Update: intensivmedizinische Studien

Intensive care medicine plays an important role in the medical care of patients as well as the economic success of hospitals. Knowledge and implementation of recent relevant scientific evidence are prerequisites for high quality care in intensive care medicine. The aim of this review is to present an overview of the most important publications in intensive care medicine published in 2010 and the first half of the year 2011 and to comment on their attributable clinical relevance for intensive care practitioners. In 2010 and up to June 2011 many studies with high patient numbers have been published. The main topics were the treatment of respiratory failure, sepsis and investigations to improve analgosedation.     

Antibiotic treatment of nosocomial pneumonia

Nosocomial pneumonia is one of the most common infectious diseases acquired in hospital and is often caused by resistant pathogens. For treatment of nosocomial pneumonia an appropriate initial antibiotic therapy is essential and exact knowledge of the specific pathogen spectrum is essential for the correct choice of the empirically calculated antibiotics. In line with a critical reevaluation of the primary treatment, pathogen-specific de-escalation therapy, a diagnosis of possible pulmonary complications (e.?g. pleural empyema) and the identification and appropriate rehabilitation measures of non-pulmonary infections are necessary. To attain the best possible outcome the respective therapy concept needs to be adjusted to the individual risk characteristics. Appropriate initial antibiotic therapy, duration of mechanical ventilation and comorbidities are the key factors for patient outcome. This approach helps to avoid the development of resistant pathogens and saves economic resources.     

Kontinuierliche lokale Wundinfusion mit Lokalan?sthetika

Wound infusion with local anesthetics is a nearly 100 years old proven and secure analgesic method. Recently special wound infusion catheters have become available which can be placed intraoperatively into the wound under direct supervision of the surgeon to infuse local anesthetics and optimize postoperative analgesia. For thoracotomy this method was modified to improve its efficacy and the catheters are used to establish a continuous paravertebral intercostal nerve block (PVB). Many studies have confirmed the analgesic power of PVB which results in a pain reduction comparable to thoracic epidural analgesia (TEA) but without TEA-specific side-effects, in particular hypotension. The efficacy of continuous local wound infusion (CLWI) is less obvious for laparotomy. If fundamental preconditions for this loco-regional method are considered (indications, choice of catheter, local anesthetic dose) the laparotomy wound could also be suitable for the use of CLWI. According to the literature currently available CLWI is not associated with an increased risk of wound infections.     

Motorische Entwicklung im Kindesalter

Monatsschrift Kinderheilkunde - Frühe Korrelate kindlicher Motorik sind die bereits intrauterin stattfindenden „general movements“. Zunehmend willkürliche, anfangs...     

Bordetella pertussis Strain Lacking Pertactin and Pertussis Toxin

A Bordetella pertussis strain lacking 2 acellular vaccine immunogens, pertussis toxin and pertactin, was isolated from an unvaccinated infant in New York State in 2013. Comparison with a French strain that was pertussis toxin–deficient, pertactin wild-type showed that the strains carry the same 28-kb deletion in similar genomes.     

Die Regulation des Serumalbuminspiegels unter physiologischen und pathologischen Bedingungen

Zusammenfassung Die gebundenen Polyribosomen aller menschlichen Leberzellen zusammen synthetisieren pro Tag etwa 12 g Albumin, was 10% des intravaskulären Albumingehaltes entspricht. In der Zelle wird Proalbumin produziert. Bei der Sekretion entsteht dann durch Abspaltung eines Peptides Albumin. Nur 40% des Gesamtkörperalbumins finden sich intravaskulär. 12 g Albumin werden täglich abgebaut oder ausgeschieden, davon ca. 30% in der Leber, den Nieren und dem Magen-Darm-Trakt. Wo die Hauptmenge des Albumins abgebaut wird, ist unbekannt. Albumin hat mit einer Halbwertszeit von 20 Tagen eine relativ konstante Abbaurate. Die absolute Abbaurate variiert in Abhängigkeit vom Serumalbumingehalt. Dieser Mechanismus gewährleistet eine wirkungsvolle Regulation des Serumalbuminspiegels. Die relative Abbaurate ist jedoch nicht völlig starr fixiert. Bei stark erniedrigtem Serumalbumingehalt, wie bei Eiweißmangelernährung, dem Syndrom der blinden Schlinge, Alkoholismus, Leberzirrhose, nephrotischem Syndrom und Erkrankungen des Magen-Darm-Traktes, wird die prozentuale Abbaurate langsam innerhalb von Tagen und Wochen herabgesetzt. Bei Zufuhr von Albumin steigt die prozentuale Abbaurate langsam an, was bei der Albuminsubstitution bei chronischen Erkrankungen zu berücksichtigen ist. Ein kurzfristig wirksamer Regelmechanismus ist die Verschiebung des Albumins vom extravaskulären zum intravaskulären Kompartiment. Der Abbau und die Synthese von Albumin werden unabhängig voneinander reguliert. Die molekularen Mechanismen der Regulation der Synthese und des Abbaus sind unbekannt, was seine Ursache teilweise in einer unzulänglichen Methodik hat.Mit Unterstützung der Deutschen Forschungsgemeinschaft     

Mechanisms of resistance to methotrexate in childhood acute lymphoblastic leukemia: circumvention of thymidylate synthase inhibition

Purpose: In about 25% of patients suffering from acute lymphoblastic leukemia (ALL) treatment failures occur that are most likely due to development of resistance to methotrexate (MTX). Blasts from patients with ALL were evaluated for MTX uptake, formation of long-chain MTX polyglutamates (MTX-Glu₅₊₆), cytotoxicity and thymidylate synthase inhibition by MTX and compared to blasts from patients with acute myelogenous leukemia (AML). Methods: Radioactively labeled MTX-Glu _n were analyzed by means of HPLC. Thymidylate synthase activity was measured by a tritium-release assay. Cytotoxicity was determined by trypan blue exclusion. Results: In most ALL blasts (n = 9) large amounts of MTX-Glu₅₊₆ (1.06–7.03 pmol/10⁷cells) and high cytotoxicity (43.5%–92.7%) were found, while in others small amounts of MTX-Glu₅₊₆ (0.0–0.39 pmol/10⁷cells) caused only weak cytotoxicity (6.0%–27.9%) (n = 5, 2 relapsed patients). Resistance to MTX in blasts from AML patients (n = 5) was also caused by reduced synthesis of MTX-Glu₅₊₆ (0.0–0.42 pmol/10⁷cells). In contrast, some ALL blasts (n = 7, 4 relapsed patients) were able to survive MTX treatment despite large amounts of MTX-Glu₅₊₆ (1.5–5.05 pmol/10⁷cells) and extensive thymidylate synthase inhibition. Conclusions: Since the majority of ALL patients were examined at first diagnosis, an inherent mechanism of resistance seems most likely. We propose a mechanism based on the switch of thymidylate synthesis to the salvage pathway. Received: 30 October 1998 / Accepted: 6 April 1999