[Extracorporeal cardiopulmonary resuscitation (eCPR)]. / Extrakorporale kardiopulmonale Reanimation (eCPR).

Extracorporeal cardiopulmonary resuscitation (eCPR) is the implementation of extracorporeal membrane oxygenation (ECMO) in selected patients with cardiac arrest and may be considered when conventional CPR efforts fail, as written in the latest international guidelines. eCPR is a complex intervention that requires a highly trained team, specialized equipment, and multidisciplinary support within a healthcare system and it has the risk of several life-threatening complications. However, there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome are lacking. Therefore, optimal timing, patient selection, location and method of implementation vary across centers. As utilization of eCPR has increased in recent years and more centers begin to perform eCPR, considerable uncertainties exist in the prehospital setting as well as in the emergency room. However, structured communication and clearly defined processes are essential especially at the interface between prehospital rescue teams and the eCPR team to achieve the highest possible benefit for cardiac arrest patients using eCPR. This article presents an algorithm for structured, evidence-based logistic considerations, patient selection, and implementation of eCPR as well as early care after establishment of extracorporeal life support (ECLS) which are mainly based on the German national recommendations for eCPR of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC published in 2019 as well as the S3 guideline "Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure" and local standard operating procedures of the authors.

Risk factors for bleeding complications after percutaneous dilatational tracheostomy: a ten-year institutional analysis.

Bleeding complications after percutaneous dilatational tracheostomy (PDT) are infrequent but may have a tremendous impact on a patient's further clinical course. Therefore, it seems necessary to perform risk stratification for patients scheduled for PDT. We retrospectively reviewed the records of 1001 patients (46% male, mean age 68.1 years) undergoing PDT (using the Ciaglia Blue Rhino® technique with direct bronchoscopic guidance) in our cardiothoracic ICU between January 2003 and February 2013. Patients were stratified into two groups: patients suffering acute moderate, severe, or major bleeding (Group A) and patients who had no or only mild bleeding (Group B). In the majority of patients, no or only mild bleeding during PDT occurred (none: 425 [42.5%], mild: 488 [48.8%]). In 84 patients (8.4%), bleeding was classified as moderate. Three patients suffered from severe bleeding; only one major bleed with need for emergency surgery occured. Patients in Group A had a significantly higher Simplified Acute Physiology Score on the day of PDT (P=0.042), higher prevalence of renal replacement therapy on the day of PDT (P=0.026), higher incidence of coagulopathy (P=0.043), lower platelet counts (P=0.037), lower fibrinogen levels (P=0.012), higher proportion of PDTs performed by residents (P=0.034) and higher difficulty grading of PDT (P=0.001). Using logistic regression analyses, difficult PDT, less experienced operator, Simplified Acute Physiology Score>40 and low fibrinogen levels were independent predictors of clinically significant bleeding after PDT. Low fibrinogen levels, as well as difficult PDT, less experienced operator and Simplified Acute Physiology Score>40 are associated with an increased risk for bleeding during PDT.

[Mid-term outcome of cardiac surgery patients with prolonged postoperative intensive care treatment]. / Mittelfristiges Outcome kardiochirurgischer Patienten mit einer verlängerten postoperativen Intensivtherapie.

BACKGROUND: The number of patients of advanced age and with severe comorbidities undergoing cardiac surgery is rising. Therefore, in addition to the cardiac surgery procedure itself, postoperative intensive care treatment plays an increasingly important role. The mid-term outcome of patients with postoperative long-term stays in intensive care and perioperative risk factors for an adverse outcome have not been sufficiently evaluated. MATERIAL AND METHODS: All patients who underwent cardiac surgery in our institution between 2000 and 2004 and who required intensive care treatment on our cardiac surgery intensive care unit for at least 1 week were analyzed. Patients who received heart or lung transplantation or surgery for congenital heart failure were excluded. A total of 31 perioperative variables were evaluated for 230 patients. Follow-up was performed 1 year postoperatively. RESULTS: In all, 4.3% of our patients required a prolonged stay in intensive care following cardiac surgery. Overall 1-year mortality among patients with a long-term stay in intensive care was 26.9%. The logistic regression identified postoperative renal failure requiring dialysis (OR 4.98) as the strongest predictor for mortality within the first year after surgery, followed by postoperative tracheotomy and preoperatively known atrial fibrillation. CONCLUSION: Mid-term survival among patients who underwent cardiac surgery followed by a complicated postoperative course is encouragingly high. The risk factors identified for an adverse prognosis may be helpful in improving therapy strategies and general therapy decision-making.

Impact of the Eurotransplant high-urgency heart allocation system on the outcome of transplant candidates in Germany.

BACKGROUND: In 2000, the Eurotransplant Foundation changed the allocation criteria following the enactment of the German Transplantation Law (GTL). Our study investigated the impact of the new allocation system on outcomes after heart transplantation (HTx) in Germany. METHODS: We compared 2 cohorts of patients who underwent HTx at our institution in two different 3-year periods before (Group 1: 01/1995-12/1997) and after (Group 2: 01/2003-12/2005) implementation of the new system. RESULTS: An increase in the ratio of HTx performed on an urgency basis was found in Group 2 (8.3 % vs. 87.2 %; P < 0.001). The median waiting time and the ischemia time were significantly lower in Group 1 ( P < 0.05). Postoperatively, the length of ICU stay was significantly higher in Group 2 ( P = 0.04). CONCLUSION: The new allocation system decreased the proportion of local and regional organ harvesting. It generates a higher ischemia time without increasing the number of transplantations and without improving the clinical outcome after HTx. The severity of heart failure, rate of secondary organ impairment, and comorbidity is markedly elevated in patients waiting for HTx on HU.

Is there really a clinical benefit of using minimized extracorporeal circulation for coronary artery bypass grafting?

BACKGROUND: Minimized extracorporeal circulation is intended to reduce the negative effects associated with cardiopulmonary bypass. This prospective study was performed to evaluate whether minimized extracorporeal circulation has a clinical benefit for coronary artery surgery patients compared to standard extracorporeal circulation. METHODS: Sixty patients were randomized into two study groups: 30 patients underwent coronary artery bypass grafting using minimized extracorporeal circulation and 30 patients were operated using standard extracorporeal circulation. Baseline characteristics, intraoperative details, postoperative data, perioperative blood chemistry determinations of hematocrit, platelets, muscle-brain fraction of the creatine kinase, cardiac troponin T and colloid osmotic pressure as measurements of intrathoracic blood volume index and extravascular lung water index were compared. RESULTS: Baseline characteristics and intraoperative details of both groups were similar. Patients who underwent minimized extracorporeal circulation showed more short-term dependency on norepinephrine ( P < 0.01). Their maximal postoperative muscle-brain fraction of the creatine kinase was lower ( P < 0.05) and their hematocrit on arrival in the intensive care unit was higher ( P < 0.01). No other significant differences were found. In both collectives, values for hematocrit ( P < 0.001), platelets ( P < 0.001), colloid osmotic pressure ( P < 0.001) and intrathoracic blood volume index ( P < 0.05) decreased, while the extravascular lung water index did not change significantly during cardiopulmonary bypass. CONCLUSIONS: A clinical advantage of minimized over standard extracorporeal circulation was not found. Furthermore, a higher number of patients in the minimized extracorporeal circulation group required postoperative norepinephrine infusions for hemodynamic stabilization. In summary, the presumed superiority of minimized extracorporeal circulation for coronary artery bypass grafting in standard patients could not be confirmed.

Onychomycosis.

The guideline on onychomycosis, as passed by the responsible German medical societies, is presented in the present study.

Tinea capitis: ringworm of the scalp.

The guideline tinea capitis, as passed by three German medical societies, is presented in the present study.

Dantrolene sodium improves the force-frequency relationship and beta-adregenic responsiveness in failing human myocardium.

BACKGROUND: Failing human myocardium is characterized by a negative force-frequency relationship and impaired beta-adrenergic responsiveness which have been related to alterations of the intracellular Ca2+ homeostasis. Dantrolene sodium is a clinically used drug that modulates myocardial [Ca2+]i handling in animal models. This study investigated the effects of dantrolene sodium on intracellular Ca2+ handling and contractile function in failing human myocardium. METHODS AND RESULTS: Twenty-three muscle strips from human left ventricular trabeculae were obtained from patients undergoing heart transplantation for end-stage heart failure caused by idiopathic dilated cardiomyopathy (n = 15). Isometric contraction and intracellular Ca2+ transients (Ca2+ indicator: aequorin) were recorded simultaneously. The experiments were performed in three separate groups exposed to control condition (n = 8), addition of dantrolene (10 micromol/l; n = 8), or addition of verapamil (1 micromol/l; n = 7). Isoproterenol induced a moderate positive inotropic effect in the control group with a maximal increase of developed tension from 10.8 +/- 2.9 to 23.4 +/- 4.7 mN/mm2 and a parallel rise in peak systolic [Ca2+]i to a maximum of 1.36 +/- 0.20 micromol/l. Dantrolene significantly improved (10.2 +/- 3.8 to 32.4 +/- 0.9 mN/mm2) and verapamil blunted (8.3 +/- 2.8 to 17.1 +/- 4.3 mN/mm2) the inotropic response to isoproterenol. The diastolic and systolic [Ca2+]i during isoproterenol stimulation were slightly lower in the dantrolene group but significantly depressed in the verapamil group as compared to the control group. Similarly, analyses of force-frequency relationships revealed an improvement of developed tension in dantrolene-treated as compared to control preparations whereas the peak systolic [Ca2+]i was almost identical. CONCLUSION: Dantrolene improves the negative force-frequency relationship and beta-adrenergic responsiveness in failing human myocardium. These effects are not accompanied by an additional increase in intracellular [Ca2+]i but might be related to modifications of the diastolic [Ca2+]i homeostasis.

[Vulvovaginitis circinata in Reiter's disease]. / Vulvovaginitis circinata bei Morbus Reiter.

A case of Reiter's disease with circinate vulvovaginitis is presented. As a clinical analogue to circinate balanitis, it should have the same diagnostic value. A combined treatment of prednisone and aromatic retinoid proved to be effective.

[UV light sensitivity of the skin--possibilities and limits of clinical diagnosis]. / UV-Lichtempfindlichkeit der Haut--Möglichkeiten und Grenzen klinischer Diagnostik.

Our study on 58 test persons showed that the sensitivity of human skin to UV light is independent of the color of skin, hair, eyes or the pigmentation of the mamillae. Therefore, the sensitivity to UV light must be ascertained by subtle phototesting. By means of the new UV phototesting set SBA-LT-400, Saalmann Co., 4900 Herford/West Germany, we determined the minimal erythema doses (MED) of UV-B and UV-A as basic, reproducible parameters regarding Central European people. 7 and 24 hours after radiation, MED showed mean values of 0.032 and 0.037 Joule/cm2, resp., for UV-B, whereas 24.1 and 25.6 Joule/cm2 were measured for UV-A. The pigmentation responses to UV radiation of human skin described in the literature can be reproduced in Mediterranean skin types only.