Library

Description / Table of Contents: Abstract. In a controlled prospective randomized study, defibrillation by emergency medical technicians (EMTs) was compared with the current standard of care in Germany (basic life support by EMTs and defibrillation by emergency physicians only) in order to answer the following questions: 1. Does EMT defibrillation improve the survival rate and long-term prognosis of patients in ventricular fibrillation as compared to the current German standards in resuscitation (basic life support by EMTs and defibrillation by emergency physicians)? 2. Are the prerequisites for the use of semiautomatic defibrillators fulfilled in the emergency medical systems (EMS) of the participating centers? Methods. The study phase includes randomization of 121 adult patients with witnessed cardiac arrest and ventricular fibrillation (VF) as first ECG rhythm. Prior to the onset of the study, all EMTs of the participating EMS systems were retrained in basic life support (BLS) measures. In each center, randomly assessed EMT-Ds (EMTs trained in Defibrillation) were trained to use semiautomatic defibrillators. With the help of one-line tape recording, the time intervals during resuscitation and treatment steps were evaluated. Successfully resuscitated patients were followed up with the help of the Glascow Coma Scale and the Pittsburgh Cerebral and Overall Performance Categories. Results. From 1 February 1991 until 28 June 1992, 159 patients with VF were randomized. In 121 cases, collapse was witnessed. 25% (14/57) of the patients receiving defibrillation by EMT-Ds (study group=S) were discharged from the hospital alive. In the control group, 52 patients were defibrillated by emergency physicians, following BLS by EMTs [control group 1=C1; discharged: 29% (15/52)]. Fifty patients received BLS and advanced cardiac life support (ACLS) by the emergency physicians crews [control group 2=C2; discharged 18% (9/50)]. In the study group, the median time interval from collapse of the patient until initiation of BLS measures was 7.7 min, 7 min in C1 and 8 min in C2. ACLS measures were initiated significantly earlier (P〈0.05) in the control groups, as compared to the study group [S: 13 min, C1: 11 min; C2: 10.3 min]. Sixty-seven percent (30/45) of the study patients and 46% (36/76) of the control patients were defibrillated within 12 min. Study patients were defibrillated earlier (P〈0.05) (S: 9.9 min; C1: 12.2 min; C2: 12.75 min); return of spontaneous circulation (ROSC) was achieved earlier (P〈0.05) in the study group [S: 14 min; C1: 19 min; C2: 18.2 min] and the number of patients in the study group requiring no epinephrine during resuscitation was higher (P〈0.01) than in the control groups [S: 35.3% (12/34); C1: 10% (4/40); C2: 10.5% (4/38)]. Furthermore, the total amount of epinephrine [mean (±standard error)] administered in the study group [S: 2.35 (±0.49) mg; C1: 6.71 (±0.98) mg; C2: 7.71 (±1.31) mg] was significantly lower (P〈0.05). No significant differences in neurological long-term prognosis were found for the groups investigated. Conclusion. Neither the initial survival rate the number of patients discharged alive, nor the neurological long-term prognosis was significantly different for any of the groups investigated. Because of apparent differences in indirect prognostic parameters (time interval until ROSC, number of patients requiring no epinephrine) and because of the fact that the time interval to the first defibrillation was reduced by EMT defibrillation, EMT-Ds may perform defibrillation if: (a) they reach the patient before the emergency physician and (b) if they are trained intensively and supervised continuously. In order to increase the efficiency of defibrillation by EMT-Ds, far-reaching changes in our EMS are mandatory: (a) a reduction in the time interval from collapse until initiation of BCLS measures by intensifying layperson CPR training; (b) an increase in the number of emergency units equipped with semiautomatic defibrillators; (c) the consistent implementation of a tiered EMS.

Description / Table of Contents: Abstract. Injury and stress are accompanied by a characteristic hormonal response and altered energy utilisation. Hyperglycaemia and negative nitrogen (N) balance are the leading symptoms of the metabolic changes in the post-operative state. In a prospective, randomised study the efficacy and metabolic effects of glucose-xylitol (GX) 35% (1 : 1) versus glucose (G) 40% were investigated in patients undergoing major surgery. Method. Twenty-four patients undergoing abdomino-thoracic oesophageal cancer surgery were treated in a standardised manner. Total parenteral nutrition was administered over 6 days (kg body wt.−1/day): day of sugery 1 – 1.25 g carbohydrate (CH); 1st postoperative day (POD) 1.5 g CH, 1 g amino acids (AA); 2nd POD 3 g CH, 1.5 g AA, 1.0 g fat; from 3rd POD 3 g CH, 1.5 g AA, 1.5 g fat (CH GX35% (n=12) or G40% (n=12), AA Intrafusin 15%, fat Intralipid 20%). Daily and cumulative N balances, blood-G profiles, blood chemistry, and physical parameters were determined. Glucagon and insulin profiles, CH losses, and oxalic acid secretion were measured. Results. Both groups were comparable for age, body mass index, clinical and physical parameters, and blood chemistry. Mean cumulative N balances after 6 days were −12.0±16.3 g N for GX35% and −5.6±19.4 g N for G40% (n.s.; Wilcoxon, P〈0.05). Blood G was similar for both groups with values ranging from 130 to 240 mg/dl on the day of surgery and below 150 mg/dl on the consecutive days. In each group 1 patient needed additional insulin therapy. Glucagon and insulin levels did not show a significant difference between the groups. Conclusion. No difference in tolerance and efficacy of nutritional support by GX versus G at a dose of 3 g⋅kg body wt.−1⋅d in oesophagectomised patients could be observed. Similar blood G profiles were in accordance with comparable glucagon and insulin levels. Because of the high standard deviations of N balances, differences in efficacy could not be proven. A significantly lower level of pseudocholinesterase (PCHE) for G40% on day 7 might indicate enhanced hepatic protein synthesis in the GX group.

Description / Table of Contents: Summary Cytogenetic investigations in patients with primary amenorrhoea revealed two cases with a structural chromosome mosaic. Chromosome analysis was done in leukocyte cultures of peripheral blood. A 21 years old patient with infantilism, hypoplastic genitalia, but normal heigh (case 1) showed mosaicism of the type 46/XX–46/Xx with supposed deletion of a part of the long arm of one X-chromosome in one of both stem-lines. The possible origin of this deletion is discussed. Buccal mucosa smears of this patient showed only few Barr-bodies (8.5%), and these tended to be smaller than usually seen. — In a 19 year old patient with the clinical signs of Turner-syndrome (case 2) mosaicism of the type 45/XO–46/X-isochromosome-X of the long arm was found. In this case Barr-bodies larger than usually seen were present in 7.5% of cells in buccal mucosa smears. A scheme is presented suggesting the possible mode of origin of this isochromosome.