Prehospital Trauma Life Support® (PHTLS®)

Introduction

There is clinical evidence that standardized management of trauma patients in the emergency department improves outcome. Standardized prehospital management has been established for stroke patients and those suffering acute coronary syndrome. Prehospital treatment of trauma patients differs quite significantly from one system to another. The data from the German Trauma Registry show that the average time from accident until arrival in the emergency department is 72 min. This needs improvement.

Results

PHTLS® is a training course that teaches a systematic approach to the trauma patient in the preclinical setting. The aim is to rapidly and accurately assess the patient’s physiologic status, treat according to priorities, and decide whether the patient is critical and needs rapid rescue and transport. Above all, it is important for caregivers to prevent secondary injury, to realize the relevance of timing in the initial treatment, and to assure a high standard of care. PHTLS® provides the participant with knowledge, skills, and necessary behaviors. The course is open to persons in all specialties involved in the initial management of severely injured patients. The German Board of Emergency Technicians e.V. inaugurated the course concept in cooperation with the National Association of Emergency Medical Technicians (NAEMT) and the American College of Surgeons (ACS) and is authorized to organize PHTLS® courses in Germany.

Conclusion

PHTLS® teaches a standardized and established approach to the trauma patient in the emergency department. It has been established in 36 countries and the content is reviewed regularly to consider new scientific evidence. Healthcare personnel in Germany have the chance to participate in this international standard of care and to introduce their own experiences into the review process.     

Morphometric and ultrastructural analyses of melanocytes,nevus cells,and melanoma cells

Summary Cytological atypia, revealed in the course of routine light microscopy, is considered a valuable indicator of malignancy in melanocytic lesions. A clear definition of the term cytological atypia, however, is lacking. Therefore, by morphometric analysis of ultrathin sections of 11 malignant melanomas (7 invasive, 3 in situ, and 1 lentigo maligna melanoma) and 10 compound nevi, we evaluated the discriminating power of the various facets of cytological atypia, i. e., nuclear area, area of the nucleolus, area of the total cell, and nuclear irregularity. In each case, at least 50 intraepidermal melanocytic cells were examined.The two-sided U-test showed significant differences between intraepidermal nevus and melanoma cells, with regard to the mean values (x) and standard deviations (s) of the nuclear area (x and s, p=0.00011), area of the nucleolus (x, p=0.00043; s, p=0.00011), and area of the total cell (x, p=0.00011; s, p=0.00093). However, only the mean values and standard deviations of the nuclear area allowed a clear distinction in each individual case.The area of the nucleus can be estimated in the course of routine histology. We therefore think that the size and variation of the nuclear area should be considered in the histological differential diagnosis between malignant melanomas and benign nevi.Presented in part at the 12th Colloquium of the Society for Ultrastructural Research and the 6th International Dermatopathology Colloquium, 17–20 April 1985, Florence, Italy     

Acute Toxicity and Changes in Quality of Life during a Combined Radio-Chemotherapy of Glioblastomas with Topotecan (Hycamtin?)

Background: Because of the pronounced radioresistance of glioblastoma multiforme the prognosis of this disease remains poor. Therefore, we investigated the impact of an additional simultaneous chemotherapy with the topoisomerase-I inhibitor topotecan (Hycamtin^®) on the quality of life and toxicity of radiotherapy. Patients and Methods: In this multicenter trial patients with histologically proven glioblastomas multiforme underwent a simultaneous radio-chemotherapy. Including pilot phase 60 patients, 41 male and 19 female, were treated. Age ranged from 26 to 76 years, the mean was 57 years. Conventional fractionated conformal radiotherapy was performed with daily doses of 2.0 Gy to a total dose of 60 Gy. 1 hour prior to irradiation 0.5 mg (absolute dose) of topotecan were administered intravenously resulting in a cumulative dose of 15 mg. Besides hematologic and non-hematologic toxicity, quality of life was assessed by Karnofsky index and Spitzer index. Additionally local control and survival time were recorded. Results: 57 patients completed the combined therapy. Median administered dose of radiation was 60 Gy (16-76 Gy). Median cumulative topotecan dose was 15 mg (7.5-18.5 mg). Grade-III toxicity was found in six cases (two hematologic, two motoric disorder, one infection, one nausea) and grade-IV toxicity in three cases (one esophagitis, one motoric disorder, one mental disorder) Two patients died of septic disease most likely caused by steroid induced immunosuppression. Mean Karnofsky index and Spitzer index initially, at the end of therapy and 6 weeks after therapy showed values of 87%, 81% and 80% and 19 points, 18 points and 19 points, respectively. Median survival time was 15 months. Conclusion: This multimodal approach for patients with glioblastoma multiforme is well tolerated. Quality of life remains preserved and outpatient treatment is possible. The relatively long median survival time even for patients bearing macroscopic tumors is promising. Hintergrund: Aufgrund der schlechten Prognose bei Patienten mit Glioblastomen ist besonderer Wert auf den Erhalt der Lebensqualität in der verbleibenden Lebensspanne zu legen. Daher untersuchten wir den Stellenwert einer zusätzlichen simultanen Chemotherapie mit dem Topoisomerase-I-Hemmstoff Topotecan (Hycamtin^®) im Hinblick auf Lebensqualität und Toxizität während der Therapie. Patienten und Methoden: Im Rahmen einer multizentrischen Therapieoptimierung erfolgte bei histologisch gesichertem Glioblastom eine kombinierte Radiochemotherapie. Einschließlich der Pilotphase wurden 60 Patienten, davon 19 Frauen und 41 Männern, behandelt. Appliziert wurden 30 Fraktionen zu je 2,0 Gy mit einer simultanen i. v. Gabe von 30 Absolutdosen zu je 0,5 mg Topotecan, entsprechend Gesamtdosen von 60 Gy bzw. 15 mg. Als Parameter der Verträglichkeit dienten die Akuttoxizität sowie der Karnofsky- und Spitzer-Index. Sie wurden zu Beginn, während und regelmäßig im Anschluss an die Therapie erfasst. Zusätzlich dazu wurden die Zeitdauer der Tumorkontrolle und des Überlebens erhoben. Ergebnisse: Insgesamt 57 Patienten beendeten die Therapie. Die Strahlen- bzw. Topotecandosen betrugen im Median 60 Gy (16-76 Gy) bzw. 15 mg (7,5-18,5 mg). In sechs Fällen fand sich eine Grad-III-Toxizität (je einmal Leukopenie, Thrombopenie, Infektion, Übelkeit, zweimal motorische Störungen) und in drei Fällen eine Grad-IV-Toxizität (je einmal Ösophagitis, motorische und Bewusstseinsstörungen). Zwei Patienten verstarben an generalisierten Infektionen, am ehesten durch die stereoinduzierte Immunsuppression bedingt. Medianer Karnofsky- und Spitzer-Index initial, zum Therapieabschluss und 6 Wochen nach Therapie betrugen 87%, 81% und 80% bzw. 19, 18 und 19 Punkte. Das mediane Überleben lag bei 15 Monaten. Schlussfolgerung: Die kombinierte Radiochemotherapie mit Topotecan innerhalb dieses Therapieschemas ist ambulant durchführbar und gut verträglich. Insbesondere das relativ lange Überleben auch bei makroskopischen Tumoren ist viel versprechend.     

Die Wertigkeit der Strahlenbehandlung im Vergleich zur extrakorporalen Stoßwellentherapie (ESWT) beim Supraspinatussehnensyndrom

BACKGROUND AND AIM: Supraspinatus tendinitis is usually treated by antiinflammatoric drugs, local injections, physiotherapy or low-dose irradiation. A novel approach is the use of Extracorporeal Shock Wave Therapy (ESWT) if conservative therapies have failed. So far there has been no controlled study comparing the effectiveness of ESWT with an established conservative method of therapy such as X-ray stimulation radiotherapy. PATIENTS AND METHOD: 30 patients with chronic supraspinatus tendinitis were admitted into the prospective randomized study. After randomization the patients were treated either with X-ray stimulation radiotherapy with 6 x 0.5 Gy on the ICRU reference point (1 fraction/day) with cobalt 60 gamma rays or three times with 2000 pulses (energy flux density ED+ 0.1 mJ/mm2) in 1 week intervals using a Storz Minilith SL1. Primary endpoint was the age-corrected constant score 3 months after intervention. RESULTS: Acute side effects caused by the irradiation were not observed, as expected. One patient described pain and one patient showed a moderate skin irritation after ESWT. In the radiotherapy group average the age-corrected constant score improved from 47.6 through 79.5 points to 87.4 points. In the ESWT group it rose from 50.1 points before ESWT to 91.4 points after 12 weeks and 97.8 after 52 weeks. CONCLUSION: No statistically significant differences were proven between ESWT and radiotherapy. ESWT appears to be equivalent but not superior to radiotherapy in treating chronic supraspinatus tendinitis syndrome. A comprehensive randomized study is, however, necessary to ensure the equivalence of ESWT.     

Marknagelung geschlossener Oberschenkelschaftbrüche

Antegrade femoral nailing with interlocking nails is the most common surgical treatment for diaphseal fractures of the femur. It can be performed with or without reaming of the shaft. The decision on whether or not reaming is indicated must be made with reference to each patient's specific problems to avoid complications. Since there is a higher risk of pulmonary complications when the reamed technique is used, unreamed nailing should be preferred in cases of multiple injuries. The different surgical tehcniques for nailing are presented, as are the disadvantages of each.     

Osteochondrale Läsionen am Talus und ihre Therapieoptionen

We examined a number of osteochondral lesions of the talar dome. The mechanism of their development, the diagnostic procedures needed and the treatment options are reviewed. We present our experience of diagnosis and treatment, the main focus being on arthroscopic treatment. The results obtained in our own small patient population are reported. Statistical analysis is not appropriate in view of the small population.     

Fanconi’s Anemia and Clinical Radiosensitivity

BACKGROUND: Patients with Fanconi's anemia (FA) may exhibit an increased clinical radiosensitivity of various degree, although detailed clinical data are scarce. We report on two cases to underline the possible challenges in the radiotherapy of FA patients. CASE REPORT AND RESULTS: Two 24- and 32-year-old male patients with FA were treated by definitive radiotherapy for locally advanced squamous cell head and neck cancers. In the first patient, long-term tumor control could be achieved after delivery of 67 Gy with a-in part-hyperfractionated split-course treatment regimen and, concurrently, one course of carboplatin followed by salvage neck dissection. Acute toxicity was marked, but no severe treatment-related late effects occurred. 5 years later, additional radiotherapy was administered due to a second (squamous cell carcinoma of the anus) and third (squamous cell carcinoma of the head and neck) primary, which the patient succumbed to. By contrast, the second patient experienced fatal acute hematologic toxicity after delivery of only 8 Gy of hyperfractionated radiotherapy. While the diagnosis FA could be based on flow cytometric analysis of a lymphocyte culture in the second patient, the diagnosis in the first patient had to be confirmed by hypersensitivity to mitomycin of a fibroblast cell line due to complete somatic lymphohematopoietic mosaicism. In this patient, phenotype complementation and molecular genetic analysis revealed a pathogenic mutation in the FANCA gene. The first patient has not been considered to have FA until he presented with his second tumor. CONCLUSION: FA has to be considered in patients presenting at young age with squamous cell carcinoma of the head and neck or anus. The diagnosis FA is of immediate importance for guiding the optimal choice of treatment. Radiotherapy or even radiochemotherapy seems to be feasible and effective in individual cases.     

彩超对锁骨下动脉窃血综合征的诊断分析

目的 探讨彩超对锁骨下动脉窃血综合征（SSS）的诊断价值。方法 分析20例临床诊断为SSS的椎动脉血流与锁骨下动脉、颈动脉、无名动脉病变及上肢动脉血流频谱的关系。结果 SSS的椎动脉血流可分为完全性椎动脉反流、部分性椎动脉反流和无椎动脉反流三种。结论 超声诊断SSS方法简便、经济、无创。     

Technische Möglichkeiten und Perspektiven des Einsatzes telemedizinischer Geräte in der Augenheilkunde

Home monitoring will soon be established as an innovative way to provide telemedical care in ophthalmology. At present there are no fundamental technical restrictions for telemedical enhancements in ophthalmology, however a wider application range and depth could lead to harmonized and simplified device and interface development. This may help to initiate new concepts in ophthalmological home monitoring.     

Periodontitis Prevalence and Severity in Adults: A Cross‐Sectional Study in Norwegian Circumpolar Communities

Background: The aim of this study is to describe the prevalence, severity, and extent of periodontitis in the adult population of circumpolar communities in Norway using data from the Tromstannen–Oral Health in Northern Norway study. Methods: In this cross‐sectional survey, data were collected from a randomized population sample (aged 20 to 79 years) in Northern Norway. Periodontal conditions were assessed for 1,911 dentate adults with a full‐mouth periodontal examination. Probing depth (PD) and bleeding on probing were measured at six sites per tooth. Radiographic bone loss (BL) was examined using orthopantomograms. Results: According to the Centers for Disease Control and Prevention/American Academy of Periodontology case definitions, 49.5% of participants had periodontitis, and 9.1% had severe periodontitis. Periodontitis prevalence and severity increased with age. Extent of BL and PD ≥4 mm also increased with age, but more rapidly and to a greater extent for BL. Prevalence of periodontitis was higher among men and varied between urban and rural areas. Periodontitis prevalence was positively associated with smoking, lower levels of education, and income. Conclusions: This study reveals a high burden of periodontitis among adults living in circumpolar communities in Norway. The results showed sociodemographic disparities regarding periodontitis and highlights the importance of further investigation of factors influencing periodontal health.