[Stroke always with an emergency physician? - Pro]. / "Schlaganfall immer mit Notarzt?" - "Pro".

Good management of acute stroke is dependent on time and expertise. In Germany emergency medical care by ambulance services sometimes occurs without an emergency physician being sent to the scene. By reviewing current literature the question of patient care in the ambulance with or without an emergency physician is discussed. Presence of an emergency physician at the scene results in high diagnostic accuracy, allows for invasive procedures to be carried out, and enables referral to a specialist centre with a stroke-unit. The "rendezvous" system of separate deployment of patient ambulance and emergency physician allow flexible assignment of the physician resulting in short response times. Current research does not support a turn away from the deployment of an emergency physician in cases of acute stroke.

[Concept for allocation of acute stroke patients: evaluation of the quality of diagnosis reached by the emergency medical services of Münster]. / Zuweisungskonzept bei akutem Schlaganfall : Untersuchung der rettungsdienstlichen Diagnosequalität in der Stadt Münster.

BACKGROUND: Acute stroke is a time- and expertise-critical emergency. An immediate and correct diagnosis by emergency medical services (EMS) in the prehospital phase and patient transfer to the nearest adequate hospital with a stroke unit is required for early treatment of acute stroke. PATIENTS AND METHODS: We evaluated all patients who were admitted by the EMS of Münster to one of the two stroke units in the town between October 2008 and December 2010 with a diagnosis of acute stroke. Furthermore all patients were critically analyzed who were admitted without a diagnosis of acute stroke by the EMS but nonetheless had a stroke and the correct diagnosis was not found until examination in the neurological department. RESULTS: We analyzed 615 patients who were admitted to the stroke units with the diagnosis of acute stroke. In 561 cases (91%) this diagnosis could be confirmed, but in 54 patients (9%) the diagnosis by the EMS was incorrect. Epileptic seizure was the most frequent false-positive diagnosis in this group of patients (39%; n = 21). Although the acute symptoms were caused by a stroke, the correct diagnosis was not defined by the EMS in 127 patients. This accounted for 18% of all patients admitted to the emergency departments by the EMS where ultimately a stroke was diagnosed. In 24% of these cases (n = 30) the emergency doctor missed the correct diagnosis, which meant 4% of all patients admitted by the EMS, finally diagnosed with an acute stroke. In all other cases in the group with a false-negative diagnosis (76% or 97 patients) an emergency doctor was not involved in the referral by the EMS. CONCLUSION: Emergency medical services should be involved in the establishment of admission programs for acute stroke patients to provide the fastest means of transportation to a stroke unit. Coma, symptoms of posterior cerebral circulation and epileptic seizures cause difficulties in ensuring an immediate and correct diagnosis. Sending an emergency doctor to the scene increases diagnostic certainty which is essential to initiate early treatment.

Dissociation between the effects of somatostatin (SS) and octapeptide SS-analogs on hormone release in a small subgroup of pituitary- and islet cell tumors.

The effects of somatostatin (SS-14 and/or SS-28) and of the three octapeptide SS-analogs that are available for clinical use (octreotide, BIM-23014 and RC-160) on hormone release by primary cultures of 15 clinically nonfunctioning pituitary adenomas (NFA), 7 prolactinomas, and 2 insulinomas were investigated. In the pituitary adenoma cultures, a comparison was made with the effects of the dopamine (DA) agonists bromocriptine and/or quinagolide. In 5 NFAs, 2 prolactinomas and 1 insulinoma somatostatin receptor (subtype) expression was determined by ligand binding studies and by in situ hybridization to detect sst1, sst2, and sst3 messenger RNAs (mRNAs). Four NFA cultures did not secrete detectable amounts of alpha-subunit, FSH, and/or LH. In the other cultures, hormone and/or subunit release was inhibited by DA-agonists (10 nM) in 9 of 11, by SS (10 nM) in 7 of 11, and by octapeptide SS-analogs (10 nM) in 3 of 10 cultures. In three NFA cultures, hormone release was sensitive to SS but not to SS-analogs. In all cultures, except for one, DA-agonists were the most effective in inhibiting hormone release. In the prolactinoma cultures, PRL release was inhibited by DA-agonists (10 nM) in 7 of 7, by SS in 4 of 4, and by octapeptide SS-analogs in 3 of 7 cultures. A dissociation between the effects of SS and SS-analogs was found in 3 cases. In the cultures sensitive to both bromocriptine and SS-28, bromocriptine was the most potent compound in 2 out of 4 cultures. In the 2 other cultures, both compounds were equally effective. In 2 insulinoma cultures, insulin release was inhibited by SS, and by octapeptide SS-analogs in only one. The presence or absence of an inhibitory effect by octreotide was in all cases in parallel with the presence or absence of the inhibitory effect by BIM-23014 and RC-160. Autoradiographic studies using [125I-Tyr0]SS28 showed specific binding in 4 of 5 NFAs, 1 of 2 prolactinomas, and 1 of 1 insulinoma. Specific [125I-Tyr3]octreotide binding was found in 2 of 5 NFAs, in 1 of 2 prolactinomas, and in the insulinoma. Two NFAs showed binding of SS28, but not of the sst2.5 specific ligand octreotide. The tumors showed variable sst1 and/or sst3 mRNA expression, whereas no sst2 expression was found. In conclusion, a dissociation between the inhibitory effects of SS on the one hand and of the octapeptide SS-analogs octreotide, BIM-23014 and RC-160 on the other hand, is observed in a small subgroup of NFAs, prolactinomas, and insulinomas, suggesting that novel sst subtype specific SS-analogs might be of benefit in the treatment of selected patients with somatostatin receptor positive secreting tumors not responding to octapeptide SS-analogs. However, in the majority of NFAs and prolactinomas, DA-agonists were equally or more effective than SS in the suppression of tumoral secretion products.