Myocardial injury in patients with acute ischemic stroke detected by cardiovascular magnetic resonance imaging.

BACKGROUND: Patients with acute ischemic stroke (AIS) are at high risk of adverse cardiovascular events. Until now, the burden of myocardial injury derived from cardiovascular magnetic resonance imaging (CMR) has not been established in this population. METHODS: Patients with AIS underwent CMR at 3 Tesla within 120 h after the index stroke as part of a prospective, single-center study. Patients with persistent atrial fibrillation were excluded. Morphology and function of both cardiac chambers and atria were assessed applying SSFP cine. Myocardial tissue differentiation was based on native and contrast-enhanced imaging including late gadolinium enhancement (LGE) after 0.15 mmol/kg gadobutrol for focal fibrosis and parametric T2- and T1-mapping for diffuse findings. To detect myocardial deformation global longitudinal (GLS), circumferential (GCS) and radial (GRS) strain was measured applying feature tracking. Cardiac troponin was measured using a high-sensitivity assay (99th percentile upper reference limit 14 ng/L). T2 mapping values were compared with 20 healthy volunteers. RESULTS: CMR with contrast media was successfully performed in 92 of 115 patients (mean age 74 years, 40% female, known myocardial infarction 6%). Focal myocardial fibrosis (LGE) was detected in 31 of 92 patients (34%) of whom 23/31 (74%) showed an ischemic pattern. Patients with LGE were more likely to have diabetes, prior myocardial infarction, prior ischemic stroke, and to have elevated troponin levels compared to those without. Presence of LGE was accompanied by diffuse fibrosis (increased T1 native values) even in remote cardiac areas as well as reduced global radial, circumferential and longitudinal strain values. In 14/31 (45%) of all patients with LGE increased T2-mapping values were detectable. CONCLUSIONS: More than one-third of patients with AIS have evidence of focal myocardial fibrosis on CMR. Nearly half of these changes may have acute or subacute onset. These findings are accompanied by diffuse myocardial changes and reduced myocardial deformation. Further studies, ideally with serial CMR measurements during follow-up, are required to establish the impact of these findings on long-term prognosis after AIS.

Automated speech recognition for time recording in out-of-hospital emergency medicine-an experimental approach.

Precise documentation of medical treatment in emergency medical missions and for resuscitation is essential from a medical, legal and quality assurance point of view [Anästhesiologie und Intensivmedizin, 41 (2000) 737]. All conventional methods of time recording are either too inaccurate or elaborate for routine application. Automated speech recognition may offer a solution. A special erase programme for the documentation of all time events was developed. Standard speech recognition software (IBM ViaVoice 7.0) was adapted and installed on two different computer systems. One was a stationary PC (500MHz Pentium III, 128MB RAM, Soundblaster PCI 128 Soundcard, Win NT 4.0), the other was a mobile pen-PC that had already proven its value during emergency missions [Der Notarzt 16, p. 177] (Fujitsu Stylistic 2300, 230Mhz MMX Processor, 160MB RAM, embedded soundcard ESS 1879 chipset, Win98 2nd ed.). On both computers two different microphones were tested. One was a standard headset that came with the recognition software, the other was a small microphone (Lavalier-Kondensatormikrofon EM 116 from Vivanco), that could be attached to the operators collar. Seven women and 15 men spoke a text with 29 phrases to be recognised. Two emergency physicians tested the system in a simulated emergency setting using the collar microphone and the pen-PC with an analogue wireless connection. Overall recognition was best for the PC with a headset (89%) followed by the pen-PC with a headset (85%), the PC with a microphone (84%) and the pen-PC with a microphone (80%). Nevertheless, the difference was not statistically significant. Recognition became significantly worse (89.5% versus 82.3%, P<0.0001 ) when numbers had to be recognised. The gender of speaker and the number of words in a sentence had no influence. Average recognition in the simulated emergency setting was 75%. At no time did false recognition appear. Time recording with automated speech recognition seems to be possible in emergency medical missions. Although results show an average recognition of only 75%, it is possible that missing elements may be reconstructed more precisely. Future technology should integrate a secure wireless connection between microphone and mobile computer. The system could then prove its value for real out-of-hospital emergencies.

[Equipment of physician-staffed ambulance systems in the state of Baden-Wuerttemberg]. / Ausstattung von Notarztbesetzten Rettungsmitteln in Baden-Württemberg.

BACKGROUND: Laws regulating emergency medical systems in the federal state of Baden-Wuerttemberg call for equipment of physician-staffed ambulances that is based on current knowledge in emergency medicine. The grade of implementation is determined using single issue complexes. METHODS: A total of 127 emergency physician bases were located and each received a questionnaire regarding the equipment of the physician-staffed ambulances and helicopters and planned supplementation of the equipment, deadline was 30 June 2001. RESULTS: Of the 127 stations 116 (91.3%) participated. A 12-lead ECG is available in 52.6%, out-of-hospital fibrinolysis is possible in 15 bases (12.9%). Alternatives to endotracheal intubation are carried in 53.3% (cricothyroidotomy: 83.3%) and 31 bases provide capnometry or other devices for verifying correct tube placement. A mobile phone is available in 88 bases (75.9%). CONCLUSIONS: When comparing equipment of physician-staffed ambulances statewide, striking differences can be found.

Inverse association between endogenous glucocorticoid secretion and L-selectin (CD62L) expression in trauma patients.

Exogenously administered glucocorticoids downregulate inflammatory host response, i.e. by inhibition of adhesion molecule expression on leukocyte surfaces. Here, possible associations between the trauma-induced endogenous secretion of cortisol and the expression of neutrophil adhesion molecules (L-selectin/CD62L, CD 11b, CD54) were studied in humans. Standardized elective hip arthroplasty was investigated as an exemplary condition of acute inflammation. In 20 patients, blood for quantification of cortisol and adrenocorticotropic hormone was obtained at minutes 10, 20, 30, 60, hours 1, 2, 4 and 10 and days 1,3 and 7. Expression of L-selectin/CD62L, CD11b and CD54 on neutrophil surfaces was determined preoperatively, and postoperatively at hours 1, 2, 3, 4, and 10 and at days 1 and 3. Secretion of both, adrenocorticotropic hormone and cortisol was significantly increased between 1-10 hours after onset of tissue injury. Compared to baseline values, CD11b expression was increased at hour 1 and normalized after day 1, whereas L-selectin/CD62L expression, mirroring this pattern was decreased until day 1. Patients with high endogenous glucocorticoid secretion exhibited significantly decreased expression selectively of L-selectin/CD62L. However, we also observed that glucocorticoids do not directly induce L-selectin shedding from neutrophil surfaces in vitro, arguing for more indirect glucocorticoid action on adhesion molecule expression. Together, this study showed that increased endogenous cortisol secretion is associated with lower expression of L-selectin on neutrophil surfaces in humans that is consistent with a downmodulating role of this neuroendocrine stress response in inflammatory leukocyte recruitment.

Absorption of vitamin B12 administered to continent ileal reservoirs for urinary diversion.

Urinary diversion through intestinal segments is a widely used method after radical cystectomy. During the last few years, new methods of bladder substitution, continent ileal neobladders, were developed. We used the method described by Hautmann et al. in 1986. 70 cm of ileum is used to form a reservoir. The ureters are implanted into the reservoir, which is then anastomosed to the urethral stump. A known problem when intestine is used for urinary diversion is the absorption of urinary solutes leading to metabolic disturbances. Therefore, the absorption of vitamin B12, instilled into the neobladders of 20 patients, was measured and related to the postoperative interval. The results show a high absorption rate 2 weeks postoperatively that is reduced quickly and significantly (p < 0.001) within the first 10 months (from more than 30 to below 5%). One year to 23 months after the operation, some neobladders absorbed no vitamin B12 at all, whereas others still absorbed significantly but only small quantities. These results may probably be attributed to the loss of villous structure as well as atrophy of the epithelial surface.

Nitrosamine excretion in patients with continent ileal reservoirs for urinary diversion.

Adenocarcinomas are a recognized complication following ureterosigmoidostomy for which the endogenous formation of N-nitroso compounds may be a risk factor. As an alternative means of urinary diversion, the continent ileal reservoir has recently been developed. Microbiological and chemical investigations on the urine of patients with an ileal reservoir showed the presence of bacteria, nitrate, nitrite and N-nitrosamines formed endogenously in the ileal pouch. The role of nitrosamines in carcinogenesis in these patients as a late stage complication resulting from the use of a continent ileal reservoir is discussed.