Post-conference session: Experience with patient self-management of oral anticoagulation

Long-term oral anticoagulation requires careful patient monitoring in order to optimize results and to limit hemorrhagic or thromboembolic complications of treatment. For this reason, any improvement in anticoagulant control and management can be expected to have far-reaching consequences in extending longevity and decreasing complications in anticoagulated patients after heart valve surgery. Because one attractive means of improving anticoagulant management is to give patients a share of the responsibility, a program was designed to encourage patients to take an active role in monitoring their own prothrombin time (PT) and managing their own oral anticoagulation. During the period from August 1986 to February 1992, 600 patients requiring long-term anticoagulation, mainly after heart valve replacement, were trained to measure their own PT at the Cardiac Rehabilitation Center (Herz-Krauslauf-Klinik, Bad Berleburg, Germany) and to manage their own therapy: 216 patients could be followed with regard to their self-determined prothrombin times. The results were within the target range in 83.1% of the PT determinations (n=12,306 measurements) taken by the patients themselves. Neither major bleeding nor thromboembolic complications were observed in 205 patient-years of self-monitoring of PT and self-management of oral anticoagulation.     

Antimykotische Wirkstoffe, 20. Mitt.: Bioisostere 6-Arylpyrimidin-Derivate

Antimycotic Agents, XX Bioisosteric 6-Arylpyrimidine Derivatives Condensation of N-(2-hydroxyethyl)-N-methylguanidine-sulfate ( 1 ) with the β-diketones 4a - e bearing 1-aryl substituents leads to the bioisosteric 2-[(2-hydroxyethyl)-methylamino]-6-arylpyrimidines 5a - e . Compounds 5a - c exhibit significant antimycotic in vivo and in vitro activities.     

Lack of Nonshivering Thermogenesis in Infants Anesthetized with Fentanyl and Propofol

Background: Sweating, vasoconstriction, and shivering have been observed during general anesthesia. Among these, vasoconstriction is especially important because-once triggered-it minimizes further hypothermia. Surprisingly, the core-temperature plateau associated with vasoconstriction appears to preserve core temperature better in infants and children than adults. This observation suggests that vasoconstriction in anesthetized infants may be accompanied by hypermetabolism. Consistent with this theory, unanesthetized infants rely on nonshivering thermogenesis to double heat production when vasoconstriction alone is insufficient. Accordingly, the authors tested the hypothesis that intraoperative core hypothermia triggers nonshivering thermogenesis in infants.

Methods: With Ethics Committee approval and written parental consent, the authors studied six infants undergoing abdominal surgery. All were aged 1 day to 9 months and weighed 2.4-9 kg. Anesthesia was maintained with propofol and fentanyl. The infants were mechanically ventilated and allowed to cool passively until core (distal esophageal) temperatures reached 34-34.5 degrees Celsius. Oxygen consumption-the authors' index of metabolic rate- was recorded throughout cooling. Because nonshivering thermogenesis triples circulating norepinephrine concentrations, arterial blood was analyzed for plasma catecholamines at [nearly equal] 0.5 degrees Celsius intervals. Thermoregulatory vasoconstriction was evaluated using forearm - fingertip, skin-surface gradients, with gradients exceeding 4 degrees Celsius, indicating intense vasoconstriction. The patients were subsequently rapidly rewarmed to 37 degrees Celsius. Regression analysis was used to correlate changes in oxygen consumption and plasma catecholamine concentrations with core temperature.

Results: All patients were vasoconstricted by the time core temperature reached 36 degrees Celsius. Further reduction in core temperature to 34-34.5 degrees Celsius did not increase oxygen consumption. Instead, oxygen consumption decreased linearly. Hypothermia also failed to increase plasma catecholamine concentrations.     

Respiratory failure with diffuse patchy lung infiltrates: an unusual presentation of squamous cell carcinoma

The case history is presented of a patient with squamous cell carcinoma of the lung with diffuse bilateral pulmonary shadowing mimicking bronchioloalveolar cell carcinoma which led to type I respiratory failure.     

Mumpsimpfstoffe: Virologische Grundlagen

Zusammenfassung Nur attenuierte Lebendimpfstoffe haben sich bisher für die Prävention der Mumpsvirusinfektion als wirksam erwiesen. Die verschiedenen Impfstämme unterscheiden sich im. Grad ihrer Attenuierung, die schwer steuerbar ist. Der Grat zwischen Restvirulenz und Überattenuierung ist schmal. Wenig attenuierte Impfstämme zeigten zwar eine höhere Immunogenität, aber auch häufiger Impfkomplikationen. Heute werden nur noch relativ stark abgeschwächte Impfstämme verwendet, die zwar kaum je zu einer impfassoziierten Erkrankung führen, deren Immunogenität aber geringer sein dürfte als ursprünglich angenommen.

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Summary The prevention of mumps virus infection reties on the application of live, attenuated mumps virus vaccines. The process of attenuation from a wildtype mumps isolate to a safe vaccine has been empirical. A lower degree of attenuation results in solid immunity but carries an increased risk of post-vaccination meningitis due to the vaccine strain. Currently used vaccine strains are highly attenuated and essentially free of vaccine strain induced disease. However, their immunogenicity may be lower than previously reported.

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Résumé La prévention des oreillons est effectuée grâce aux vaccins contenant des virus ourliens vivants atténués. La différence entre un virus ourlien sauvage et un atténué est très petite. Un virus légèrement atténué engendre une forte immunité mais augmente le risque de développer des méningites postvaccinales. Actuellement on utilise des souches fortement atténuées qui ne font que très peu de complications mais dont l'immunogénicité semble plus faible que prévue.

     

Spectral analysis of prespeech sounds (spontaneous cries) in infants with unilateral cleft lip and palate (UCLP): a pilot study.

OBJECTIVE: The objectives of the present study were: (1) to analyze the cry features of infants with cleft lip and palate (UCLP) by means of spectral analysis, (2) to describe changes of the acoustic parameters from birth until 9 months of age, and (3) to compare these data with existing cry data of infants without cleft (control group). DESIGN: The study was designed on a interdisciplinary, prospective, and longitudinal basis. SETTING: Interdisciplinary study: (1) Institute of Anthropology at the Humboldt-University, Berlin; (2) Heidelberg University Hospital: Interdisciplinary Cleft Palate and Craniofacial Center. PATIENTS AND METHOD: The cry parameters of five patients with complete unilateral cleft lip, alveolar ridge, and hard and soft palate were analyzed from birth to 9 months of age. The patients were treated with the same protocol. At the age of 24 months, sensomotor development was assessed using the KIPHARD test. Perceptual judgment of speech, performed after 36 months of life, included nasal resonance, nasal emission of air, articulation disorders, and speech intelligibility. MAIN OUTCOME MEASURE: The cry parameters of fundamental frequency (F(0)), pitch period perturbation quotient (PPQ), and cry duration (Tsam) were analyzed. RESULTS: Contrary to the expectation that laryngeal parameters are not affected by vocal tract malformations, differences of cry parameters were found between the patients with UCLP and the non-cleft group. Particularly, the F(0) and its short-time variability (PPQ) were affected. CONCLUSIONS: The preliminary results of this study showed that F(0) and PPQ of spontaneous cries are influenced in patients with UCLP, and a cry analysis might become a noninvasive tool for early detection of an at-risk status for neuromuscular development and prediction of an at-risk status for later speech and language acquisition in infants with cleft lip and palate. Future research strategies are outlined.     

Posttraumatische Belastungsstörung

Current activities in the case management of patients with post-traumatic stress disorders are reported. In 2002 a project was initiated by accident insurance associations. The aim is to detect accident victims with stress disorder at an early stage and to avoid medical mismanagement.     

Electrophysiological changes in the acute “axonal” form of Guillain–Barre syndrome

The acute “axonal” form of Guillain—Barre syndrome is characterized by rapid progression to severe widespread paralysis and respiratory dependence within 2–5 days of the onset of weakness with very poor and delayed recovery. In 3 cases studied within the first 7 days, the maximum thenar, hypothenar, tibialis anterior, and extensor digitorum bervis “M” potentials were either very reduced in size or absent in response to stimulation at the usual most distal sites of stimulation at the wrist, fibular head, and/or ankle. In the latter instances, advancing the site of stimulation closer to the motor point often evoked an M response. Furthermore, continued distal advance of the site of stimulation evoked progressively larger sized M potentials. Over succeeding days even these very distally evoked M potentials. Maximum conduction velocities in motor nerve fibers just prior to total loss of excitability were often very reduced. The pattern in these cases is most consistent with progressive loss of excitability and conduction in nerve fibers undergoing axonal degeneration, although coexisting primary demyelination in the terminal segment could not be excluded as the basis for the sometimes very slowed conduction velocities. © 1993 John Wiley & Sons, Inc.     

Transient impairment of visual perception induced by single interictal occipital spikes

We have previously reported that focal occipital interictal epileptiform discharges (spikes) cause transiently prolonged reaction time (RT) and increased nonperception of stimuli, especially in the visual field contralateral to the spike. One subject with very frequent spikes was capable of carrying out a visual recognition task along with the RT task. During central fixation, computer-generated random digits were flashed for 150 ms at random locations on a screen. Some stimuli were delivered during spikes, by means of an amplitude-threshold trigger, whereas control stimuli were delivered at random times between spikes. Following each stimulus, the subject had to press a button for RT and then report the digit perceived. There was a statistically significant increase in nonresponse rate (nonperception) during spikes compared to controls, and this effect was maximal contralateral to the spike. Moreover, among the responses, perceptual accuracy (correct vs incorrect) was significantly impaired during spikes, again predominantly in the visual field contralateral to the spike. Thus, not all focal interictal spikes are necessarily "subclinical;" at least some induce a transient cortical dysfunction of the same kind as produced more enduringly from a structural lesion in the same location. These findings may have clinical relevance in patients, especially children, with very frequent epileptiform discharges and higher cortical dysfunction.