[Syncope from the viewpoint of a neurologist]. / Synkope aus der Sicht des Neurologen.

Syncope is a pathogenetically diverse syndrome that often requires an interdisciplinary investigation. In addition to cardiovascular reasons of syncope neurological diseases and differential diagnoses have to be considered. In particular, neurodegenerative disorders, such as Parkinson's disease or polyneuropathy may cause orthostatic intolerance and syncope due to a malfunction of autonomic reflexes. Furthermore, important differential diagnoses of syncope, such as epilepsy, drop attacks or circulatory disorders in the territory of the basilar artery are attributed to the neurological field.

[HIV test and prevention]. / HIV-Test und Prävention.

Successful prevention of an HIV epidemic is still a desirable goal. As young people are mainly affected by new infections and AIDS mortality has fallen virtually to zero, the long-term total costs of HIV management are increasing. This report describes how the targeted application of HIV testing can influence the HIV epidemic. The crucial point is the early diagnosis of primary HIV infection in standard situations whereby early diagnosis and counselling result in behavioral modifications preventing new transmission.

[Interhospital transport of intensive care patients in Lower Saxony : statewide need-based and effective management]. / Intensivverlegung in Niedersachsen : Landesweite bedarfsgerechte und effektive Sicherstellung.

BACKGROUND: Since 2007 interhospital transport of intensive care patients in Lower Saxony appertains to the performance requirements of emergency medical services. Against this background the Working Group for Evaluation of Intensive Care Transport (Arbeitsgemeinschaft Evaluation Intensivverlegung) was established. This group formulated standardized definitions for the requirements of intensive care transport vehicles and a federal statewide monitoring of intensive care transport was implemented to analyze if simultaneously on-call intensive care transport systems (intensive care helicopter and ground based mobile intensive care units) can be deployed need-based and efficiently. METHODS: A prospective follow-up study and evaluation of intensive care transport in Lower Saxony between April 1(st) 2008 and July 31(st) 2010 was carried out. RESULTS: A total of 6,779 data records were evaluated in this study of which 4,941 (72.9%) missions were located in Lower Saxony, 2,928 (43.2%) missions were carried out by helicopters and 3,851 (56.8%) by ground based mobile intensive care units. The mean duration of a mission was 3 h 59min±2 h 25 min, 4 h 39 min±2 h 23 min by ground based mobile intensive care units and 2 h 21 in±30 min by helicopter units. All systems proved to be feasible for intensive care transport. The degree of urgency was estimated correctly in 94.8% of the evaluated missions and 58.0% of the transfers could not be deployed. In 76.8% patients were transferred to hospitals with a higher level of medical care, 51.7% of patients were transferred for intensive care therapy and 40.4% for an operation/intervention. Of the patients 38.2% required mechanical ventilation and in 48.3% invasive monitoring was carried out. CONCLUSION: Interhospital transfer of intensive care patients can be carried out need-based with a limited number of intensive care transport vehicles if the missions are deployed effectively by standardized disposition in accordance with performance requirements.

The effects of high-frequency jet ventilation (HFJV) on pneumoperitoneum-induced cardiovascular changes during laparoscopic surgery.

BACKGROUND: Standard mechanical ventilation may cause adverse cardiovascular effects in addition to those already related to positive-pressure pneumoperitoneum (PP) during laparoscopic surgery. High-frequency jet ventilation (HFJV) is associated with much less airway pressure, with potentially less influence on venous return, thus potentially it may reduce those effects. The aim of this study was to evaluate the benefits of HFJV to reduce the adverse cardiovascular effects during laparoscopic cholecystectomy. METHODS: We conducted a randomized prospective trial, comparing 12 patients undergoing elective laparoscopic cholecystectomy under conventional mechanical ventilation (control) with 13 similar subjects under HFJV (study). Both groups were categorized as ASA I-II and underwent total intravenous anesthesia. Cardiac functionality was continuously evaluated by analysis of arterial pressure wave changes (Edwards Flo-Trac sensor and Vigileo monitor). RESULTS: There was no significant difference between both groups regarding age, gender, BMI, and general medical condition, as well as hemodynamic stability and blood gases throughout surgery. A significant reduction in cardiac output was noted in the control group under PP during the initiation of anti-Trendelenburg position (from 5.6 to 5.0 l/min, P = 0.049). A reciprocal change was observed regarding stroke volume. Such changes were not noticed under HFJV. Total peripheral resistance was significantly increased during PP, and heart rate was not significantly affected throughout surgery in both groups. Unexpectedly, we did not observe marked adverse hemodynamic changes in the control group during PP without position adjustment. CONCLUSIONS: The use of HFJV in upper laparoscopic surgery can impede the adverse cardiovascular changes that usually occur during induction of PP. We also suggest that the use of total intravenous anesthesia (as used in our study) may also lessen the cardiovascular impairment during PP.

[An expert system neurology--possibilities and limitations]. / Ein Expertensystem für das Fachgebiet Neurologie--Möglichkeiten und Grenzen.

We present an expert system Neurology, which was developed completely on basis of the commercial available data base program Filemaker-7.0. At present it covers approximately 400 diagnoses of neurological and psychiatric diseases. After the input of cardinal symptoms, course and localisation of the disease the program calculates a first set of possible differential diagnoses and asks for additional symptoms or the performance of apparative diagnostics to investigate the final diagnose. At first, the performance of the expert system was tested with 15 predetermined neurological case reports. Users with different previous knowledge of Neurology performed the input. In this test the program was able to identify the correct diagnose in nearly all cases and the diagnostic proposals were superior to those of the users with minor neurological training. In a second test with real patient data, the rate of correct diagnoses was approximately 80%. In summary, the used computer algorithms proved as appropriate for the aim of giving Neurological diagnoses. Possible additional applications could be student training or the use as interdisciplinary reference work.

Exacerbation of migraine attacks during treatment with the selective serotonin reuptake inhibitor sertraline. A case report.

Abnormal signal transmission in central serotonergic pathways is supposed to play an important role in the pathogenesis of migraine and major depression. We report on a patient, who was treated during an episode of depression with the selective serotonin reuptake inhibitor (SSRI) sertraline and developed frequent migraine attacks under this therapeutical regime. Single migraine attacks were treated successfully with triptanes. Although SSRIs may be beneficial for migraine prophylaxis at long term administration, this case suggests that acute administration of SSRIs in migraineurs may include the risk of worsening migraine.

Follow-up of advanced diabetic neuropathy: useful variables and possible pitfalls.

BACKGROUND: The course of advanced diabetic neuropathy (DN) is largely unknown. AIM: To find variables allowing the follow-up of late stages of DN. METHODS: Thirty diabetic patients with DN were observed. Patients were examined at intervals of 6 months over a period of 2 years. The compound muscle action potentials (CMAPs) were recorded in extensor digitorum brevis (EDB) and flexor hallucis brevis (FHB) muscles. Clinical severity of DN, nerve conduction studies (NCS), quantitative sensory testing (QST) and heart rate variability (HRV) were evaluated. The data were compared with age- and sex-matched controls. RESULTS: All measures were sensitive to the detection of DN. Significant deterioration during follow-up was exclusively found in CMAP analysis of the EDB (p<0.05) and FHB muscles (p<0.03). NCS, QST and HRV remained unchanged within the 2 years of observation. Coincidental changes might occur, if only two time points are chosen for followup. CONCLUSION: Our results indicate that ongoing axonopathy predominates in advanced DN. Repeated testing helps to minimize the impact of coincidental or chance changes in DN follow-up studies.

Power spectral analysis of heart rate variability during helium pneumoperitoneum: The mechanism of increased cardiac sympathetic activity and its clinical significance.

BACKGROUND: Carbon dioxide pneumoperitoneum (PP) is known to induce increased cardiac sympathetic expression. The role of the insufflated gas involved in this mechanism should be elucidated in an attempt to eliminate its possible serious consequences. METHODS: Twenty-five patients undergoing elective laparoscopic cholecystectomy were prospectively analyzed for cardiac autonomic nervous activity by spectral heart rate variability. In 15 patients, helium was used as CO(2) substitution for abdominal insufflation (study group). Four frequency bands of interest were obtained from the power spectrum of R-R intervals, as well as the ratio between the low and high frequency (LF/HF), using the fast Fourier transformation algorithm to characterize the synergy of both autonomic branches during PP. RESULTS: Significantly increased values of the power spectrum related to the LF and VLF bands (from 130 to 377 msec(2)/Hz and from 145 to 516 msec(2)/Hz, respectively) were inspected during CO(2) PP, as well as increased LF/LH ratio (2.1). Using helium as CO(2) substitution has eliminated the significant changes in the power spectrum that reflect increased cardiac sympathetic activity. CONCLUSIONS: The elimination of sympathetic predominance by helium PP indicates the central role of CO(2) in establishing this phenomena. Considering this information and its other known advantages, helium should be considered for use during prolonged laparoscopic procedures for high-risk patients.

Sudomotor function in familial dysautonomia.

BACKGROUND: Patients with familial dysautonomia (FD) manifest episodic hyperhidrosis despite the reduction of sudomotor fibres and sweat glands associated with this autonomic neuropathy. We assessed peripheral sudomotor nerve fibre and sweat gland function to determine if this symptom was due to peripheral denervation hypersensitivity. METHODS: In 14 FD patients and 11 healthy controls, direct and axon reflex mediated sweat responses were determined by measuring transepidermal water loss (TEWL) after application of acetylcholine via a microdialysis membrane, a novel method to evaluate sudomotor function in neuropathy patients. Results were compared with data from conventional quantitative sudomotor axon reflex testing (QSART). Using microdialysis, interstitial fluid was analysed for plasma proteins to evaluate protein extravasation induced by acetylcholine as an additional parameter of C-fibre function. RESULTS: Although reduced axon reflex sweating was expected in FD patients, neither direct or axon reflex mediated sweat responses, nor acetylcholine induced protein extravasation differed between control and patient groups. However, the baseline resting sweat rate was higher in FD patients than controls (p<0.05). TEWL and QSART test results correlated (r = 0.64, p = 0.01), proving the reliability of TEWL methodology in evaluating sudomotor function. CONCLUSION: The finding of normal direct and axon reflex mediated sweat output in FD patients supports our hypothesis that, in a disorder with severe sympathetic nerve fibre reduction, sudomotor fibres, but not the sweat gland itself, exhibit chemical hypersensitivity. This might explain excessive episodic hyperhidrosis in situations with increased central sympathetic outflow.

Assessment of the neurogenic flare reaction in small-fiber neuropathies.

To improve sensitivity of the analysis of axon reflex flare reaction, the authors used a laser Doppler scanner and analyzed flare intensity and size induced by histamine iontophoresis simultaneously at the foot and thigh in patients with small-fiber neuropathy (n = 10) and controls (n = 9). Flare size, but not laser Doppler flux, clearly distinguished patients from controls at both locations (p < 0.01) and may be useful for evaluation of small-fiber neuropathies.

Dermal microdialysis provides evidence for hypersensitivity to noradrenaline in patients with familial dysautonomia.

OBJECTIVES: To use the technique of dermal microdialysis to examine sensitivity of skin vessels to noradrenaline (NA) in patients with familial dysautonomia (FD) and in healthy controls. METHODS: In 14 patients with FD and 12 healthy controls, plasma extravasation, local laser Doppler blood flow, and skin blanching were observed before, during, and after application of 10(-6) M NA through a microdialysis membrane, located intradermally in the skin of the lower leg. RESULTS: Maximum local vasoconstriction measured by laser Doppler blood flow did not differ between patients with FD and controls. In contrast, patients with FD had an earlier onset of vasoconstriction (p = 0.02). Moreover, reaction to NA was more prominent and prolonged in FD, shown by a larger zone of skin blanching around the microdialysis membrane (p < 0.001) and delayed reduction of the protein content in the dialysate after termination of NA application (p = 0.03). CONCLUSION: These data support the hypothesis that peripheral blood vessels of patients with FD show a denervation hypersensitivity to catecholamines. This may be one mechanism contributing to the major hypertension that frequently occurs during "dysautonomic crises" in FD.

Power spectral analysis of heart rate variability during positive pressure pneumoperitoneum: the significance of increased cardiac sympathetic expression.

BACKGROUND: Positive pressure pneumoperitoneum (PPP) effects on the autonomic nervous system (ANS) might be of clinical importance, as imbalance in the autonomic cardiac control might lead to serious consequences. METHODS: Fifteen healthy patients undergoing elective laparoscopic cholecystectomy were analyzed for cardiac autonomic nervous activity by spectral heart rate variability, during awake state, before and after intubation, during CO2 PPP (14 mmHg), and after CO2 evacuation. The very low, low, high and very high frequency (VLF, LF, HF, VHF respectively) bands of the spectral density of the heart rate variability (HRV) and their normalized values, as well as the LF/HF ratio, were obtained from the power spectra of R-R intervals, using the fast-Fourier transformation algorithm. RESULTS: Using Friedman's nonparametric test, only the difference between the power of LF during anesthesia (median 30.74) and the middle of PPP (median 195.66) was found to be significant (p<0.012). Such change was recorded in 14 patients (p = 0.001, sign test). CONCLUSIONS: Increased LF power reflects sympathetic cardiac activation. As the LF range accounts for regulation of blood pressure and baroreflex, several mechanisms may explain this activation. This in turn may predispose patients who suffer from cardiac disease to higher risk of developing ventricular arrhythmias, besides the possible adverse hemodynamic consequences of PPP.

The laparoscopic approach to abdominal hydatid cysts: a prospective nonselective study using the isolated hypobaric technique.

HYPOTHESIS: The laparoscopic isolated hypobaric technique that we developed and use is safe and feasible for almost all kinds of hepatic and extrahepatic abdominal hydatid cysts. DESIGN: A case series. PATIENTS: Between August 1992 and December 1999, 31 patients with no selection criteria underwent 32 consecutive laparoscopic operations for 52 symptomatic hydatid cysts located in the liver (49), spleen (1), and pelvis (2). Eleven patients underwent surgery for between 2 to 5 cysts. INTERVENTIONS: The main surgical maneuvers (puncture, parasite neutralization, and complete evacuation) were performed through an assembled transparent cannula, in which a vacuum was created, while its tip adhered firmly to the cyst wall. Following evacuation of the cyst contents, we attempted to perform partial pericystectomy, omentoplasty, and closed-suction drainage. MAIN OUTCOME MEASURES: Surgical complications and postoperative disease recurrence. RESULTS: Mean cyst diameter was 8.4 cm (range, 3.5-25 cm). Seven cysts were subdiaphragmatic, and 6 were on the posterior (hidden) aspect of the liver. Mean postoperative follow-up was 49 months. Forty-one cysts contained live parasites, and 11 were secondarily infected. Twenty-four cysts were complex. Perioperative complications occurred in 5 patients, including 1 patient who died 1 month after surgery owing to Candida sepsis. Mean hospital stay was 6 days. No evidence of recurrence was recorded during follow-up. CONCLUSIONS: The isolated hypobaric laparoscopic technique described provides a safe and efficacious approach to almost all types of abdominal hydatid cysts and takes advantage of the recognized benefits of the laparoscopic approach.

Central and peripheral adverse hemodynamic changes during laparoscopic surgery and their reversal with a novel intermittent sequential pneumatic compression device.

OBJECTIVE: To study the influence of a novel intermittent sequential pneumatic compression device (Lympha-press) on the adverse cardiac and peripheral hemodynamic changes induced by positive-pressure pneumoperitoneum (PPPn) in laparoscopic surgery. SUMMARY BACKGROUND DATA: Creation of PPPn is known to cause adverse central and peripheral hemodynamic changes. An intrasubject observational study was undertaken to quantitate these adverse changes and to assess the influence of an intermittent sequential pneumatic compression system on these adverse hemodynamic changes during laparoscopic surgery with PPPn. METHODS: The study involved 16 consecutive patients undergoing laparoscopic surgery with PPPn of 12 mmHg and 30 degrees head-up tilt position. The following peripheral hemodynamic recordings were made using Doppler ultrasound: peak systolic velocity (PSV), end diastolic velocity (EDV), and cross-sectional area of the femoral vein. Central monitoring included cardiac output and stroke volume by transesophageal Doppler, blood pressure, and pulse. The hemodynamic state based on these parameters was assessed before induction of PPPn with the anesthetized patient in the supine position, after induction of PPPn and head-up tilt position with Lympha-press off, and during PPPn and head-up tilt position with Lympha-press on, and after desufflation with the patient in the supine position under general anesthesia. RESULTS: Positive-pressure pneumoperitoneum and the head-up tilt position resulted in a 33% reduction in PSV, a 21% reduction in EDV, and a 29% increase in cross-sectional area of the femoral vein. This was associated with a 20% reduction in cardiac output and an 18% reduction in stroke volume. Activation of Lympha-press during PPPn and the head-up tilt position resulted in a 129% increase in PSV and a 55% increase in EDV by 55%. It also increased the cardiac output by 27% and stroke volume by 16%, with no effect on cross-sectional area. Compared with the pre-PPPn stage, there was no difference in cardiac output or stroke volume, but the PSV was higher by 78% and the EDV by 32%. After abdominal desufflation in the supine position, the cardiac output and stroke volume were restored to the pre-PPPn level, but persistent and significant elevations were observed during the period of study in PSV, EDV, and cross-sectional area. CONCLUSIONS: Significant and individually variable central and peripheral hemodynamic changes are encountered during laparoscopic surgery with PPPn and the head-up tilt position. These are reversed by intermittent sequential pneumatic compression using Lympha-press.

[Effects of recommendations and patient seminars on effectivity of outpatient treatment for headache]. / Können Therapieempfehlungen oder Patientenseminare die Effektivität der ambulanten Versorgung von Patienten mit Kopfschmerzen verbessern?

BACKGROUND: Treatment of patients suffering from migraine and/or tension-type headache in primary care needs to be improved. To this purpose we tested two strategies for implementation of evidence-based recommendations for treatment of headaches: first, communication of recommendations to the primary care physicians and, second, standardized communication and discussion of these recommendations with patients in combination with exercising of progressive muscle relaxation during patient seminars. METHODS: Patients with at least 2 migraine attacks/month or 8 days of tension-type headache/month were included in the study. Evidence-based pharmacological and non-pharmacological recommendations of the Medicines Committee of the German Medical Profession for treatment of migraine and tension-type headache have been offered to primary care physicians by printed material and during conferences. Patient seminars at 10 days for 2 hours were organized by the outpatient pain facility of the neurological department of the university of Erlangen. During seminars the patients were informed about these recommendations and learned progressive muscle relaxation. Agreed therapy between physician and patient was documented by physicians and patients during a 6 months treatment interval and compared with the recommended therapy. Effectivity of treatment was assessed by pre-post changes of days of headache/month, attack frequency/month, headache intensity (visual analogue scale), pain related impairment (German version of the Brief Pain Inventory), and health related quality of life (German Version of the SF-36). 51 patients were documented by 24 primary care physicians after communication of recommendations and 46 patients completed the patient seminar. Data of both groups were compared with those of 80 patients from primary care physicians before interventions. RESULTS: Communication of recommendations for headache therapy to primary care physicians did not improve conformity of the agreed therapy with the recommended. Contrary conformity of the agreed therapy for pharmacological treatment of migraine attacks and interval therapy of migraine by progressive muscle relaxation with the recommended therapy improved significantly. However, interventions did not significantly improve the outcome quality of outpatient treatment as compared to the therapy of primary care physicians before interventions. CONCLUSION: Effectivity of headache treatment in primary health care could not be improved by communication of evidence-based recommended therapy to primary care physicians nor by direct information of patients about these recommendations in combination with provided availability to learn progressive muscle relaxation.

Breast Hematoma Complicating Thrombolytic Therapy.

Thrombolytic therapy (TT) is now established as the main treatment of acute myocardial infarction (MI). Spontaneous breast hematoma, usually a rare complication of anticoagulant therapy, has been described in the last five decades, but not after thrombolytic therapy. We present three patients who developed the rare complication of breast hematoma after TT, out of 495 women treated with TT in ICCU in our hospital, because of acute MI in the last 12 years. One patient needed blood transfusion and in another patient, atypical ductal nuclei were observed in fine needle aspiration (FNA) of breast hematoma, needing further evaluation. As thrombolytic therapy becomes more widespread and essential in treating patients suffering acute occlusion of coronary, retinal, pulmonary or peripheral arteries, it is expected that more women will present with breast hematoma following such treatment.

Xanthogranulomatous appendicitis--an incidental finding of localized pathology.

The clinical, histopathological, and electron microscopic features of an unusual case of xanthogranulomatous appendicitis are reported. The patient, a 37-year-old female, presented with typical signs of acute appendicitis and the appendix appeared slightly dilated at laparatomy. The histopathological sections showed numerous xanthoma cells mixed with inspissated fecaliths. Electron microscopy disclosed the presence of xanthoma cells filled with electron-lucent lipid droplets of variable size. The ultrastructural characteristics of these cells enabled the distinction of two types of lipid-laden histiocytes, in relationship to the size of the lipid droplets. Since the lipid droplets were seen also in cells other than histiocytes, it appears that these changes are secondary to a common mechanism, comprising factors such as obstruction, hemorrhage, inflammation, and local hypoxia.