Forehead SpO2 monitoring compared to finger SpO2 recording in emergency transport.

Continuous peripheral oxygen saturation monitoring using a finger pulse oximeter is standard in prehospital emergency medicine. Forehead peripheral oxygen saturation monitoring has been enhanced for better performance during movement and in cold ambient temperatures, both of which are common during emergency transport. We compared a new forehead monitor with standard finger pulse oximeter. The forehead technique had significantly fewer mean (SD) alarms per patient (3.0 (2.2)) than the finger pulse oximeter (7.8 (4.0)) and shorter durations of malfunction (76 (60) s compared to 333 (170) s) when using the finger pulse oximeter. We conclude that measuring peripheral oxygen saturation monitoring with a forehead sensor provides better monitoring quality in emergency care.

Implementation of the Vienna Hydrotherapy Group for Laryngectomees--a pilot study.

GOALS: Laryngectomy involves several problems for the individual, such as the need to cope with a stoma, adjustment to tracheostomal breathing, and the formation of a voice. Contact with water, resulting in aspiration, may prove fatal for laryngectomized patients in the absence of appropriate aids. The aim of this pilot study was to conduct a hydrotherapy group for laryngectomized patients and to evaluate its feasibility and outcome in relation to the goals of therapy. PATIENTS AND METHODS: Six male patients who had undergone laryngectomy were included in a pilot study. The patients underwent a structured hydrotherapy rehabilitation program (three times a week for 8 weeks), using a special underwater therapy device. The patients' posture was controlled by posturography and their endurance capacity by standard ergometry and the 6-min walk. The parameters of fatigue, expectoration, mobility, elasticity/flexibility, postural control/coordination, and general well being were registered on a visual analog scale (VAS). Quality of life was assessed by having the patients fill out the German version of the SF-36 Health Survey. MAIN RESULTS: Posturograpy findings showed an improvement of two subtests ( p<0.028). Exercise testing showed an improved endurance capacity ( p<0.028). The patients were able to walk a greater distance in the 6-min walking test ( p<0.028). The VAS also showed an improvement of endurance capacity ( p<0.028), fatigue ( p<0.028), expectoration ( p<0.043), mobility of the neck and shoulder ( p<0.027), flexibility ( p<0.027), postural control and coordination ( p<0.028), and general well being ( p<0.028). On the SF-36 Health Survey, the patients were improved in the items "Physical functioning" ( p<0.027), "Vitality" ( p<0.027) "Role-physical" ( p<0.026), and "Social functioning" ( p<0.043). CONCLUSIONS: A hydrotherapy group for laryngectomized patients proved to be safe, feasible, and effective in this pilot study.

Aerobic exercise for a patient suffering from metastatic bone disease.

A 48-year-old female patient suffering from advanced breast cancer with metastatic bone disease participated in an aerobic exercise program consisting of ergometer cycling three times a week for 1 year. Feasibility, safety and beneficial effects of the program were proven for the patient in this case study. VO(2)max (20.2% after 16 weeks, 52.7% after 12 months) and peak work capacity (15.5% after 16 weeks, 35.7% after 12 months) had increased. The patient experienced a marked improvement in physical performance and in quality of life. Aerobic exercise, initiated and executed with appropriate care, may serve as a useful additional means of palliative treatment in some cancer patients with bone metastases.

Muscle-nerve-muscle neurotization of the orbicularis oris muscle.

INTRODUCTION: A denervated half of the orbicularis oris muscle is not reinnervated spontaneously by axon sprouting from the intact contralateral side. The borderline between the facial nerve territories seems to act as a barrier. The muscle-nerve-muscle technique was advocated as a technique to reneurotize a denervated half of the orbicularis oris muscle in cases of marginal mandibular paralysis. MATERIAL AND METHODS: This muscle-nerve-muscle neurotization was tried to induce reinnervation of a denervated angle of the mouth in four patients. Grafts were harvested from the sural nerve. Functional recovery was assessed by measurement of facial movements and by electrophysiological examination. RESULTS: In three of the four cases presented, this technique helped to improve function of the lower lip. The clinical relevance of the results is discussed.

Health related quality of life in patients with long-standing insulin dependent (type 1) diabetes mellitus: benefits of regular physical training.

BACKGROUND AND AIMS: Regular exercise is recommended to diabetic patients in addition to dietary restrictions and drug therapy. We have studied whether health related quality of life (HRQOL) can be improved by a regular physical training program. METHODS: 23 otherwise healthy patients with history of type 1 diabetes for 20 +/- 10 years were included. 15 patients (age: 41 +/- 2 years) participated in an aerobic physical training program over 4 months and 8 patients (33 +/- 11 years) served as a control group. HRQOL was assessed by a validated questionnaire (MOS SF-36). Tests were carried out at baseline and after 4 months. RESULTS: Physical training increased peak oxygen uptake (VO2max) by 27 +/- 13% after 4 months (p = 0.04) in the training group. There was no significant change in hand or leg isometric muscle strength. All HRQOL scales improved in the training group with significantly higher (p < 0.04) Social Functioning and Vitality scores, respectively. Moreover, insulin requirements decreased during physical training program (p < 0.05). CONCLUSIONS: Our data indicate that physical exercise training in patients with type I diabetes mellitus improves metabolic control and various aspects of HRQOL. Besides enhanced cardiorespiratory capacity, this is an important subjective benefit in patients with longstanding insulin dependent (type 1) diabetes mellitus.

Neuromuscular electric stimulation in heart transplantation candidates with cardiac pacemakers.

Twenty percent of heart transplantation candidates have cardiac pacemakers. Application of neuromuscular electric stimulation (NMES) in patients with pacemakers is controversial because of potential electromagnetic field interference and subsequent failure of the pacemaker. We present a safety protocol as a procedure before applying NMES in pacemaker patients. In 4 patients with chronic heart failure, NMES was applied under supervised conditions for 20 minutes to evaluate the individual risk. No changes in the clinical state and no complications secondary to electromagnetic field interference were observed. A check of pacemaker function after this 20-minute stimulation revealed no changes in the pacemaker parameters. After a thorough safety protocol, NMES of knee extensor muscles in patients with pacemakers appears to be safe.

Cross-cultural adaptation of the Minnesota Living with Heart Failure Questionnaire for German-speaking patients.

We performed a cross-cultural adaptation of the "Minnesota Living with Heart Failure Questionnaire" (LHFQ) for use in German-speaking chronic heart failure patients. The instrument was translated and back translated, pre-tested and reviewed by a committee. The German version was tested in 114 patients with chronic heart failure. Reliability was assessed by a test-retest procedure and Cronbach's coefficient alpha of internal consistency (0.94). To assess concurrent validity, we compared the LHFQ sum scores with the New York Heart Association classification rating (r = 0.53; p < 0.0001), the 6-minute walk (r = -0.39; p < 0.0001), the left ventricular ejection fraction (r = -0.24; p = 0.011) and big-endothelin (r = 0.27; p = 0.004). Construct validity on the LHFQ scores in comparison with the Medical Outcomes Study SF-36 Health Survey (MOS SF-36) was significant (-0.41 to -0.74; all p < 0.0001). The reliability and validity of the German version of the LHFQ was proved; the questionnaire can be recommended for use in future clinical trials.

First experiences with outpatient care of patients with implanted axial flow pumps.

As known from patients with pulsatile ventricular assist devices (VADs), early mobilization, physical exercise, and return to normal life are essential for optimal recovery. Recently, implantable rotary pumps became available for extended left ventricular support as bridges to transplantation. Modified procedures are essential for patient training and hospital discharge. The MicroMed-DeBakey VAD was implanted in 10 patients with end-stage heart disease. After recovery, regular ergometer training was performed with loads adapted to the patient's condition. Procedures for patient observation under outdoor conditions and a blood pressure measuring device for low pulse pressure conditions were developed. Improvement of physical condition was achieved in 8 patients. In the first 2 patients, exercise capacity was limited due to flow obstruction. In the following patients, an increase of workload on the ergometer up to 120 W was observed. Correlated with training, lactate/load relationship and heart rate decreased. Three patients were discharged from the hospital during support. The DeBakey-VAD system can support patients for extended time periods and is suitable for recovery and exercise. Under optimal patient and environmental conditions, discharge from the hospital can be obtained.

Isokinetic strength testing in patients with chronic heart failure--a reliability study.

Measurement of skeletal muscle strength gains increasing importance as outcome parameter in patients with chronic heart failure. This study aimed at establishing short-term reliability of isokinetic strength measurements of knee extensor and flexor muscles in 38 patients with chronic heart failure. Strength tests were performed on the Cybex 6000 dynamometer. Trunk fixation was restricted to pelvic fixation. Two bouts of strength testing were performed on day 1 and one on day 5. Each isokinetic bout consisted of 3 reciprocal knee extension and flexion movements with an angular speed of 60 degrees per second. Isometric strength was measured at 30 degree knee angulation. Intraclass correlations ranged between 0.96 and 0.99 for isokinetic and isometric peak torque of knee extensor muscles and 0.82-0.96 for flexor muscles. Analysis of repeated measurements showed significant differences among the values of flexor peak torque in the isokinetic mode and between all measurements in the isometric mode (p < 0.05). Pearson's correlation coefficients for isokinetic and isometric extensor peak torques ranged between 0.95 and 0.99, for flexor peak torques between 0.81 and 0.85 (all p < 0.0001). Measurement of isokinetic knee extensor and flexor peak torque is a reliable method to assess muscle strength in patients with chronic heart failure even with altered trunk fixation.

Physical performance and health-related quality of life in men on a liver transplantation waiting list.

Twenty-six men on a liver transplant waiting list (12 had alcoholic cirrhosis, 8 suffered from posthepatitic cirrhosis, and 6 from cirrhosis of other etiologies) were eligible for this observation. Nineteen subjects underwent exercise testing to determine oxygen uptake at anaerobic threshold. In all patients dynamometry was performed to determine isokinetic muscle strength of knee extensor muscles, and handgrip. Quality of life was evaluated in all patients with the MOS SF-36 questionnaire. Child-Pugh A patients showed 54 +/- 8%, Child-Pugh B patients 36 +/- 2%, and Child-Pugh C patients 31 +/- 4% of VO2 max predicted at the anaerobic threshold (Kruskal-Wallis ANOVA, p < 0.05). Isokinetic muscle strength of the quadriceps femoris (left/right) was 149 +/- 20/134 +/- 14 Nm in Child-Pugh A, 108 +/- 16/114 +/- 19 Nm in Child-Pugh B, and 89 +/- 10/81 +/- 11 Nm in Child-Pugh C patients (Kruskal-Wallis ANOVA, p < 0.05). MOS-SF36 revealed a Child-Pugh class dependent reduced functional status (Kruskal-Wallis ANOVA, p < 0.05). No significant differences in target parameters were found when analysed according to the etiology of cirrhosis. Patients on the liver transplant waiting list do have a stage dependent reduction in physical health. These data are the basis for longitudinal studies measuring the effects of preoperative rehabilitation programs in these patients.

Experimental study of muscle-nerve-muscle neurotization.

A laboratory model for the study of possible reinnervation by muscle-nerve-muscle (MNM) neurotization is presented. Preliminary studies revealed that MNM neurotization occurs in synergistically closely-related facial muscles. However, for larger antagonistic somatic muscle (flexor and extensor), this phenomenon could not be reproduced. The potential clinical relevance of these findings is presented and discussed.

Aerobic capacity in adult dermatomyositis/polymyositis patients and healthy controls.

OBJECTIVE: Assessment of myositis patients has relied on symptoms, strength testing, and serum muscle enzyme activity. Recently, functional assessments and evaluation of strength by dynamometry and of disease activity by magnetic resonance imaging have also been added. Aerobic testing in selected patients has been considered useful. DESIGN: Case-control study. SETTING: University Hospital, Vienna, Austria. PATIENTS: Twenty-two subjects (8 outpatients with chronic dermatomyositis and 3 outpatients with chronic polymyositis, and 11 healthy controls) participated, allowing the identification of 11 case-control pairs matched by age (+/-3 years) and gender (mean age, 48+/-14 yrs; ratio of women to men, 18/4). MAIN OUTCOME MEASURES: Target parameters were peak oxygen uptake (peak VO2) to estimate aerobic exercise capacity and peak isometric torque for muscle strength. Creatine phosphokinase (CPK) was measured to assess elevation of muscle enzymes. RESULTS: The mean peak VO2 in patients with dermatomyositis/polymyositis was 15.3 mL/min/kg (SD = 5.8) and in the healthy controls 28.7 mL/min/kg (SD = 7.8). Cardiorespiratory capacity expressed as peak VO2 was thus significantly reduced at 53% (p = .0001) of the control value. Muscle strength expressed as peak isometric torque was significantly lower (p = .01) in patients (mean 148+/-73 Nm) when compared to the control group (mean 261+/-99 Nm). In myositis patients peak VO2 and peak isometric torque correlate well with each other (r = .7631; p = .0001), but not at all with serum CPK levels (r = .056; p = .869). CONCLUSION: Peak VO2 is significantly diminished in patients with dermatomyositis/polymyositis, compared with age- and sex-matched controls. Serum CPK did not significantly correlate with VO2. Aerobic exercise testing may be a useful assessment parameter in selected patients with dermatomyositis/ polymyositis.

Cross-cultural adaptation of the Roland-Morris questionnaire for German-speaking patients with low back pain.

STUDY DESIGN: Cross-cultural adaptation and cross-sectional psychometric testing. OBJECTIVES: To develop and validate a cross-cultural version of the Roland-Morris Questionnaire for use in German-speaking patients with low back pain. SUMMARY OF THE BACKGROUND DATA: Clinical research related to the management of back pain would be facilitated enormously if a small number of patient-oriented questionnaires became widely used. If the transposition of a questionnaire from its original cultural context is done by simple translation, it is unlikely to be successful because of language and cultural differences. Therefore, a simple direct translation of a questionnaire from one language to another does not permit its use in clinical trials. METHODS: The instrument was translated and back-translated, pretested, and reviewed by a committee. The German version of the Roland-Morris Questionnaire was tested in 125 patients with low back pain. The study was conducted at the spa resort at Senftenberg, Austria, which is visited by patients from all countries of German-speaking Europe. Reliability and concurrent construct validity were assessed with Pearson's correlation coefficient on the Roland-Morris Questionnaire scores compared with the scales of the Medical Outcome Study Short Form-36 questionnaire. RESULTS: Pearson's correlation coefficient for test-retest reliability of the German version was r = 0.82 (P = 0.0001), and Cronbach's alpha was 0.81. The concurrent validity was r = 0.81 (Roland-Morris Questionnaire/pain rating; P = 0.0001), r = 0.48 (Roland-Morris Questionnaire/forward bending; P = 0.0001), and r = -0.47 (Roland-Morris Questionnaire/lateral bending; P = 0.0001). Correlation between the functional scales of the Medical Outcome Study Short Form-36 questionnaire and the Roland-Morris Questionnaire sum scores ranged from r = -0.29 (emotional limitations; P = 0.0011) to r = -0.71 (physical limitations; P = 0.0001). CONCLUSION: Because the German version of the Roland-Morris Questionnaire seems to be reliable and valid for the assessment of the functional status in German-speaking patients with low back pain, the use of this translated instrument can be recommended in future clinical trials.

[Transthoracic recording of pulmonary venous flow for diagnosis of high pulmonary capillary wedge pressure]. / Transthorakale Registrierung des Lungenvenenflusses zur Diagnose eines hohen Pulmonalkapillar-Druckes.

69 patients (46 men, 23 women, age 34 to 78 mean 56 years, all in sinus rhythm) with suspected cardiac insufficiency underwent transthoracic Doppler echocardiography followed by hemodynamic measurement of the pulmonary capillary wedge pressure (= PCP). The echocardiographic measurements included: 1) the peak systolic (S) and diastolic (D) pulmonary venous flow (PVF) velocity (all patients); 2) the E and A peak velocity (62 patients) and 3) the deceleration time (DT, 57 patients) of the mitral flow curve (mean values from 5 to 15 beats). PCP was high (> or = 15 mm Hg) in 27 patients and low (< or = 14 mm Hg) in 42. There were significant correlations between the PCP and all 3 echo parameters: (PCP-S/D: r = -0.69, PCP-E/A: r = 0.66 PCP-DT: r = -0.48, p < 0.05 for all correlations). The sensitivity, specificity, positive and negative predictive accuracy of a pulmonary venous S/D ratio < 1.0 for detecting a high PCP were 82, 83, 76 and 88% respectively, which is similar to the results of previous transesophageal studies. However, slightly reduced S/ID ratios (0.8 to 0.99) were often associated with a normal PCP, and only ratios below 0.8 should be considered as indicative of a high PCP. The mitral flow parameters E/A > or = 1.5 and DT < or = 0.12 s were equally useful in detecting a high PCP: sensitivity, specificity, positive and negative predictive accuracy were 68 and 86, 90 and 80%, 79 and 73%, 84 and 90% respectively. However, E/A ratios between 1.0 and 1.49 were not very useful, representing a high PCP in one third of the cases. There were significant correlations and a high degree of agreement in predicting a high or low PCP between the three Doppler echo parametes, particularly between S/D and E/A ratios. The analysis of pulmonary venous flow by transthoracic echocardiography is a useful method for the non-invasive detection of a high PCP. However, this method no more accurate than the much simpler analysis of mitral flow. The application of the pulmonary venous flow method is indicated when mitral flow cannot be interpreted, for example because of tachycardia, aortic incompetence or an E/A ratio in the ambiguous range (1.0 to 1.49).