Continuous monitoring of liver oxygenation with near infrared spectroscopy during naso-gastric tube feeding in neonates.

Near infrared spectroscopy (NIRS) is a non-invasive method of estimating the haemoglobin concentration changes in certain tissues. It is frequently used to monitor oxygenation of the brain in neonates. At present it is not clear whether near infrared spectroscopy of other organs (e.g. the liver as a corresponding site in the splanchnic region, which reacts very sensitively to haemodynamic instability) provides reliable values on their tissue oxygenation. The aim of the study was to test near infrared spectroscopy by measuring known physiologic changes in tissue oxygenation of the liver in newborn infants during and after feeding via a naso-gastric tube. The test-retest variability of such measurements was also determined. On 28 occasions in 25 infants we measured the tissue oxygenation index (TOI) of the liver and the brain continuously before, during and 30 minutes after feeding via a gastric tube. Simultaneously we measured arterial oxygen saturation (SaO2), heart rate (HR) and mean arterial blood pressure (MAP). In 10 other newborn infants we performed a test-retest analysis of the liver tissue oxygenation index to estimate the variability in repeated intra-individual measurements. The tissue oxygenation index of the liver increased significantly from 56.7 +/- 7.5% before to 60.3 +/- 5.6% after feeding (p < 0.005), and remained unchanged for the next 30 minutes. The tissue oxygenation index of the brain (62.1 +/- 9.7%), SaO2 (94.4 +/- 7.1%), heart rate (145 +/- 17.3 min-1) and mean arterial blood pressure (52.8 +/- 10.2 mm Hg) did not change significantly. The test-retest variability for intra-individual measurements was 2.7 +/- 2.1%. After bolus feeding the tissue oxygenation index of the liver increased as expected. This indicates that near infrared spectroscopy is suitable for monitoring changes in tissue oxygenation of the liver in newborn infants.

Incidence des fractures du fémur proximal dans le canton de Vaud. [Incidence of proximal femoral fractures in the Canton of Vaud].

Hip fractures place a major and increasing burden on health services in Western countries. Reported incidence rates vary considerably from one geographic area to another. No published data are available for Switzerland or surrounding countries, but such descriptive indicators are indispensable in orienting national or regional policies. To fill this gap and to assess the similarity of hip fracture incidence in Switzerland and other countries, we collected data from several sources in 26 public and private hospitals, in the Canton of Vaud (total population: 538,000) for 1986, which allowed us to calculate the incidence (for people over twenty years old) and assess related parameters. 577 hip fractures were identified among the resident population, indicating a crude average annual incidence rate of 140 per 100,000 (95% confidence interval: 128, 152). Corresponding rates for males and females were 58 (47, 68) and 213 (193, 232). Standardized rates and international comparisons show that Swiss rates are slightly lower than those of most industrial countries. More detailed results of relative risks for various study variables are presented and the pathogenesis of hip fractures is discussed.

Das Holprinzip in der Pädiatrie und Neonatologie [The collecting principle in pediatrics and neonatology]

Quality medical care during transport of critically ill pediatric and neonatal patients is only possible if the referring hospital and the regional center cooperate closely. The experience of physicians and nurses involved is of great importance, and the choice of the transporting team should depend on the medical status of the patient and the skills of the physicians and nurses or paramedics. Critically ill children and neonates should be transported by specialized teams. Our statistics from the last 12 years show an increasing number of transports, with the majority of patients being referred from peripheral hospitals.

Telemedizin und Ethik "Sicht des Sozialethikers und Theologen

Die Digitalisierung und Vernetzung der Gesellschaft hat diese entscheidend verändert. Auch Denk- und Handlungsweisen in der Medizin werden durch die neuen Informationstechnologien in erheblichem Maße beeinflusst. Von welcher Art ist dieser Einfluss? Verändert sich das Arzt-Patienten-Verhältnis? Bekommen wir den "gläsernen Patienten"? Gibt es Auswirkungen auf die Berufsstände im Gesundheitswesen? Verändert diese Technologie die Sozialsysteme möglicherweise sogar grundsätzlich? Werden wir bald von intelligenten technischen Systemen beherrscht? Sollten wir (bedenkenlos) alles machen, was wir (technisch) könn(t)en? Wo sind die Grenzen, wo müssen wir bremsen? Müssen wir über eine neue Ethik nachdenken oder "ist alles schon mal da gewesen"? Diesen und ähnlichen Fragen gehen die Beiträge in dieser Buchpublikation nach. In einem ersten Teil werden zur Einführung und zur Anregung Zukunftsszenarien entwickelt, und zwar für die Gebiete Medizinische Bildgebung, Medizinische Robotik und Telemedizin. Der zweiteTeil reflektiert allgemein über ethische Aspekte der Informationstechnik und der Informationstechnik, zunächst ohne direkten Bezug zur Medizin. Dieser wird im dritten Teil hergestellt. Den Schwerpunkt bildet hier die Telemedizin, weil diese ein geeignetes Modell zur ethischen Diskussion über Technik und Medizin darstellt. Der vierte Teil enthält eine Diskussion zum Thema "Werden die neuen Entwicklungen von Informationstechnik in der Medizin zum Fluch oder zum Segen für die Gesellschaft?". Schließlich sind in einem fünften Teil die Ergebnisse und Erkenntnisse in Thesenform zusammenzufassen. Diese "Dresdner Thesen zu ethischen Aspekten der Telemedizin" sind nach der Veranstaltung in einem mehrmonatigen Prozess entstanden, an dem die Herausgeber und die Autoren beteiligt waren.

Allocation d'organes et exigences de justice

(Résumé de l'ouvrage) Die Verteilung knapper menschlicher Organe wirft schwierige Fragen der Verteilungsgerechtigkeit und der Organisation auf. Rein medizinische Aussagen etwa über die Überlebenschance eines Organs in einem bestimmten Empfänger sind vorausgesetzt, bestimmen aber nie allein die Entscheidung. Effizienzüberlegungen sprechen zwar häufig für die primäre Berücksichtigung des Empfängers mit der grössten Lebenserwartung. Schon der Einbezug qualitativer Kriterien für die Überlebensphase kompliziert die Materie, erst recht aber die Berücksichtigung auch der Wartezeit als Element der Gleichbehandlung, der Dringlichkeit für den Empfänger oder gar von Marktkriterien. Auch die Frage einer Priorität für den seinerseits Spendewilligen wird kontrovers diskutiert. Und selbst dann, wenn man sich über die Gewichtung der unterschiedlichen Kriterien von Verteilungsgerechtigkeit einig wäre, bliebe immer noch die optimale organisatorische Durchsetzung dieser Entscheidung zu klären: soll man zum Beispiel mit regionalen, nationalen oder übernationalen Pools arbeiten? Die zweite Tagung im Tagungszyklus zu Grundsatzfragen der Transplantationsmedizin erörterte Themen rund um die Allokationproblematik bei Organen. Referenten aus verschiedenen Ländern, Sprachregionen und Disziplinen sprachen über medizinische, ethische, juristische, aber auch ökonomische Aspekte der Verteilung von Organen.

Organallokation : ethische und rechtliche Fragen

Die Verteilung knapper menschlicher Organe wirft schwierige Fragen der Verteilungsgerechtigkeit und der Organisation auf. Rein medizinische Aussagen etwa über die Überlebenschance eines Organs in einem bestimmten Empfänger sind vorausgesetzt, bestimmen aber nie allein die Entscheidung. Effizienzüberlegungen sprechen zwar häufig für die primäre Berücksichtigung des Empfängers mit der grössten Lebenserwartung. Schon der Einbezug qualitativer Kriterien für die Überlebensphase kompliziert die Materie, erst recht aber die Berücksichtigung auch der Wartezeit als Element der Gleichbehandlung, der Dringlichkeit für den Empfänger oder gar von Marktkriterien. Auch die Frage einer Priorität für den seinerseits Spendewilligen wird kontrovers diskutiert. Und selbst dann, wenn man sich über die Gewichtung der unterschiedlichen Kriterien von Verteilungsgerechtigkeit einig wäre, bliebe immer noch die optimale organisatorische Durchsetzung dieser Entscheidung zu klären: soll man zum Beispiel mit regionalen, nationalen oder übernationalen Pools arbeiten? Die zweite Tagung im Tagungszyklus zu Grundsatzfragen der Transplantationsmedizin erörterte Themen rund um die Allokationproblematik bei Organen. Referenten aus verschiedenen Ländern, Sprachregionen und Disziplinen sprachen über medizinische, ethische, juristische, aber auch ökonomische Aspekte der Verteilung von Organen.

Le myélome à chaînes légères ou les pièges du diagnostic du myélome [Light chain myeloma or the pitfalls of myeloma diagnosis]

The diagnosis of multiple myeloma is often suggested by disturbances found in routine laboratory tests such as sedimentation rate, electrophoresis of serum proteins and search for proteinuria. In light chain myeloma these tests are nonspecific and therefore misleading. We present 8 cases of light chain myeloma and discuss the diagnosis of multiple myeloma with its associated pitfalls.

Traitement des fibroses pulmonaires idiopathiques [Treatment of idiopathic pulmonary fibrosis]

Idiopathic pulmonary fibrosis still has to be diagnosed by elimination. Neoplasm, toxic treatments, collagen vascular disease, professional exposure or diagnosis such as sarcoidosis have to be ruled out. The repercussions on gas exchange are the most reliable indications of the severity of the disease, the pulmonary function test or chest x-rays alone being often misleading. Transbronchic biopsies, thoracotomy or thoracoscopies provide a precise diagnosis. In many cases only broncho-alveolar lavage and a high resolution CT-scan are performed to rule out infection or tumor and to assess the inflammatory state of the disease. Due to the often poor prognosis of this disease and its often poor response to steroids, the role of cytostatic drugs, cyclosporine and colchicine, and of pulmonary graft is discussed.

Klinisch-immunologische Teste--Standortbestimmung 1976

[Clinical-immunological tests; current state].

Utilité et limites du dosage de l'antigène carcinoembryonnaire (CEA) dans la surveillance postopératoire de malades atteints de carcinomes du côlon et du rectu

An attempt is made to define the usefulness and limitations of carcinoembryonic antigen (CEA) radioimmunoassay for evaluation of tumor resection and detection of tumor relapse in patients with large-bowel carcinoma. In 45 patients for whom complete tumor resection was reported, all but 5 showed a drop in CEA to normal values after surgery. The 5 patients whose CEA did not fall to below 5 ng/ml showed a subsequent rise in CEA level and later were all found to have a tumor relapse. The results indicate that an incomplete drop in circulating CEA level one month after surgery is a bad prognostic sign. Twenty-two of these patients were followed up by repeated CEA radioimmunoassay for several months after surgery; 8 showed a progressive increase in CEA levels preceding clinical diagnosis of tumor relapse by 2-10 months. The clinical history of these 8 patients is briefly described. The results demonstrate that relapses of colon and rectum carcinoma can be detected by increased CEA levels months before the appearance of any clinical evidence.

Quelques mécanismes moléculaires impliqués dans la pathogenèse du diabète de type II et leur importance thérapeutique potentielle [Various molecular mechanisms involved in the pathogenesis of type II diabetes and their potential therapeutic importance]

The pancreatic beta cell presents functional abnormalities in the early stages of development of non-insulin dependent diabetes mellitus (NIDDM). The disappearance of the first phase of insulin secretion induced by a glucose load is a early marker of NIDDM. This abnormality could be secondary to the low expression of the pancreatic glucose transporter GLUT2. Together with the glucokinase enzyme, GLUT2 is responsible for proper beta cell sensing of the extracellular glucose levels. In NIDDM, the GLUT2 mRNA levels are low, a fact which suggests a transcriptional defect of the GLUT2 gene. The first phase of glucose-induced insulin secretion by the beta pancreatic cell can be partly restored by the administration of a peptide discovered by a molecular approach, the glucagon-like peptide 1 (GLP-1). The gene encoding for the glucagon is expressed in a cell-specific manner in the A cells of the pancreatic islet and the L cells of the intestinal tract. The maturation process of the propeptide encoded by the glucagon gene is different in the two cells: the glucagon is the main hormone produced by the A cells whereas the glucagon-like peptide 1 (GLP-1) is the major peptide synthesized by the L cells of the intestine. GLP-1 is an incretin hormone and is at present the most potent insulinotropic peptide. The first results of the administration of GLP-1 to normal volunteers and diabetic patients are promising and may be a new therapeutic approach to treating diabetic patients.

Concentrations plasmatiques et articulaires pendant l'administration de céfacétrile pour arthrite septique (6 cas) [Serum and joint levels of cefacetrile during its administration for septic arthritis]

Six patients, five of whom had normal and one impaired renal function, and all suffering from purulent arthritis caused by cephalosporin-sensitive germs, were given a seven-day course of 8 g cephacetrile daily. On the first day, 6 g were administered by continuous intravenous infusion at the rate of 500 mg/h, followed by 2 g over a further 45 min. On days 2 to 7, the patients received 2 short infusions of 4 g each at an interval of 12 h. In four patients with normal renal function, serum half-life ranged from 0.8 to 1.4 h, serum levels during continuous infusion from 19 to 31 microgram/ml, and total clearances from 265 to 434 ml/min. In one patients, these values were 1.6 h, 70 microgram/ml and 131 ml/min respectively (small volume of distribution). The concentrations in the synovial fluid varied from 2 to 29 mcirogram/ml; they were generally lower than the serum levels, but clearly exceeded the minimum inhibitory concentrations for germs commonly present in purulent arthritis. In five patients, the synovial fluid became germ-free and the arthritis was clinically cured. In the case presenting with renal insufficiency, the serum half-life was 5.8 h. During continuous administration, a steady state was not attained; peak serum levels amo9nted to 75 microgram/ml and the total clearance to 61 ml/min. The cephacetrile concentrations in the synovial fluid were very high (26 and 67 microgram/ml). In this case, in which the renal insufficiency associated with mycosis fungoides was present before the treatment, renal function deteriorated futher during treatment while the arthritis improved.

Historia morbi atrocis--deux nouveaux cas de ruptures spontanées de l'oesophage (syndrome de Boerhaave) [Historia morbi atrocis--2 new cases of spontaneous rupture of the esophagus (Boerhaave syndrome)].]

We report the case of two patients hospitalized within a few weeks of each other and both presenting with spontaneous rupture of the esophagus whose evolution proved fatal. We take the opportunity of drawing attention to this rare and challenging disease, which is often diagnosed too late.

Dépistage du cancer du sein par l'examen physique: qui en bénéficie? [Physical examination in screening for breast cancer: who benefits?].

A survey was undertaken among a representative sample of the female population, aged 20 to 74, of the Canton of Vaud, Switzerland (total population 550,000) to assess the knowledge, attitudes and practices of women in respect to breast cancer and its prevention. The present study focuses on access by women to medical preventive measures (breast examination by physician and information on breast self-examination). The data are analyzed in relation to the individual risk factors affecting women, in particular age. While with age the risk of breast cancer grows in a linear fashion, the proportion of women having their breast examined by a physician declines. Women over 50 who had no children before the age of 30 constitute an especially high risk category, with the lowest access to information and prevention. This is explained in large part by the fact that they consult gynecologists less often. In this regard it should be noted that a visit to a gynecologist's office is associated much more often with breast examination than a visit to a family physician. It is important to take such findings into account in providing more appropriate and complete care for those groups. This involves sensitization of the physician and improved information for the women themselves.

"Iatrogenicity cascade": doing harm by treating harm?

An electronic survey on substance-induced epileptic crisis was conducted in order to investigate whether doctors, who recognise their own prescription errors, increase their therapeutic aggressiveness, resulting in a so-called "iatrogenicity cascade". Two pairs of clinical vignettes were constructed, in which a patient suffers from iatrogenic (original version) or non-iatrogenic (control version) epileptic crisis. Vignettes were randomised and sent to doctors at the University Hospital of Lausanne, Switzerland, at an interval of 3 weeks. The results of the present survey in the surveyed population of doctors suggest that inappropriate prescription does not increase therapeutic aggressiveness.