Brachial cuff measurements of blood pressure during passive leg raising for fluid responsiveness prediction.

OBJECTIVE: The passive leg raising maneuver (PLR) for fluid responsiveness testing relies on cardiac output (CO) measurements or invasive measurements of arterial pressure (AP) whereas the initial hemodynamic management during shock is often based solely on brachial cuff measurements. We assessed PLR-induced changes in noninvasive oscillometric readings to predict fluid responsiveness. STUDY DESIGN: Multicentre interventional study. PATIENTS AND METHODS: In ICU sedated patients with circulatory failure, AP (invasive and noninvasive readings) and CO measurements were performed before, during PLR (trunk supine, not modified) and after 500-mL volume expansion. Areas under the ROC curves (AUC) were determined for fluid responsiveness (>10% volume expansion-induced increase in CO) prediction. RESULTS: In 112 patients (19% with arrhythmia), changes in noninvasive systolic AP during PLR (noninvasiveΔ(PLR)SAP) only predicted fluid responsiveness (cutoff 17%, n=21, positive likelihood ratio [LR] of 26 [18-38]), not unresponsiveness. If PLR-induced change in central venous pressure (CVP) was at least of 2 mm Hg (n=60), suggesting that PLR succeeded in altering cardiac preload, noninvasiveΔ(PLR)SAP performance was good: AUC of 0.94 [0.85-0.98], positive and negative LRs of 5.7 [4.6-6.8] and 0.07 [0.009-0.5], respectively, for a cutoff of 9%. Of note, invasive AP-derived indices did not outperform noninvasiveΔ(PLR)SAP. CONCLUSION: Regardless of CVP (i.e., during "blind PLR"), noninvasiveΔ(PLR)SAP more than 17% reliably identified fluid responders. During "CVP-guided PLR", in case of sufficient change in CVP, noninvasiveΔ(PLR)SAP performed better (cutoff of 9%). These findings, in sedated patients who had already undergone volume expansion and/or catecholamines, have to be verified during the early phase of circulatory failure (before an arterial line and/or a CO measuring device is placed).

[Portal contrast medium-enhanced spiral computed tomography of the liver--the correlation of radiological and intraoperative findings and the evaluation of resectability]. / Portal kontrastverstärkte Spiral-Computertomographie der Leber--Korrelation radiologischer und intraoperativer Befunde und Beurteilung der Resektabilität.

PURPOSE: To evaluate the accuracy of spiral computed tomography during arterial portography (SCTAP) in the detection, localization, and resectability of liver tumors in a correlative study between radiology and intraoperative findings. METHOD AND MATERIALS: Retrospectively, SCTAP images of 168 consecutive patients before liver tumor resection were analyzed. The SCTAP studies (100 ml lopromid 300 by automated injector with a flow of 3 ml/s; slice thickness, table feed and reconstruction index 5 mm each; scan-delay 30 s; 120 kV; 250 mAs) were evaluated for the detection, localization, and resectability of focal liver lesions by three experienced radiologists in consensus and were correlated with histopathological and intraoperative findings where available (59/168). RESULTS: The sensitivity of SCTAP for the detection of liver tumors was 91% for all lesions and 84% for lesions < 1 cm. The specificity was only 19% due to a high rate of false-positive lesions (30%) and preselection effects. Typical pitfalls in false positive lesions were inhomogeneous liver perfusion near the portal vein, the falciform ligament, and the gallbladder (19/42). In 30% of the patients SCTAP correctly diagnosed inoperability, in 23% the intraoperative tumor expansion was larger than expected from SCTAP images, which would have changed operability. CONCLUSION: The SCTAP has a high sensitivity in the detection and localization of liver tumors and is a valuable method in the preoperative diagnostic procedure. The method is limited by many false-positive lesions often due to inhomogeneous liver perfusion and the insufficient evaluation of local tumor spread. Therefore, SCTAP should be replaced by MRI in the near future.

[Pneumococcal pneumonia in a patient with HIV infection. Development to excavation. Apropos of a case]. / Pneumopathie à pneumocoque chez une patiente infectée par le VIH. Evolution vers l'excavation. A propos d'un cas.

An HIV-infected patient presented with pneumococcal pneumonia with abscess formation. The causal effect of the pneumococcal infection on abscess formation was discussed. Since the advent of antibiotics, necrotizing pneumococcal pneumonia is rarely observed but clinicians should nevertheless be aware of this possibility, particularly because of the HIV epidemic.

[Myocardial infarction by spontaneous dissection of coronary arteries in a subject with type IV Ehlers-Danlos syndrome]. / Infarctus du myocarde par dissection spontanée des artères coronaires chez un sujet atteint d'un syndrome d'Ehlers-Danlos de type IV.

Acute myocardial infarction with spontaneous coronary dissection was fatal in a 33-years-old man. Autopsy and family history revealed type IV Ehlers-Danlos syndrome. In this disease, conjunctive tissue is fragilized due to a deficit in type III collagen which leads to spontaneous ruptures in large and medium sized arteries. The present case is the first with a proven rupture of the coronary arteries. This disease should be entertained in young people with no atherogenous risk factor and an acute coronary disorder since peripheral skin and joint syndromes may be discreet or missing. Treatment is difficult in case of spontaneous coronary dissection. Thrombolysis is not possible and diagnosis may require angiography which is in itself dangerous due to the fragility of the coronary vessels.

Double-blind, placebo-controlled trial of antithrombin III concentrates in septic shock with disseminated intravascular coagulation.

BACKGROUND: Septic shock is frequently complicated by a syndrome of disseminated intravascular coagulation (DIC). Numerous uncontrolled clinical studies have reported that antithrombin III (ATIII) substitution might prevent DIC and death in septic shock. METHODS: We conducted a randomized double-blind placebo-controlled trial in patients with a documented septic shock and DIC. The patients received either a placebo or ATIII (90 to 120 IU/kg in loading dose, then 90 to 120 IU/kg/d during 4 days). Administration of fresh frozen plasma, platelets, and fibrinogen concentrates was restricted to patients with hemorrhages and severe decreases in prothrombin time, platelet count, and fibrinogen levels. RESULTS: Thirty-five patients entered the study (18 placebo, 17 ATIII). Both groups were well balanced for all demographic, hemodynamic, and biologic data. Three patients were excluded before the treatment allocation code was broken. In the ATIII group, ATIII levels were rapidly corrected and remained over normal levels until day 10; sequential protein C and protein S levels were not modified. The duration of DIC was significantly reduced: in the ATIII group, 64 percent of patients were cured of DIC at day 2, and 71 percent were cured at the end of treatment vs in the placebo group, 11 percent (p < 0.01) and 33 percent (p < 0.05), respectively. In the 32 included patients, the mortality in ICU was reduced by 44 percent in the ATIII group (p = 0.22, NS). Care loads and transfusion requirements were not different. No side effect was observed. CONCLUSIONS: Mortality was reduced by 44 percent in this trial, but the difference did not reach the statistical significance. Circulating protein C and protein S levels were not modified by ATIII supplementation. High doses of ATIII concentrates significantly improved sepsis-induced DIC during septic shock. The trend toward improved survival suggests further randomized studies.

Retinoic acid induces the expression of alkaline phosphatase in P19 teratocarcinoma cells.

Retinoic acid (RA), the natural acid derivative of vitamin A, can induce the differentiation of some cell lines, such as the murine P19 teratocarcinoma cell line. RA can alter the expression of specific genes and the level of the corresponding protein. This report describes the effect of RA on the level of the alkaline phosphatase (ALP) mRNA and protein in P19 teratocarcinoma cells. RA caused a rapid, dose-dependent, and protein synthesis-dependent induction of ALP activity. The increased enzyme activity was detected 4 h after initiation of treatment and maximum induction of ALP activity required 48 h of RA exposure. Increased enzymatic activity was coincidental with increased levels of both a 67-kDa ALP protein and ALP mRNA. By Northern (RNA) blot analysis the increase of a 2.7-kilobase ALP mRNA was observed within 3 h of RA treatment. The RA-induced enhanced ALP mRNA level did not appear to be mainly due to the stabilization of preexisting mRNA, but rather to an increase in transcription of the ALP gene.

Lisuride plus selegiline in the treatment of early Parkinson's disease.

We treated 20 early Parkinson's disease subjects with the dopamine agonist lisuride in combination with the MAO-B inhibitor selegiline (L-deprenyl). We started with lisuride alone for one month, then we added selegiline versus placebo to lisuride in double-blind conditions for 3 months; finally all patients received lisuride and selegiline for another 3 months. Lisuride alone (1.43 +/- 0.10 mg) significantly improved PD. When selegiline (10 mg/day) was added in the double-blind phase the mean lisuride dosage could be reduced by 22.8% without deterioration of the clinical effects, and the same occurred in the former placebo group when selegiline was added. The combination of both drugs was well tolerated. These data are of interest for the interpretation of the effects of selegiline.

Can we differentiate symptomatic and neuroprotective effects in parkinsonism? The dopamine agonist lisuride delays the need for levodopa therapy to a similar extent as reported for deprenyl.

Delaying levodopa therapy by a drug currently is being perceived by patients and doctors as an indication for a beneficial effect on the progression of Parkinson's disease. We discuss this view critically and present results from a retrospective analysis of data of 185 consecutive patients treated with lisuride monotherapy which show a significant degree in postponing levodopa therapy. These clinical observations have indicated that the initiation of levodopa administration could be postponed in some 60% of patients for 1 year or more, whilst after several years most patients required levodopa as an addition or alternative treatment. Some patients (approximately 10%, 5 out of 66 at one center at Turku, and 12 out of 119 in an Italian multicenter study) did well on lisuride alone for greater than or equal to 5 years. Thus, the results for long-term lisuride monotherapy in the controlled prospective study by U.K. Rinne could be confirmed by the data from the various Italian centers with similar long-term experiences, with even more favourable results. Comparable results as obtained with deprenyl in the DATATOP study could be found with lisuride monotherapy patients. This demonstrates that symptomatic therapy with the dopamine agonists lisuride is able to postpone levodopa therapy to a similar extent as has been reported in the case of deprenyl. In the latter case, a favourable effect on the progression of the disease had been postulated. We compare published data on both drugs and conclude that the delay in levodopa therapy observed with both drugs is compatible with the assumption of a symptomatic or general activating effect, and that other criteria need to be used for studying the progression of a neurodegenerative disease.

Possible role of gonadal hormones as triggering factors in migraine.

There is a large evidence that fluctuating peripheral gonadal hormones can trigger migraine attacks in women. It has been proposed that the main factor involved is a rapid fall in circulating estrogen levels. We have analysed migraine and headache attacks reported in some recent studies involving oral contraceptives and propose that also at least in a part of these cases, the withdrawal of the exogenous estrogens initiates the attack. Possible mechanisms are discussed and further studies are proposed.

[Significance of biographies for aging research (gerontology as a social science)]. / Zur Bedeutung von Biographien für die Alter(n)sforschung (Gerontologie als Gesellschaftswissenschaft).

The main purpose of the paper is to show the importance of biography, within the framework of life-events and social needs. Gerontology always deals with life history, although this often is done quite in an one-sided manner. The author tries to characterise the relations between past, actual situation on future in social terms. Personality and its ideas about life play the most important role. The paper also refers methodical aspects of biography.

[Family, career and age as socialization factors of the middle and later adult years]. / Familie, Beruf und Lebensalter als Sozialisationsfaktoren des mittleren und höheren Erwachsenenalters.

The authors deal with the connections of age, family and vocational activity. By using Marx term "Gratisdienst" they develop an ideal of family functions for the vocational education of grown-up children. Family in this sense is individually and socially of importance as a medium of transmission. The authors also show the importance for society and give examples how the so called post-parental (post-familial) phases in family and lifecourse is orientated towards professional integration of the children. Some aspects how to use and explain this potential funds under socialist conditions in the GDR are discussed.

[Social aspects of ageing and old age in socialist society (author's transl)]. / Soziale Aspekte des Alterns und Altseins in der Sozialistischen Gesellschaft.

The term social age(ing) is discussed within a historical context. The basic idea is that social and biological existence should not be separated although both can overlap. The paper also goes into the tasks of a social scientist engaged in the subject of age research. Some theoretical questions are based on the "way of life" theory and it's constituting elements.

[Some aspects of way of life of elderly women in socialist society (author's transl)]. / Zu einigen Aspekten der Lebensweise älterer Frauen in der sozialistischen Gesellschaft.

Aspects in the way of life, in aging and being aged and the position of women in socialist society are related together. Within that efforts are especially elderly women treated who's development show sexually and socially determined differences compared to elderly men. The role and the position of women in socialist society is seen as a result of historical processing. According to the different circumstances in life different ways of life are evident. They get reproduced in different patterns and attitudes. That concerns individuals as well as the society as a whole.