The traumatic dural sinus injury — a clinical study

Summary In a period of 13 years 978 cases of severe head injuries were operated on in our clinic. An analysis of the medical reports includes injuries of the superficial dural sinus (39 cases=4%): among these injuries of the anterior and central part of the superior sagittal sinus (66 per cent), injuries of the transverse sinus (18 per cent), injuries of the posterior part of the superior sagittal sinus (8 per cent), and combined injuries of different dural sinuses (8 per cent).Clinical data, i.e. the causes of accident, radiological examination results, intracranial lesions, operation technqiues and outcome are analysed and discussed. The analysis of cases with dural sinus injuries shows a high mortality rate (total mortality rate: 16 patients=41%; intra-operative mortality rate: 8 patients=20%).     

Influence of an antidiabetic treatment with sulfonylurea drugs on long-term survival after acute myocardial infarction in patients with type 2 diabetes. The LAngendreer Myocardial infarction and Blood glucose in Diabetic patients Assessment (LAMBDA).

INTRODUCTION: Patients with type 2 diabetes show a significantly higher mortality after acute myocardial infarction than non-diabetic patients. The influence of sulfonylureas on the survival after acute myocardial infarction is still under debate. PATIENTS AND METHODS: Survival of 562 patients, consecutively admitted to an intensive care unit with the diagnosis acute myocardial infarction, was prospectively assessed for > 3 years. At the time of hospital admission, patients were grouped as (a) non-diabetic patients; (b) patients with newly diagnosed type 2 diabetes; (c) patients with known type 2 diabetes not treated with sulfonylureas and (d) patients with known type 2 diabetes treated with sulfonylureas. Survival-analysis was performed according to Kaplan-Meier. RESULTS: 324 patients were non-diabetics, in 86 cases type 2 diabetes was newly diagnosed at the time of hospital admission, 77 patients with known diabetes had taken sulfonylureas (glibenclamide in all cases) prior to the acute myocardial infarction, 75 patients were on any other antidiabetic treatment. Long-term-survival was significantly shorter in patients with type 2 diabetes compared to the non-diabetic patients (p < 0.0001). However, no significant differences were observed between the patients with type 2 diabetes treated with sulfonylurea-drugs and those receiving any other antidiabetic treatment (p = 0.53) CONCLUSIONS: An antidiabetic treatment with sulfonylurea-drugs prior to acute myocardial infarction does not have negative effects on the long-term survival. Larger prospective studies will be necessary to finally clarify this question.     

Arbeitnehmerstatus von „locum-Ärzten“ an Krankenhäusern?

Ohne Zusammenfassung     

Characteristics of teenage mothers and predictors of breastfeeding initiation in the Michigan WIC Program in 1995. Women, Infants, and Children.

Although breast milk is recommended as the optimal source of infant nutrition, breastfeeding initiation is below recommended levels, especially among teenage mothers. Breastfeeding initiation rates among Michigan (US) teenage mothers (12-19 y) were compared by demographics and health behaviors. Multivariate analyses determined which factors were significant independent predictors of breastfeeding initiation among teenage mothers enrolled prenatally in the Michigan Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program in 1995. Significant predictors independently associated with breastfeeding initiation were race/ethnicity, education, marital status, postpartum anemia status, parity, prenatal trimester of WIC enrollment, and smoking. The strongest predictor of breastfeeding initiation differed for white mothers (positive predictor: education beyond high school [OR = 3.13]) and black mothers (negative predictor: multiparous [OR = 0.25]). Initiation rates for this population of teenage mothers fall below the national average for mothers of all ages and the US Healthy People 2010 goals. Research is needed concerning how breastfeeding support and education can be improved to reach the US national health goals.     

Über das Verhalten der blutbildenden Organe der erwachsenen Menschen in vitro

Ohne ZusammenfassungMit 10 Abbildungen im Text.Die Arbeit wurde ausgeführt mit Unterstützung der Lady Tata Memorial-Stiftung, der wir für die Ermöglichung unserer Arbeiten zu größtem Danke verpflichtet sind.     

Narkosegasbelastung des Personals in der Kinderanästhesie

Methods. To assess the occupational exposure of the anaesthetist to anaesthetic gases, a total of 1 German and 25 Swiss hospitals were investigated. A Brüel & Kjær Type 1302 multi-gas monitor was used to measure concentrations of nitrous oxide and halogenated anaesthetic agents in the anaesthetist's breathing zone. Measurements were performed during 114 general anaesthetic, 55 of which were in patients under 11 years of age. In these 55 patients, the influence of various factors on the exposure (time-weighted average concentrations) was estimated by comparing different data groups. The efficiency of the applied scavenging equipment was examined by surveying the exhalation valve with a leak detector (type TIF 5600, TIF Instruments, Miami). Results. Sessions with patients under 11 years of age revealed much higher anaesthetic gas exposures compared to older patients. The concentrations of nitrous oxide were on average threefold (Fig. 1), those of the halogenated anaesthetics fivefold higher (Fig. 2) for the younger patients. In 11- to 16-year-old patients the exposure level was the same as in adult patients. The measurements showed a reduction of 85% in exposure if an efficient scavenging system (i.e., no waste gas discharge to room air through the exhalation valve) or lower fresh gas flow were used (Fig. 4); 42% of the inspected scavengers were inefficient, and reduced the exposure on average by only 30%. In operating theatres with a ventilation rate of at least ten air changes per h, the measured concentrations of anaesthetic gases in the inhalation zone of the anaesthetists were reduced more than 50% compared to poorly ventilated rooms (Figs. 4 and 5). The use of tracheal intubation or laryngeal mask airway (LMA) anaesthesia resulted in a reduction of 80% in exposure compared to standard face masks if efficient scavenging was used. The exposures during sessions with inefficiently scavenged Bain coaxial systems or unscavenged semi-open delivery systems of the Jackson-Rees type were tenfold higher than with scavenged rebreathing circuit systems (Fig. 6). During anaesthesia with IV or double-mask induction, the average levels of inhalation anaesthetics were reduced by about 80% compared to inhalational induction with standard masks (Fig. 7). The anaesthetist's working technique is a very important factor that strongly influences the concentrations. Poor work practices, like lifting off the face mask with anaesthetic gas flow turned on, increased the exposure of the anaesthetist and other operating room personnel drastically, even if the other conditions (scavenger and room ventilation) were good. Discussion. The exposure levels of anaesthetic gases are generally higher during anaesthesia in children up to 10 years of age than in older patients. Nevertheless, the measurements showed that exposure during paediatric anaesthesia can be kept below the recommended limit (8-h TWA in Switzerland) of 100 ppm nitrous oxide and 5 ppm halothane or 10 ppm enflurane or isoflurane. Causes of high exposures were particularly high fresh gas flows often applied without scavenging or together with inefficient scavenging devices and the high part of mask anaesthesia and inhalation induction with a loosely held mask. To achieve an effective reduction of occupational exposure, well-adjusted and maintained scavenging systems and low-leakage work practices are of primary importance. As leakage can never be completely avoided, a ventilation rate of at least ten air changes per h should be maintained in operating rooms and rooms where anaesthesia is induced to keep down concentrations of waste anaesthetic gases. High exposure during mask anaesthesia and inhalation induction can be prevented by further measures. Using a LMA instead of a standard mask reduces the exposure to the same level as endotracheal intubation. The exposure during induction can be reduced remarkably by the use of the double-mask system or IV induction. Applying low fresh gas flows reduces not only the exposure concentrations in the theatres, but also the contribution to the environmental burden (`?greenhouse effect?' and ozone layer destruction).     

Recanalization of chronically occluded coronary arteries.

A chronic coronary occlusion consists of an atherosclerotic plaque and one or several thrombi. It clinically imitates a tight stenosis but is exempt from the risk of truly unstable angina or myocardial infarction. Hence, quality of life is at stake and not longevity. This holds true for balloon angioplasty as well as for surgery. Indications for angioplasty are based on an estimate of technical difficulties and clinical risks balanced against potential subjective benefit and amount of viable myocardium concerned. An occlusion flush at the orifice of the vessel, tapering into a small sidebranch, with bridging collaterals, or devoid of collaterals is no target for angioplasty. Primary success is around 65% and complications are extremely rare. Abrupt vessel closure is common but harmless. No Q-wave infarctions have been reported in that context. The need for emergency bypass surgery may arise from acute closure of a vessel proximal to the occlusion in an exceptional case. Duration and length of occlusion are the most important predictors of success. Recurrence averages 62% (17% reocclusion and 45% restenosis). An important factor for the high recurrence rate is the competitive pressure exerted by the collaterals on standby. Recurrence happens almost exclusively within the first six months. It is innocuous but produces symptoms prompting further interventions (repeat angioplasty or bypass surgery). The conventional technique uses a stiff guidewire and advances the balloon catheter close to the tip of the guidewire for additional rigidity. New technologies are under investigation but no breakthrough has happened so far. They encompass blunt mechanical instruments (e.g., Magnum wire), drills of various velocities, laser energy applied directly to the tissue (some angioscopically guided, some triggered by on-line spectral tissue analysis), catheters dispersing laser energy through a sapphire or converting it into heat (hot tip), and electrical or radiofrequency heat applicators. As low-yield procedures had better be low-risk and low-cost, there are definite limits to how sophisticated, complicated, risky, and expensive tools and techniques for percutaneous coronary recanalization can become. Close relatives of conventional gear such as the Magnum system offer themselves as first choice equipment complemented, in case of need, by mechanical drills.     

Radiologische Leistungen im Nacht- und Bereitschaftsdienst

Zusammenfassung In der Zeit vom 01. Juli 1990 bis zum 30. Juni 1994 wurden 65 113 Untersuchungen au?erhalb der Regeldienstzeit durchgeführt. Die vorliegende Analyse schlüsselt die Leistungen auf nach Alter und Geschlecht im Vergleich zum Gesamtkollektiv dieser Vierjahresperiode, nach dem Zeitpunkt der Untersuchung, nach den untersuchten Organen und nach der eingesetzten Technik. Ca. ¹/₃ der Leistungen fallen in den Zeitraum zwischen 16.00 und 20.00 Uhr und k?nnten durch einen versetzten Tagdienst aufgefangen werden. Ein weiteres Drittel entf?llt auf den Zeitraum zwischen 20.00 und 8.00 Uhr am Folgetag. Der Rest entf?llt auf Feiertage und Wochenenden. Die h?ufigste Anforderung betrifft Thoraxaufnahmen auf den Intensivstationen. Etwa die H?lfte dieser Untersuchungen werden au?erhalb der Dienstzeit angefertigt; 17,2 % der Untersuchungen im Nacht- und Bereitschaftsdienst betreffen Computer- und Magnetresonanztomographie. Das am 01. 01. 93 in Kraft getretene Gesundheitsstrukturgesetz führte zu keinen nennenswerten Verschiebungen hinsichtlich Art, Umfang und H?ufigkeit der Untersuchungen im Nacht- und Bereitschaftsdienst. Eingegangen am 17. Juni 1996 Nach überarbeitung angenommen am 24. Juli 1996     

The Nursing Outcomes Classification: Validation by Rehabilitation Nurses

Measuring patient outcomes is important to rehabilitation nurses and the patients they serve. This article describes research conducted at the University of Iowa College of Nursing to develop the Nursing Outcomes Classification (NOC) and the validation of this research by surveys conducted through specialty nursing organizations, particularly the Association of Rehabilitation Nurses. Nurses responded to surveys designed to validate (a) the importance of outcome indicators to the achievement of an outcome and (b) nursing's contribution to the achievement of the indicators. The results of the surveys indicated that rehabilitation nurses believe that nursing makes a substantial contribution to most outcomes and indicators.