Biomedical subjects
Publications and source records attributed to T Busch.
Massive hemothorax developed in a 58-year-old man 12 hours after a left pneumonectomy. The source of bleeding was a tear in the pulmonary vein stump caused by a titanium clip that had been used during mediastinal lymphadenectomy. Postoperatively, the clip progressively sawed through the vascular wall of the pulmonary vein due to friction during the cardiac cycle.
Nitric oxide (NO) is detectable in the exhaled gas of adults during spontaneous respiration and, according to current knowledge, mainly originates from the paranasal sinuses. We studied total NO excretion rates by chemiluminescence in preterm infants whose paranasal sinuses are known to be only partially pneumatized. NO excretion was 7.15 +/- 1.13 nl/min (mean +/- SD, range 6.33-9.36 nl/min) measured from spontaneously exhaled nasal gas (n = 6) and 0.3 +/- 0.05 nl/min (range 0.26-0.36 nl/min) measured from the lower airways in intubated individuals (n = 3). These values are considerably lower than those reported for older children and adults. Body weight-related amounts of NO excretion, however, seem comparable between infants and adults.
We describe a patient requiring a HeartMate 1000 IP left-ventricular assist device (LVAD) due to cardiogenic shock. After prolonged gastrointestinal bleeding without identifying the source of bleeding technetium scintigraphy pointed to the right lower abdomen. The patient underwent a laparotomy and inflamed ileum was resected. Pathologic examination revealed cytomegalovirus ileitis. This was treated with ganciclovir and acyclovir. The patient is now (14 months later) awaiting heart transplantation since she could not be weaned from LVAD. The diagnostic and management problems are discussed as well as the relevance for future transplantation.
To investigate whether relevant levels of nasal nitric oxide (NO) are produced in the absence of paranasal sinuses, we studied 17 healthy baboons, mammals without any paranasal sinuses. The animals were anesthetized with ketamine hydrochloride and breathed spontaneously. While the baboons breathed through a face mask (mouths closed) connected to a respirator, NO concentrations in exhaled gas were sampled from the expiratory limb and analyzed by chemiluminescence. While the animals were breathing ambient air, nasal gas was sampled via a thin plastic tube and analyzed for NO concentrations by chemiluminescence. Mean NO concentration in the exhaled gas was 1.00 +/- 0.59 parts/billion, and NO release was 4.28 +/- 2.72 nl/min. A NO concentration of 4.79 +/- 2.08 parts/billion was found in the nasal gas (NO release: 7.18 +/- 3.13 nl/min). An age-dependent increase in nasal NO levels was not observed. Exhaled and nasal NO concentrations in baboons were markedly lower than in mammals with paranasal sinuses, suggesting that paranasal sinuses might be an anatomic requirement for production of relevant nasal NO levels.
INTRODUCTION: Anterior ischemic optic neuropathy (AION) describes a defect of the optic nerve leading to irreversible loss of vision in most cases. Pathophysiology of this disease is manifold and has been discussed as a posthemorrhagic complication as well as a neurological complication after operations with cardiopulmonary bypass. METHODS: On the basis of two cases, the clinical picture is described in relation to the available literature. Preoperative risk factors, operative data, cardiopulmonary-bypass, postoperative complications and clinical symptoms are discussed together with ophthalmologic findings in order to elucidate the pathophysiology of this process. RESULTS: There is no reliable and effective treatment of anterior ischemic optic neuropathy. Neither corticosteroids, osmotic diuretics, hemodilution nor surgical decompression of the optic nerve have proved successful. Hence, measures to avoid ischemic optic neuropathy have priority. The following risk factors were determined: History of glaucoma or other ophthalmological problems, prolonged cardiopulmonary bypass-time and myocardial ischemia, general oedema during cardiopulmonary bypass, excessive hemodilution with low hemoglobin and hematocrit, hypo- or hypertension, systemic hypothermia, need for vasoactive medication. CONCLUSIONS: Influenced by a variety of factors, pathophysiological microvascular changes provoke anterior ischemic neuropathy with sudden painless loss of vision, irreversible in most cases. Since therapeutic trials have failed, prevention of possible causes is the only way to avoid this rare but severe complication of cardiac surgery.
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We have performed a retrospective review of our experience with the intraaortic balloon counterpulsation pump (IABP) during the last decade, to identify aspects of risk factors, complications, and management that affect peripheral vascular morbidity and mortality. Data from 472 patients who had the IABP inserted during the ten-year period from December 1985 to December 1995 were retrospectively reviewed. Risk factors, implantation techniques, complications, and significant variables were evaluated. One hundred forty-five vascular complications needed surgical therapy in 116 patients. Mean age was 62.2 +/- 12.9 years. There were 84 (72.5%) men and 32 (27.5%) women. Mortality rate was 28.3% (n = 181). The mortality for patients with ischemic vascular complications was significantly higher than in patients who did not suffer any vascular complication (59.6% vs 30.1%, p = 0.0001). Complications included acute limb arterial occlusion in 99 cases (68.3%), compartment syndrome in 27 (18.6%), groin hematoma in 15 (10.3%), and persistent lymph fistula in 4 (2.8%). Of these, 97 (76.9%) occurred during IABP therapy and 29 (23.1%) after IABP explantation. Thromboembolectomy was required for 61 (42.2%) of the ischemic limbs. Associated procedures were 24 (16.5%) profundaplasties, 10 (7%) infrainguinal bypasses (5 (3.4%) femoropopliteal supragenicular, 3 (2.2%) femoropopliteal infragenicular, and 2 (1.4%) infrapopliteal), 26 (17.9%) fasciotomies, and 5 (3.4%) amputations. A history of peripheral vascular disease (31 patients [43.6%] with vs 95 [23.6%] without, p < 0.05) and the presence of diabetes mellitus (70 patients [49.2%] with vs 56 [16.9%] without) increased the risk of limb ischemia significantly. Female sex, insertion of IABP by percutaneous technique, and direct removal with groin compression were associated with higher ischemic complication rates, the differences however were not significant. Itis concluded that 1. Limb ischemia remains the primary complication after IABP insertion; 2. Femoral artery thromboembolectomy is usually sufficient for revascularisation; 3. Adequate implantation and surgical explantation techniques are essential to reduce the IABP-related morbidity; 4. Identification of subclinical disease may aid in the management of subsequent acute limb ischemia; 5. The presence of peripheral vascular disease and diabetes mellitus are associated with higher ischemic complication rates.
BACKGROUND: Increasing evidence suggests that conventional PD solutions are detrimental to host defence mechanisms of peritoneal cells. We tested a new amino-acid-based and bicarbonate-buffered PD solution under in vivo and in vitro conditions. METHODS: During a prospective, cross-over randomized, intraindividual study 10 CAPD patients were investigated with three different solutions: Amino/Bic, 1% amino acid, 34 mmol/l bicarbonate; Glu/Bic, 1.5% glucose, 34 mmol/l bicarbonate; and Glu/Lac, 1.5% glucose, 35 mmol/l lactate. A PET was performed and transport properties (clearance, D/P ratio, MTAC) were calculated. Prostanoid and cytokine concentrations were measured in serum and the 6 h effluent. Using an in vitro model, mononuclear leukocytes of healthy donors were also incubated with the test fluids. In vivo results. Peritoneal clearance and MTAC of small solutes (creatinine, urea) were not significantly altered by amino acids or bicarbonate. Peritoneal permeability and transperitoneal excretion of higher-weight protein molecules (beta 2-microglobulin, albumin, IgG) were increased with Amino/Bic compared to Glu/Lac (P < 0.05) (D/P ratio albumin: Amino/Bic, 0.027 +/- 0.003; Glu/Bic, 0.023 +/- 0.003; Glu/Lac, 0.022 +/- 0.002). Application of Amino/Bic was accompanied by an increased effluent concentration of Il-6, Il-8, TNF alpha, PGE2, and 6-keto-PGF1a (P < 0.05). Dialysate nitrite/nitrate and cGMP concentrations (as indicators of NO generation) did not differ between the solutions. In vitro results. Both bicarbonate fluids demonstrated a better preservation of the mitochondrial dehydrogenases activity (MTT assay) compared to Glu/ Lac (P < 0.01) (Amino/Bic: 80.6 +/- 3.2%; Glu/Bic: 86.0 +/- 1.8%; Glu/Lac, 64.9 +/- 2.3%, referred to RPMI as control). Constitutive and LPS stimulated release of Il-1 beta and Il-6 was less suppressed with both bicarbonate fluids (P < 0.05) (LPS-stim. Il-6 release: Amino/Bic, 33.0 +/- 6.6%; Glu/Bic, 65.5 +/- 10.3%; Glu/Lac, 1.5 +/- 0.7% referred to RPMI). CONCLUSION: Application of an amino-acid/bicarbonate solution resulted in a small but significant increase in peritoneal permeability. Also increased concentrations of various cytokines/prostanoids were measured in the effluent. According to in vitro testing with mononuclear phagocytes both bicarbonate-buffered fluids were to the same extent less inhibitory to certain cell functions than lactate-buffered solution.
OBJECTIVE: To determine whether (1) the recently developed pneumatic cycler for automatic peritoneal dialysis (APD) achieves individually adjustable adequate dialysis efficacy, and (2) changing from continuous ambulatory peritoneal dialysis (CAPD) to APD results in an appropriate increase of dialysis efficacy. PATIENTS AND METHODS: Between July 1994 and August 1995 dialysis treatment for chronic renal failure was performed in 17 patients (four women, 13 men: mean age 42.9 +/- 11.6 years). Ten patients decided primarily on APD, seven changed over from CAPD to APD because of inadequate dialysis efficacy. Adequacy of dialysis was judged by clinical criteria, weekly creatinine clearances (wCcr) and urea levels (urea elimination related to distribution volume [wKT/V]). RESULTS: Mean treatment period with APD was 7.9 +/- 0.3 hours, dialysate volume 19.4 +/- 2.3 1. An ultrafiltration of 1253 +/- 643 ml was achieved. Mean serum creatinine was 13.1 +/- 3.5 mg/dl, mean serum urea-nitrogen 61 +/- 15 mg/dl. wCcr was 78.6 +/- 27.2 1, wKT/V 2.21 +/- 0.33. All patients were adequately dialysed with various forms of APD. In those patients who changed from CAPD the dialysis efficacy, judged by weekly urea-nitrogen elimination, increased by 50% from 1.42 +/- 0.29 to 2.14 +/- 0.20 (P < 0.05). With the pneumatic cycler the different dialysis modes were achieved without problem. CONCLUSION: APD with the new pneumatic cycler provided an adequate and attractive option, from both medical and psychosocial aspects, in the dialysis of patients in chronic renal failure. Changing from CAPD to APD in certain patient groups clearly increased dialysis efficacy so that changing over to haemodialysis can often be avoided.
Nitric oxide (NO) produced in the respiratory tract is released into the respiratory gases of humans, rabbits, guinea-pigs, and rats. We analysed the NO concentrations in the exhaled gas of four awake Asian elephants. Two methods were employed: (1) exhaled gas was sampled from the elephants' trunks with a 1 L syringe and analysed for NO concentrations by chemiluminescence; (2) respiratory gas was continuously aspirated via a thin plastic tube positioned within the trunk and on-line analysed for NO concentrations by chemiluminescence. Syringe sampling (n = 4), when corrected for dilution by ambient air using linear regression analysis, revealed a mean NO concentration of 31 parts per billion (ppb); highest exhalatory concentrations measured during continuous suctioning were 27 and 28 ppb (n = 2). The exhaled NO concentrations in elephants are similar to those found in humans measured with a comparable technique. This supports the hypothesis that a size-independent 'normal value' of endogenous NO is provided in the airways which may contribute to regulation of pulmonary ventilation and perfusion by autoinhalation in some mammals.
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The laser flare cell meter (LFCM) is introduced as an instrument that quantifies noninvasive anterior chamber protein. The relationship between laser flare measurement and actual protein concentration in vivo and in vitro was assessed. The intensity of light scattering by helium neon laser beam is measured by LFCM and depends on protein concentration and molecular size. Total protein, albumin and transferrin were measured using nephelometry and the Coomassie method. We tested 63 patients undergoing routine cataract surgery. Laser flare measurements were made before surgery. The mean in vivo flare was 8.25 photons/ms, standard deviation 9.57 photons/ms. Before surgery paracentesis was performed in 61 patients. In vitro aqueous flare was 10.55 +/- 7.68) photons/ms. Biochemical analysis showed a mean anterior chamber protein concentration in 51 patients of 33.65 (+/- 27.36) mg/dl, a mean albumin concentration in 38 patients of 15.78 (+/- 11.03) mg/dl, and a mean transferrin concentration in 33 patients of 2.01 (+/- 0.88) mg/dl. Up to a "cell" count of 40/0.075 mm3 there is a statistically significant correlation. Laser flare values compared with biochemical analysis showed for total protein a correlation coefficient of r = 0.695 in vivo and r = 0.753 in vitro. A "cell" count higher than 40/0.075 mm3 produces marked overestimation of protein concentration by laser flare values. There is a statistical significant linear correlation between photon count by LFCM and total aqueous protein concentration by biochemical analysis in vivo and in vitro in normal cataractous eyes.
After six years of home haemodialysis and two years of continuous ambulatory peritoneal dialysis a 59-year-old woman developed an aluminium-induced osteopathy, myopathy and normochromic anaemia. She was at first treated with intravenous, then peritoneal, deferoxamine, 1 g every other day. Before treatment, 15.8 micrograms aluminium (Al) had been eliminated daily, with a peritoneal clearance of 0.3 ml/min; after intravenous deferoxamine a mean of 774.3 +/- 102.3 micrograms Al was eliminated per day, after peritoneal deferoxamine 646.7 +/- 89.6 micrograms of Al per day, with a peritoneal clearance of 2.2 +/- 0.9 (intravenous) and 1.9 +/- 0.7 ml/min (intraperitoneal). After four months of deferoxamine administration, mostly intraperitoneally as an out-patient, the osteomalacia clearly improved, as did the myopathy and anaemia.
Aluminum concentrations in the dialysate and serum of 14 patients on CAPD were measured every six months. Additionally, in ten of the patients Al elimination was measured after a bolus ingestion of 1800 mg aluminium-chloride-hydroxide-complex. There was no significant difference between serum Al concentrations initially (47.3 +/- 8.2 micrograms/l), at six months (55.4 +/- 9.5 micrograms/l), and after 12 months (44.3 +/- 10.1 micrograms/l) although the Al concentration in the dialysate had been decreased from 16.6 +/- 2.3 micrograms/l to 1.5 +/- 0.2 in the last six months. The Al concentrations in the effluent dialysate were 14.5 +/- 1.3 micrograms/l initially, 15.6 +/- 1.2 micrograms/l after six months and 11.9 +/- 2.6 micrograms/l after 12 months. During kinetic studies a constant rise of serum Al concentration was found until the fifth hour, from 29.9 +/- 2.5 to 42.5 +/- 4.0, and a decline after 24 hours to 32.4 +/- 3.0 micrograms/l. The quantity of Al eliminated was 41.1 +/- 8.7 micrograms/24 h, equivalent to 1.2% of the ingested dose. In patients with residual renal function, renal Al clearance was almost double the peritoneal one. These results indicate that Al elimination by CAPD is not efficient and ingestion of Al-containing phosphate binders can result in Al accumulation.
1. Aluminium concentrations were measured in hair, plasma and bone samples from different groups of chronic renal insufficient patients and from a control group (75 healthy volunteers plus 21 deceased subjects). A cross-sectional study with 40 haemodialysis patients and two longitudinal studies were undertaken, the first comprising of 12 home haemodialysis patients and the second 16 patients undergoing continuous ambulatory peritoneal dialysis (CAPD). 2. Before introduction of water treatment by reverse osmosis, the hair aluminium levels of home haemodialysis patients were elevated compared to controls. Aluminium in the hair of all other groups were within the normal range. Hair aluminium levels were not related to the daily aluminium intake, nor to the cumulative aluminium intake, nor to bone and plasma aluminium concentrations. 3. Plasma aluminium concentrations in all patients were higher than in the controls. Dialysis without reverse osmosis water treatment increased aluminium plasma levels. After installation of reverse osmosis units there was a decrease in the aluminium concentrations in plasma. In CAPD patients insignificant increases in the aluminium levels in plasma were observed. When low contaminated dialysis fluid was available the plasma aluminium concentrations returned to the initial level. 4. Aluminium concentrations in bone were increased in renal insufficient patients compared with controls. Aluminium bone content increased with increasing cumulative aluminium intake by phosphate binding therapy. 5. Hair analysis is of very limited value for the diagnosis of aluminium exposure. Bone analysis is suitable for the assessment of the individual body burden.
The present study represents the first randomized, double-blind trial comparing the clinical efficacy of tromantadine (Viru-Merz) vs aciclovir. Both medication groups contained 60 patients. The inclusion criteria required that patients show a history of recurrent manifestations of herpes orofacialis and that they not be recruited later than 24 h following the initial prodromal symptoms. Medication was dispensed randomly in identical tubes to cover a treatment period of up to 5 days. The patients were instructed to keep the tubes close at hand, to initiate therapy as soon as possible after experiencing the first symptoms of the recurrence and to visit the company physician within 24 h after the onset of symptoms. The herpes lesions were assessed daily by the same doctor for 14 days, except on weekends. The data of 119 patients (59 treated with tromantadine, 60 treated with aciclovir) were evaluated. The average time between the first signs of a new recurrence and the beginning of treatment was 7 hours in both treatment groups. The course of the healing process was rated by 4 subjective symptoms (itching, burning, skin tautness and pain) and by the following objective criteria: number of days in the vesicular stage and duration of complete healing, abortive lesions and new lesions. The results of these assessments showed no differences between the medication groups. Global clinical efficacy and tolerance were rated as being "very good" and "good" in more than 83% by patients and doctor in both groups. The results show that it is the early application of the virustatic that is important for successful treatment--regardless of the choice of agent tested.
Since dialysis solutions in CAPD are now nearly aluminum free, the only source for elevated aluminum levels are aluminum-containing phosphate binders. Elimination with CAPD is insufficient to prevent aluminum accumulation. Therefore, we investigated a phosphate binder consisting of calcium alginate, a natural polyuronic acid, containing 100 mg calcium/g substance in 14 patients on CAPD over a period of one year. The patients had previously been treated with aluminum-containing phosphate binders for a period of 24.3 +/- 21.3 months. During a period of 3 weeks before changing to the new phosphate binder the mean (+/- SD) serum phosphorus concentration was 1.8 +/- 0.4 mmol/l, while at the end of one year of treatment with calcium alginate the concentration was 1.6 +/- 0.4 mmol/l. In order to lower serum phosphorus to this level, it was necessary to increase the mean (+/- SD) amount of calcium alginate from 6.9 +/- 1.3 g per day at the beginning of the study to 8.3 +/- 2.1 g per day at the end. The mean (+/- SD) serum calcium concentration did not change throughout the study period. Serum levels of alkaline phosphatase, 1.25 (OH)2 vitamin D3, and intact parathyroid hormone did not change as well. The mean (+/- SD) serum aluminum level declined from 36.0 +/- 20 to 14.0 +/- 11.3 micrograms/l after 6 months (p less than 0.001). In conclusion, calcium alginate is a good alternative to aluminum-containing phosphate binders and to phosphate binders on a calcium base as it does not lead to hypercalcemia. It prevents aluminum intoxication and has no serious side effects.