Regionalization of obstetrics exemplified by the Bern University Obstetric Clinic]

Report about practical experience with concentration of high risk pregnancies in a regional center. It is better to transport the fetus in utero than to transport the neonate.     

Individual timing of blood counts in G-CSF prophylaxis after myelosuppressive chemotherapy reduces G-CSF injections, blood counts, and costs: a prospective randomized study in children and adolescents

In children and adolescents, prophylactic application of G-CSF after myelosuppressive chemotherapy reduces the duration of neutropenia, of hospitalization, and of parenteral antibiotic treatment. In acute lymphoblastic leukemia, non-Hodgkin lymphoma, and solid tumors, G-CSF support allows dose intensification of chemotherapy. On the other hand, each G-CSF injection causes pain and costs. We set up the hypothesis that besides strategies as restricted indications, delayed start, lower doses, and stringent rules for discontinuation, individualized timing of blood count might optimize G-CSF prophylaxis. We randomized 64 cycles of G-CSF prophylaxis in eight children and adolescents being treated for acute lymphoblastic leukemia or solid tumors to standard twice a week or to individually timed blood counts. Primary study endpoints were the numbers of G-CSF doses and of blood counts, and the total costs of G-CSF support. Per cycle, individual timing of blood count resulted in a median of one G-CSF injection fewer [estimated population median (EPM) 1.40, 95% confidence interval (CI) 0.57-2.20] and one blood count fewer (EPM 1.00, 95% CI 0.74-1.33). The total costs of G-CSF support and of blood counts were thereby reduced by a median of US $ 152 per cycle (EPM 191, 95% CI 97-318). The results of this study suggest that individual timing of blood counts during prophylactic G-CSF support in children and adolescents undergoing chemotherapy for malignant disease can significantly reduce the number of injections and blood counts performed, thus resulting in less pain and lower costs. These findings need confirmation in a larger randomized trial.     

Intestinale neuronale Dysplasie des Erwachsenen als Ursache der chronischen Obstipation Morphometrische Charakterisierung der Coloninnervation

Zusammenfassung. Die intestinale neuronale Dysplasie (IND) ist eine ursprünglich bei Kindern beschriebene Entwicklungsst?rung des Plexus submucosus. In den letzten Jahren lie? sich diese Anomalie auch beim Erwachsenen mit chronischer Obstipation beobachten. Das Ziel der vorliegenden Arbeit bestand in einer morphometrischen Objektivierung dieses Krankheitsbildes. Die Untersuchung wurde vergleichend an Biopsien von 10 Erwachsenen mit IND und 10 Kontrollprobanden durchgeführt. Als bester diagnostischer Indikator einer IND erwies sich der Nachweis von 6–10 Riesenganglien mit mehr als 7 Nervenzellen in 15 Biopsieschnitten. Die IND stellt eine interessante histologisch verifizierbare Ursache einer chronischen Obstipation des Erwachsenen dar.      

Hypokalaemia and sudden cardiac death--lessons from implantable cardioverter defibrillators

The cases of four patients experiencing ventricular arrhythmia secondary to drug-induced hypokalaemia requiring treatment by a previously implanted cardioverter defibrillator (ICD) are reported here. In three cases, hypokalaemia developed within a short period of time after modification of diuretic regimen with loop and thiazide diuretics had been carried out or potassium-sparing drugs had been withdrawn. In one patient, hypokalaemia occurred after months of treatment with several potassium-sparing and non-potassium-sparing diuretics. The fact that the combination of thiazide and loop diuretics can be associated with pronounced hypokalaemia and life-threatening arrhythmias, which may be terminated by device treatment in patients with an ICD but may be fatal in patients with structural heart disease but without an ICD, is highlighted here. Prompt recognition and correction of hypokalaemia is mandatory if such patients present to the emergency department.     

Purine Nucleoside Phosphorylase Deficiency: EVIDENCE FOR MOLECULAR HETEROGENEITY IN TWO FAMILIES WITH ENZYME-DEFICIENT MEMBERS

Purine-nucleoside phosphorylase (NP) deficiency is associated with severely defective thymus-derived (T)-cell and normally functioning bone marrow-derived (B)-cell immunity. In this study, two unrelated families with a total of three NP deficient members were investigated.High pressure liquid chromatography of the plasma of the three patients showed inosine levels greater than 66 muM. This nucleoside was absent from the plasma of their parents and control samples.NP was purified from normal human erythrocytes by affinity chromatography and an antiserum prepared in rabbits was used to study the NP variants in the two families.In family M the patient had no detectable erythrocyte NP activity and no detectable immunological-reacting material (irm) to the NP antibody. The parents, who are second cousins, had less than one-half of normal enzyme activity and approximately 14% irm attributable to a variant protein. Their electrophoretic patterns revealed a series of isozymes with slower than normal migration.In family B the patients had 0.5% residual enzyme activity and about one-half normal irm. Their electrophoretic pattern showed faintly staining bands which migrated faster than normal NP. The mother of the patients had one-half normal enzyme activity, 11% irm attributable to her variant protein, and a normal electrophoretic pattern. The father had less than one-half normal enzyme activity, equal amounts of normal and variant irm, and an electrophoretic pattern that showed increased activity of the more rapidly migrating isozyme bands.The combined use of immunological and electrophoretic techniques has shown the presence of three separate mutations; one in family M and two in family B associated with severely defective T-cell function.     

Effect of intensive nutritional counseling and support on clinical outcomes of hemodialysis patients

ObjectiveProtein–energy wasting is frequently found in patients on hemodialysis (HD). Anorexia and hypophagia contribute to malnutrition and increased morbidity and mortality, but the clinical impact of correcting hypophagia remains uncertain. We evaluated whether the correction of hypophagia influences morbidity and mortality in anorexic patients on HD.MethodsThirty-four patients on HD were enrolled in a 2-y follow-up program including regular nutritional assessments. Patients not meeting the nutritional requirements during the follow-up received nutritional counseling, consisting of advice, individually tailored diets, and, for a failed dietary intervention, artificial nutrition. Biochemical, anthropometric, and body composition parameters, morbidity, and mortality were recorded in all patients at 12 and 24 mo.ResultsAt baseline, 14 patients (41%) were anorexic, and 20 patients (59%) were non-anorexic. Anorexic patients were hypophagic and presented with a decreased fat-free mass. After 12 and 24 mo, cholesterol, albumin, lymphocyte count, and body mass index did not differ between the groups, whereas fat-free mass (percentage) in supplemented anorexic patients significantly improved in no longer differing from non-anorexic patients (65.8 ± 4.4 versus 65.4 ± 8.9, respectively, P = NS; 65.8 ± 4.4 versus 66.7 ± 10.78, respectively, P = NS). Morbidity and mortality were not different between the two groups.ConclusionIn patients on HD, nutritional counseling and nutritional support positively affect the nutritional status in hypophagic patients and make the risk of morbidity and mortality in anorexic patients comparable to those of non-anorexic patients.     

A case of coronary vasospasm treated with stent placement

We report about a 49 year old woman with repeated chest pain at rest. During hyperventilation significant ST-segment elevation in leads V1-V5 appeared. Bicycle stress test did not provoke any ECG changes. Coronary angiography showed a significant stenosis of the left anterior descending coronary artery. Successful balloon angioplasty followed by stent implantation was performed. After an uneventful course of twelve months, hyperventilation could provoke neither chest pain nor ECG changes again without any antispastic medical treatment. Impact of fixed atherosclerotic lesions for the occurrence of coronary vasospasm, usefulness of hyperventilation as a non-invasive provocation test and therapy are discussed.     

Comparison of costs and safety of a suture-mediated closure device with conventional manual compression after coronary artery interventions.

The aim of this study was to assess costs and safety of immediate femoral sheath removal and closure with a suture-mediated closure device (Perclose, Menlo Park, CA) in patients undergoing elective (PCI). A total of 193 patients was prospectively randomized to immediate arterial sheath removal and access site closure with a suture-mediated closure device (SMC; n = 96) or sheath removal 4 hr after PCI followed by manual compression (MC; n = 97). In the SMC group, patients were ambulated 4 hr after elective PCI if hemostasis was achieved. In the MC group, patients were ambulated the day after the procedure. In addition to safety, total direct costs including physician and nursing time, infrastructure, and the device were assessed in both groups. Total direct costs were significantly (all P < 0.001) lower in the SMC group. Successful hemostasis without major complication was achieved in all patients. The time to achieve hemostasis was significantly shorter in the SMC group (7.1 +/- 3.4 vs. 22.9 +/- 14.0 min; P < 0.01) and 85% of SMC patients were ambulated on the day of intervention. Suture-mediated closure allows a reduction in hospitalization time, leading to significant cost savings due to decreased personnel and infrastructural demands. In addition, the use of SMC is safe and convenient to the patients.