) was the prominent diagnosis. After emergency treatment 61.8% patients had been admitted to hospital. In most settings a PCT was not involved in the treatment of palliative care patients or their relatives (92.7%). CONCLUSIONS: Our data demonstrate that care of cancer patients in the final stage of the disease is relevant in emergency medicine. These patients are in need of help based on principles of palliative care. Under these circumstances cooperation of the medical disciplines (emergency and palliative medicine) concerned seems to be necessary. This may increase the possibility for patients to stay at home for the last days of their life. Because of this we are convinced that basic knowledge of palliative care should be integrated into the German model of post-graduate training regulations for emergency care. Combining parts of the curricula (palliative and emergency medicine) it would be possible for emergency physicians to guide their treatment by the ideas and strategies of palliative care. But we are also convinced that the system of PCT should increase and become more involved in prehospital care in emergency cases of palliative care patients.

Are quality differences responsible for different adverse reactions reported for SD-plasma from USA and Europe?

Thromboembolic adverse reactions reported after transfusion of SD-plasma in the United States (US) prompted us to perform a comparative study with SD-plasma from the US and the European (EU) market. In SD-plasma from US, residual tri-N-butyl phosphate was found, and citrate concentrations were lower than in EU-plasma. Except for substantial losses of FV, FVIII and antiplasmin found for all SD-plasmas, clotting factor activities were mainly retained. However, for SD-plasma from US, markedly elevated concentrations of lipoprotein (a) [Lp(a)], fibrin monomer and a particularly high degree of complement activation (C3a des-Arg) were observed. Furthermore, pronounced differences were found for protein S. Although SD-plasma pools from US contained nearly normal concentrations of free and bound protein S antigen, protein S activities were almost completely absent. In contrast to this, SD-plasma from EU showed a moderate loss of both protein S activity and free antigen. Antitrypsin inhibitor activities were much more diminished in SD-plasma from US than from EU. In view of a possible thrombogenicity of SD-plasma from US, the loss of protein S and elevated Lp(a) concentrations could be of significance. The very high levels of C3a des-Arg in US plasma could possibly have an additional effect, through priming platelet activation after transfusion.