Neonatal cholestatic hepatitis from carbamazepine exposure during pregnancy and breast feeding

OBJECTIVE: To report a case of transient cholestatic hepatitis occurring in an infant between the third and seventh weeks of life, most likely due to carbamazepine exposure during pregnancy and breast feeding. CASE SUMMARY: A boy, born to an epileptic mother who had been treated with carbamazepine monotherapy throughout pregnancy and breast feeding, experienced asphyxia at birth with transient hepatic dysfunction in the first week of life. After full recovery from asphyxia, he experienced a second period of liver dysfunction, presenting as cholestatic hepatitis that lasted approximately 5 weeks. Infectious and metabolic etiologies as well as extrahepatic biliary atresia were excluded. DISCUSSION: Carbamazepine is known to induce hepatic damage in children and adults. As the drug crosses the placenta and is excreted into breast milk, infants of mothers taking carbamazepine might also develop liver dysfunction. In addition to the present case, there are 2 well-documented case reports of cholestasis in association with transplacental and transmammary carbamazepine exposure. CONCLUSIONS: Carbamazepine-induced hepatitis may occur in association with prenatal exposure and breast feeding. This may expose infants to unnecessary diagnostic procedures, and should therefore be mentioned in the company's product information.     

Chemotherapy-induced nausea and vomiting in routine practice: a European perspective

Goals of work The aim of this study was to evaluate the occurrence of chemotherapy-induced nausea and vomiting (CINV) and its effect on patients ability to carry out daily life activities following moderately to highly emetogenic, first-cycle chemotherapy in routine practice in cancer centers of four different European countries.Patients and methods This was a prospective, cross-sectional, nonrandomized, self-assessment study in 249 patients enrolled from cancer centers in Spain, Austria, Germany, and Switzerland. The study population consisted of 78% women, with a mean age of 54. Breast, lung, and ovarian cancers made up 75% of all cancers in the study. Patients received a mean of 2.0 chemotherapy agents and 2.5 antiemetic drugs.Main results A total of 450 emetic episodes experienced by 243 patients was recorded over 5 days following chemotherapy, with an average of 1.8 episodes per patient (range: 0–28). A higher percentage of patients (38%) suffered from delayed compared to acute emesis (13%). Between 42% and 52% of all patients suffered from nausea (visual analogue scale 5 mm) on any one day, peaking at day 3. Using the Functional Living Index for Emesis (FLIE) questionnaire, 75% of patients with nausea and 50% with vomiting reported a negative impact of these conditions on performance of daily living.Conclusions CINV remains a significant problem in routine practice, particularly in the delayed phase posttreatment. Overall, CINV had a negative impact on patients daily life.     

Behavioral characterization of the novel GABAB receptor-positive modulator GS39783 (N,N'-dicyclopentyl-2-methylsulfanyl-5-nitro-pyrimidine-4,6-diamine): anxiolytic-like activity without side effects associated with baclofen or benzodiazepines

The role of GABAB receptors in various behavioral processes has been largely defined using the prototypical GABAB receptor agonist baclofen. However, baclofen induces sedation, hypothermia and muscle relaxation, which may interfere with its use in behavioral paradigms. Although there is much evidence for a role of the inhibitory neurotransmitter GABA in the pathophysiology of anxiety, the role of GABAB receptors in these disorders is largely unclear. We recently identified GS39783 (N,N'-dicyclopentyl-2-methylsulfanyl-5-nitro-pyrimidine-4,6-diamine) as a selective allosteric positive modulator at GABAB receptors. The aim of the present study was to broadly characterize the effects of GS39783 in well-validated rodent models for motor activity, cognition, and anxiety. The following tests were included: locomotor activity in rats and mice, rotarod and traction tests (including determinations of core temperature) in mice, passive avoidance in mice and rats, elevated plus maze in rats, elevated zero maze in mice and rats, stress-induced hyperthermia in mice, and pentobarbital- and ethanol-induced sleep in mice. Unlike baclofen and/or the benzodiazepine chlordiazepoxide, GS39783 had no effect in any of the tests for locomotion, cognition, temperature, or narcosis. Most interestingly, GS39783 had anxiolytic-like effects in all the tests used. Overall, the data obtained here suggest that positive modulation of GABAB receptors may serve as a novel therapeutic strategy for the development of anxiolytics, with a superior side effect profile to both baclofen and benzodiazepines.     

Entwicklung bodengebundener Notarzteinsätze im Stadtgebiet Leipzig von 2003 bis 2013

Background

The annual number of physician-based emergency missions reported is continuously increasing. Data from large cities concerning this development over long periods is sparse.

Material and methods

In this retrospective study the charts of all ground-based physician-staffed emergency missions in the city of Leipzig for the first quarters of 2003 and 2013 were analyzed. Patient characteristics, injury and illness severities, mission location, hospital admission rate, as well as emergency interventions were collated. The emergency mission rate was calculated as rescue missions per 1000 inhabitants per year.

Results

The number of physician-staffed emergency missions increased by approximately 24% between 2003 and 2013 (6030 vs. 7470, respectively). The emergency mission rate was 48 vs. 58 in the 2 study periods. The median patient age increased from 66 to 70 years. The number of geriatric patients (age ≥ 85 years: n = 650 (11%) vs. n = 1161 (16%), p < 0.01) also increased. The corresponding number of emergency missions in nursing homes showed a fourfold (n = 175, 3% vs. n = 750, 10%, p < 0.01). The percentage of hospital admissions also increased (n = 3049, 51% vs. n = 4738, 66%, p < 0.01). A change in patient distribution to level I hospitals was noticed (n = 1742, 29% vs. n = 3436, 46%, p < 0.01).

Conclusion

The findings suggest that the necessity for the high number of physician-staffed emergency missions should be verified, especially in the context of strained emergency healthcare resources. The basis of an optimized use of resources could be a better inclusion of alternative, especially ambulant, healthcare structures and the implementation of a structured emergency call questionnaire accompanied by a more efficient disposition of the operating resources, not least in view of the economic aspects. Taking the concentrated patient allocation to level 1 hospitals into consideration, there is a need for optimized patient distribution strategies to minimize the overload of individual institutions and thereby improve the general quality of care at the interface between preclinical and clinical emergency medicine.

     

Durchführung einer prähospitalen Notfallnarkose und Atemwegssicherung

Background

The goal of rapid sequence induction (RSI) in cases of emergency situations is to secure the airway as quickly as possible to prevent pulmonary aspiration of gastric contents; however, the technique itself is not standardized. For example, the choice of drugs, application of cricoid pressure and the patient position remain controversial. A survey of emergency medical services (EMS) physicians throughout Germany was carried out to assess the different RSI techniques used and with respect to complying with the national guidelines for emergency airway management anesthesia and local standard operating procedures (SOP).

Material and methods

Between 1 April 2017 and 31 May 2017, EMS medical directors in Germany were contacted and asked to distribute a 28-question online questionnaire to local EMS physicians. Of the questions 26 were multiple choice and 2 with plain text. After 6 weeks an e?mail reminder was sent. In addition, the survey was distributed via social media to EMS physicians.

Results

In total the survey was opened 2314 times and 1074 completed responses were received (completion rate 46%). Most of the participants were male (78%) and anesthesiologists (70%) and only one quarter had a local SOP for RSI. The most frequently used muscle relaxant was succinylcholine (62%) and over half of the participants reported using cricoid pressure (57%). There was a distinction between the specialist disciplines in the selection of drugs. Propofol was used most by anesthesiologists, while the others still used etomidate on a larger scale. Nearly 100% could fall back on supraglottic devices (one third laryngeal mask, two thirds laryngeal tube) but only 32.8% with the recommended esophageal drainage. A video laryngoscope was available to 51% of all EMS physicians surveyed.

Conclusion

The results of the survey demonstrate heterogeneity in RSI techniques used by EMS physicians in Germany. Medical equipment and safe care practices, such as labeling of syringes varied considerably between different service areas. The recommendations of the S1 national guidelines on emergency airway management and anesthesia should be adhered to together with the implementation of local SOPs.

     

Transport beatmeter Notfallpatienten vom Hubschrauber zum Krankenhauszielort (HOVER-Studie)

Background

In Germany more than 110,000 helicopter emergency medical service (HEMS) missions are carried out annually. A considerable number of patients are ventilated during the flight. So far, structured surveys with respect to the ground transport from the helipad to the hospital facility and handover of ventilated patients in the emergency room (ER) are not available in the German-speaking HEMS system. The handover of ventilated HEMS patients in the ER (HOVER I study) explored the use of the helicopter ventilator and medical equipment during the transport from the hospital landing site to the ER.

Method

After approval by the HEMS operators, emergency medical doctors and HEMS technical crew members (HEMS-TC) of 145 German-speaking HEMS bases were invited to participate in an anonymous online survey (period: 1 February 2018–1 March 2018). Each participant was only allowed to submit the survey once.

Results

Data of 569 participants were completely analyzed, with responses from 429 emergency physicians and 140 HEMS-TC (75% from Germany, 13% Switzerland, 11% Austria, 1% Italy and Luxembourg). The most frequent type of aircraft used was the Eurocopter (EC)/Airbus helicopter (H) 135 (60.5%) followed by the EC/H 145 (33%). The majority of the respondents (53%) principally used the helicopter ventilator machine for patient transport from the helipad to the ER, 38% used it depending on the circumstances and 7% never used it. Of the participants 52% always took the emergency backpack for patient transport to the ER, 43% depending on the situation and 5% never took it along. The availability of oxygen or a ventilator at the helipad was considered to be helpful (59% and 45%, respectively), obligatory (25% and 14%, respectively) but was also considered unnecessary by some participants (16% and 40%, respectively). The collection of the HEMS team by a hospital team at the helipad was rated as helpful (64%) or mandatory (19%), 12% considered it to be unimportant and 5% even disturbing. For most respondents (58.5%) the responsibility for the patient ended after a structured handover on reaching the internal hospital target area (e.g. the ER).

Conclusion

The management of the handover of ventilated emergency patients in German-speaking HEMS is heterogeneously structured. Only approximately 50% of the participants frequently carried the helicopter ventilator and emergency equipment during patient transport to the ER. Depending on the situation, more than 90% of the respondents used the helicopter ventilator and emergency backpack during the transport. The collection of the HEMS team by a hospital team at the helipad was appreciated by the majority of participants. The use of the helicopter ventilator for patient transport to the ER needs to be explored in future studies.The study was registered at the Research Registry (www.researchregistry.com) under the following number: researchregistry2925

     

Out-of-hospital airway management during manual compression or automated chest compression devices

Background

Airway management during resuscitation is pivotal for treating hypoxia and inducing reoxygenation. This German Resuscitation Registry (GRR) analysis investigated the influence of the type of airway used in patients treated with manual chest compression (mCC) and automated chest compression devices (ACCD) after out-of-hospital cardiac arrest (OHCA).

Methods

Out of 42,977 patients (1 January 2010–30 June 2016) information on outcome, airway management and method of chest compressions were available for 27,544 patients. Hospital admission under cardiopulmonary resuscitation (CPR), hospital admission with return of spontaneous circulation (ROSC), hospital discharge and discharge with cerebral performance categories 1 and 2 (CPC 1,2) were used to compare outcome in patients treated with mCC vs. ACCD, and classified by endotracheal intubation (ETI), initial supraglottic airway device (SAD) changed into ETI, and only SAD use.

Results

Outcomes for hospital admission under ongoing CPR, hospital admission with ROSC, hospital discharge and neurologically intact survival (CPC 1,2) for mCC (84.8%) vs. ACCD (15.2%) groups were: 8.4/38.6%, 39.2/27.2%, 10.6/6.8%, 7.9/4.7% (p < 0.001), respectively. Only mCC with SAD/ETI for ever ROSC (OR 1.466, 95% CI: 1.353–1.588, p < 0.001) and mCC group with SAD/ETI for hospital admission with ROSC showed better outcomes (odds ratio [OR] 1.277, 95% confidence interval [CI]: 1.179–1.384, p < 0.001) in comparison to mCC treated with ETI. Compared to mCC/ETI, all other groups were associated with a decrease in neurologically intact survival.

Conclusion

Better outcomes were found for mCC in comparison to ACCD and ETI showed better outcomes in comparison to SAD only. This observational registry study raised the hypothesis that SAD only should be avoided or SAD should be changed into ETI, independent of whether mCC or ACCD is used.

     

„Resuscitative endovascular balloon occlusion of the aorta“

Die Anaesthesiologie - Verbluten ist beim Traumapatienten die häufigste vermeidbare Todesursache. Dabei finden sich im zivilen Rettungsdienst in Europa lebensbedrohliche Blutungen meist in...     

Gender-specific effect of metabolic syndrome on rate adjusted QT interval in middle-aged participants of an atherosclerosis prevention program

INTRODUCTION: The metabolic syndrome is a matter of immense public concern for atherosclerosis prevention. Key features are visceral obesity, dyslipidemia, hyperglycemia in the non-diabetic range, and arterial hypertension. Subclinical atherosclerosis is the clinical consequence of metabolic syndrome, which may influence the QT interval. The aim was to investigate the rate corrected QT interval in subjects with metabolic syndrome in comparison to those without cardiometabolic risk factor clusters, and to explore gender differences in cardiac repolarization between the two groups. PATIENTS, MATERIALS AND METHODS: Heart rate and QT interval were automatically measured from surface ECG in 1086 participants (767 men, 319 women) from the Salzburg-Atherosclerosis-Prevention-program-in-subjects-at-High-Individual-Risk (SAPHIR). To omit the QT adjustment bias inherent in Bazett's formula we used a QT adjustment method with linear scaling as described by Rautaharju. RESULTS: The prevalence of metabolic syndrome was 13.8% among males and 10% among females. Mean rate adjusted QT (QTa) intervals were longer in women than in men. Presence of metabolic syndrome, however, was associated with significantly prolonged QTa only in men but not in women. Adjustment for relevant confounders reduced the difference of mean QTa in men from 9.24 to 5.83 ms (95% CI 0.9-10.8), but this difference was still statistically significant (p = 0.021). The effect of metabolic syndrome on QTa was only partly mediated by hypertension and insulin resistance. In females, however, no relevant differences were detected for QTa interval between subjects categorized by presence or absence of metabolic syndrome. CONCLUSIONS: The findings indicate a significant association between metabolic syndrome and rate-invariant QT in middle-aged men after adjustment for other risk factors. QT measurement may provide additive diagnostic and prognostic information in populations undergoing cardiovascular risk screening. However, the effect of metabolic and hormonal factors on ventricular repolarization seems to differ between the sexes.