Validierung des NACA-Score anhand objektivierbarer Parameter

Zusammenfassung In einer retrospektiven Studie mit Daten aus 104.962 Primäreinsätzen von 28 Luftrettungszentren der ADAC-Luftrettung und des Bundesinnenministeriums vom 01.01.1999 bis 31.12.2003 wurde die Validität des präklinisch erhobenen NACA-Scores untersucht. Zur Klassifikation der Vitalfunktionen wurde der physiologisch orientierte, für die präklinische Patientenversorgung konzipierte MEES als Score genutzt. Für die Beurteilung der Notfallschwere war der kritischste Messwert für die jeweilige Vitalfunktion aus der präklinischen Versorgungsphase maßgebend. Die Ergebnisse zeigen, dass pathologische Messparameter der Vitalfunktionen für die Einordnung im NACA-Score durch den Notarzt in z. T. mehr als der Hälfte der Fälle keine Berücksichtigung finden. Selbst eindeutige Verläufe wie eine Reanimation oder der Tod des Patienten werden nicht korrekt klassifiziert. Auch unbestritten vitalbedrohende Krankheitsbilder wie der akute Myokardinfarkt (Fehleinschätzung: 51,5%), die Lungenembolie (40,1%) oder das Polytrauma (22,5%) werden im NACA-Score nicht als vitalbedrohend (mindestens NACA-Stufe V) eingeordnet. Zusammenfassend muss festgestellt werden, dass in Übereinstimmung mit der Literatur die Einordnung der Notfallschwere im NACA-Score durch den Notarzt stark subjektiven Einflüssen unterliegt. Daraus ergibt sich, dass der NACA-Score für wissenschaftliche Fragestellungen, zur Qualitätskontrolle und zur retrograden Beurteilung der Einsatzindikation allein ungeeignet ist. Es sollte ein modifizierter NACA-Score erarbeitet werden, der sich auf objektive Messwerte stützt.     

Repair of large midline incisional hernias with polypropylene mesh: Comparison of three operative techniques

Polypropylene mesh is widely used for the reconstruction of incisional hernias that cannot be closed primarily. Several techniques have been advocated to implant the mesh. The objective of this study was to evaluate, retrospectively, early and late results of three different techniques, onlay, inlay, and underlay. The records of 53 consecutive patients with a large midline incisional hernia — 25 women and 28 men, mean age 60.4 (range 28–94) — were reviewed. Polypropylene mesh was implanted using the onlay technique in 13 patients, inlay in 23 patients, and underlay in 17 patients. Either the greater omentum or a polyglactin mesh was interponated between the mesh and the viscera. The records of these 53 patients were reviewed with respect to: size and cause of the hernia, pre- and postoperative mortality and morbidity, with special attention to wound complications. Patients were invited to attend the outpatient clinic at least 12 months after implantation of the mesh for physical examination of the abdominal wall. Postoperative complications occurred in 14 (26.4%) patients. The onlay technique had significantly more complications, as compared to both other techniques. Reherniation occurred in 15 (28.3%) patients. The reherniation rate of the inlay technique was significantly higher than after the underlay technique (44% vs 12%, P=0.03) and tended to be higher than the onlay technique (44% vs 23%, P=0.22). Repair of large midline incisional hernias with the use of a polypropylene mesh carries a high risk of complications and has a high reherniation rate. The underlay technique seems to be the better technique.     

Nonheme iron in sickle erythrocyte membranes: association with phospholipids and potential role in lipid peroxidation

Previous studies documented the abnormal association of heme and heme proteins with the sickle RBC membrane. We have now examined RBC ghosts and inside-out membranes (IOM) for the presence of nonheme iron as detected by its formation of a colored complex with ferrozine. Sickle ghosts have 33.8 +/- 18.2 nmol nonheme iron/mg membrane protein, and sickle IOM have 4.3 +/- 3.0 nmol/mg. In contrast, normal RBC ghosts and IOM have no detectable nonheme iron. The combination of heme and nonheme iron in sickle IOM averages nine times the amount of membrane- associated iron in normal IOM. Kinetics of the ferrozine reaction show that some of this nonheme iron on IOM reacts slowly and is probably in the form of ferritin, but most (72% +/- 18%) reacts rapidly and is in the form of some other biologic chelate. The latter iron compartment is removed by deferoxamine and by treatment of IOM with phospholipase D, which suggests that it represents an abnormal association of iron with polar head groups of aminophospholipids. The biologic feasibility of such a chelate was demonstrated by using an admixture of iron with model liposomes. Even in the presence of tenfold excess adenosine diphosphate, iron partitions readily into phosphatidylserine liposomes; there is no detectable association with phosphatidylcholine liposomes. To examine the bioavailability of membrane iron, we admixed membranes and t-butylhydroperoxide and found that sickle membranes show a tenfold greater peroxidation response than do normal membranes. This is not due simply to a deficiency of vitamin E, and this is profoundly inhibited by deferoxamine. Thus, while thiol oxidation in sickle membranes previously was shown to correlate with heme iron, the present data suggest that lipid peroxidation is related to nonheme iron. In control studies, we did not find this pathologic association of nonferritin, nonheme iron with IOM prepared from sickle trait, high-reticulocyte, postsplenectomy, or iron-overloaded individuals. These data provide additional support for the concept that iron decompartmentalization is a characteristic of sickle RBCs.     

Experimental and clinical possibilities of MR spectroscopy of the heart

MR-spectroscopy of the heart is a relatively new technique for the study of various aspects of cardiac metabolism. The majority of results has so far been obtained with the isolated perfused heart. Here, 31P-MR spectroscopy can be employed to measure high-energy phosphate metabolism and intracellular pH repeatedly and non-invasively. Using a technique called saturation transfer, velocities of enzymatic reactions, such as the creatine kinase reaction, can be measured. Intra- and extracellular Na+ and K+ concentrations can be registered with 23Na- and 39K-MR in conjunction with shift reagent. 13C-MR can be used to tackle carbohydrate metabolism. In-situ-R-spectroscopy allows determination of high-energy phosphates in intact large mammals. Clinical applications of MR-spectroscopy remain to be defined; preliminary results indicate high diagnostic and prognostic potential for patients with coronary artery disease and congestive heart failure.     

Multimodale Behandlung einer Alopecia universalis

Alopecia universalis is characterized by total loss of body hair and can occur at any age, causing significant psychological morbidity in most cases. Though there is evidence to suggest that alopecia universalis is an autoimmune disease, the cause of the disease is still not known with certainty. Spontaneous recovery is unusual (<10%), and the long-term prognosis in cases not responding to therapy is poor, despite the variety of therapies available. Experience of immunosuppressive treatment in children with alopecia universalis is limited. We report on a 4-year-old boy, who was successfully treated for refractory alopecia universalis with prednisolone and cyclosporine A by mouth combined with topical application of tacrolimus. Our case report shows that systemic immunosuppression may be a promising treatment option for some children with alopecia universalis who are badly distressed by their condition. However, potential treatment-related risks have to be weighed against the psychosocial stress experienced by these patients and their families.     

„Scalping“

An 18-month-old boy was brought to hospital because of massive swelling and extensive haematoma of the forehead and eyelids. At first the mother reported that the child had fallen from his tricycle. Cranial computed tomographyy revealed an extensive subgaleal haematoma but bony injuries were not found. The results of police investigations revealed that the mother had locked the child’s head firmly between her arm and chest and jerked it backwards and forwards several times. The mother was convicted of child abuse.