Ambulant Treatment Research Articles

Nasal continuous positive airway pressure (nCPAP) therapy in obstructive sleep breathing disorders

The therapeutic efficacy and the incidence of significant side effects of nasal continuous positive airway pressure (nCPAP) treatment was investigated in 1140 patients with sleep-related apnoea (1089 men, 51 women; mean age 53.2 +/- 9.2 [16-84] years). All had been treated for the condition with nCPAP at the Marburg University Medical Polyclinic between 1986 and 1992. The mean number of attacks of apnoea and/or hypopnoea per hour of sleep ("respiratory disturbance index", RDI) was 45.8 +/- 25.6 before treatment and 3.5 +/- 4.8 under nCPAP. 21.1% of patients had an apnoea index of no more than 10/h. 11.6% an RDI of no more than 15/h. The average airway pressure was 8.7 (3-18) cm H2O. The treatment was successful in 1023 patients and these decided to continue the treatment long-term. The RDI could not be lowered under 10/h in 63 patients, while 4 patients declined ambulant treatment despite the demonstrated efficacy of nCPAP. Three patients developed acute left ventricular failure in the initial phase of the treatment, while in another 16 patients long-persisting central hypoventilation was shown to occur. These data show that treatment with nCPAP can be employed for all degrees of severity of obstructive sleep apnoea. However, because of the potentially life-threatening side effects, the introduction of the treatment must be undertaken in the sleep laboratory under continuous monitoring.

Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial

Objective To evaluate the benefits of paramedic practitioners assessing and, when possible, treating older people in the community after minor injury or illness. Paramedic practitioners have been trained with extended...

Stroke Symptoms and the Decision to Call for an Ambulance: Turn on People’s Minds!

To the Editor: We read with great interest the article by Mosley et al1 on factors related to calling an ambulance for stroke patients. The authors reported that “stroke” was referred as the problem (unprompted) by ≈50% of callers, whereas fewer than half of the calls were made within 1 hour from symptom onset. We agree with the authors on the necessity of interventions to more strongly link stroke recognition to immediate action to increase the number of stroke patients …

Community MRSA

Additional to epidemic methicillin resistant Staphylococcus aureus (haMRSA) which had been disseminated in and between hospitals, MRSA emerged in the community independent upon the nosocomial setting (caMRSA). caMRSA possess the capacity to form Panton-Valentine-Leukocidin (PVL) as a special virulence factor. In general PVL-positive S. aureus isolates are associated with necrotizing skin and soft tissue infections as well as with necrotizing pneumonia. caMRSA are less "broad" resistant against different groups of antibiotics as haMRSA and require special attention when performing antimicrobial susceptibility testing. Prevention of further dissemination of caMRSA requires appropriate diagnosis, therapy and sanitation of the carrier state. Hygienic measures have not only to be taken in ambulant treatment but also in households of affected patients.

Robotic-assisted transhiatal esophagectomy

Despite its reduced aggressiveness and excellent results obtained in certain diseases, minimally invasive surgery did not manage to significantly lower the risks of esophageal resections. Further advances in technology led to the creation of robotic systems with their unique maneuverability of the instruments and exceptional view on the operative field, thus setting the prerequisites for performance in complex surgical procedures and offering new possibilities to a disease notorious for its dismal prognosis. The robotic-assisted transhiatal esophagectomy technique was used in a patient with squamous cell carcinoma of the lower esophagus that had high medical risk for surgical therapy. Esophageal resection and reconstruction were possible through a robotic-assisted minimally invasive transhiatal approach. There were no intraoperative incidents, blood loss was minimal, and lymph node dissection and removal was possible during the procedure. Early ambulation and conservative treatment of the mild complications that occurred offered a favorable postoperative outcome. The robotic-assisted transhiatal esophagectomy technique is feasible and safe. Complex procedures become less technically demanding with the help of the robotic system and, thus, the minimally invasive approach can be offered for the benefit of selected patients. Further studies are required to confirm these observations and to establish the role of this procedure in the future.

A comparison of pharmacologic therapy with/without timely coronary intervention vs. primary percutaneous intervention early after ST-elevation myocardial infarction: the WEST (Which Early ST-elevation myocardial infarction Therapy) study

Uncertainty exists as to which reperfusion strategy for ST-elevation myocardial infarction (MI) is optimal. We evaluated whether optimal pharmacologic therapy at the earliest point of care, emphasizing pre-hospital randomization and treatment was non-inferior to expeditious primary percutaneous coronary intervention (PCI). Which Early ST-elevation myocardial infarction Therapy (WEST) was a four-city Canadian, open-label, randomized, feasibility study of 304 STEMI patients (> 4 mm ST-elevation/deviation) within 6 h of symptom onset, emphasizing pre-hospital ambulance treatment and participation of community and tertiary care centres. All received aspirin, subcutaneous enoxaparin (1 mg/kg), and were randomized to one of three groups: (A) tenecteplase (TNK) and usual care, (B) TNK and mandatory invasive study < or = 24 h, including rescue PCI for reperfusion failure, and (C) primary PCI with 300 mg loading dose of clopidogrel. Time from symptom onset to treatment was rapid (to TNK for A = 113 and B = 130 min and for PCI in C = 176 min). The primary outcome, a composite of 30-day death, re-infarction, refractory ischaemia, congestive heart failure, cardiogenic shock, and major ventricular arrhythmia, was 25% (Group A), 24% (Group B), and 23% (Group C), respectively. However, there was a higher frequency of the combination of death and recurrent MI in Group A vs. Group C (13.0 vs. 4.0%, respectively, P-logrank = 0.021), yet no difference between Group B (6.7%, P-logrank = 0.378) and C. These data suggest that a contemporary pharmacologic regimen rapidly delivered, coupled with a strategy of regimented rescue and routine coronary intervention within 24 h of initial treatment, may not be different from timely expert PCI.

Drug Users' Participation in Addiction Care: Different Groups Do Different Things

This study allocated 201 (nearly) daily users of heroin and/or crack into four groups, depending on their addiction care participation. Earlier studies have compared treatment groups and nontreatment groups. In this study the treatment group is divided into three categories: (1) drug users in contact with only treatment agencies—i.e., methadone maintenance, clinical and ambulant drug treatment; (2) drugs users in contact with only care agencies—i.e., day and night shelters and drug consumption rooms, which have no explicit aims to change patterns of drug use; and (3) drug users in contact with both treatment and care agencies. This allocation intro three different groups fits the notion of harm reduction, one of the policy aims in the Netherlands. The fourth group consists of drug users in contact with neither treatment nor care agencies. The results show that it is useful to distinguish these four categories, instead of two. The four groups are different from each other with respect to some of their characteristics (e.g. debt situation, prostitution. homelessness) and their drug use (e.g. drug use in public, use of crack, and use of other drugs). A much clearer distinction can be made between the “care” group and the “treatment and care” group. Treatment and care agencies can thus better match their services to their clients or patients.

The ambulant treatment of spinal tuberculosis.

The ambulant treatment of spinal tuberculosis.

Stationäres Interventionskonzept auf Basis der Dialektisch-Behavioralen Therapie zur Behandlung akuter Krisen bei Borderline-Patienten

Whereas the Dialectical-Behavioral Therapy (DBT) by Marsha Linehan for chronic suicidal female patients with borderline personality disorder has also been successfully implemented for in-patient treatment, the management of recurrent crisis has continued to be a significant challenge especially for hospitals taking part in the mandatory health coverage. Therefore, we have established an acute, short-term crisis treatment concept for both genders on a locked unit which takes the different circumstances of acute crisis into account. It ought to be used under the conditions of acute psychiatry and at the same time meet psychotherapeutic demands of borderline treatment. The treatment basis is DBT. The treatment focus is to improve stress-tolerance, especially by skills-training, regarding the individual situation and problems at time of admittance. The in-patient treatment should not take more than three weeks. The short-time aim is a fast reintegration in ambulant treatment or motivation for a specific therapy as DBT, middle- and long-time aims are the improvement of the ability to cope with crises and to demand less in-patient care.

Barriers to accessing ambulance services in rural Victoria for acute asthma: Patients’ and medical professionals’ perspectives

To study the attitudes and perceptions of rural asthma patients and medical health professionals towards accessing ambulance services for acute asthma. Health professional and patient based focus groups, audit of ambulance patient care records and self administered survey. Asthma patients and medical professionals from rural south-western Victoria. The audit of patient care records included 69 asthma case records, and identified short response times (mean, 7 min; SD, 5 min), and documented patient improvement in clinical status in response to ambulance treatment. The focus group analysis identified patient perceptions which act as barriers to accessing ambulance services in acute asthma. These included the perception of response time delays, '000' call centre delays and misunderstanding of the role of paramedics, and when it is appropriate to call an ambulance for acute asthma. These perceptions were expressed by both patients and medical professionals, and both groups had poor knowledge of how and when to access ambulance services for acute asthma. The misperceptions expressed are of particular concern in a rural population where distance can cause prolonged response times to treatment, and patients who are acutely ill need to contact emergency services promptly and appropriately to improve patient health outcomes.

Involuntary hospitalisations in accordance with guardianship law during eight years tripled

REQUEST: In 1992 the guardianship law came into force. A study about involuntary hospitalisations in accordance with guardianship law between 1992 and 2000 in a small social-psychiatrically well supplied region of Southern Lower Saxony should be made. This study about hospitalisation and guardianship proceedings was made in the district courts of jurisdiction in the catchment area at the regional and the university hospital in Göttingen, including diagnosis, reason of hospitalisation and personal characteristics of patients. During study period a new guardianship law came into force, involuntary hospitalisations have doubled. Diagnostic and personal characteristics are described. A comparison: Hospitalisation in accordance with Mental Health law are more numerous and doubled during the last twelve years. Despite improved ambulant and in-hospital treatment involuntary hospitalisations considerably increased. Possible reasons are discussed: Better perception of necessity of in-hospital treatment, shorter but long-term unsuccessful in-hospital treatment, temptation because of the wording of the law sounds liberal, social demand of harder sanctions for unnormal behaviour. Psychiatrists, social workers and judges obviously support this social concurring behaviour or they are unable to prevent it.

The Cologne internet-manual of pain therapy--33 months online, experiences and evaluation

The improvement of ambulant treatment for patients with chronic headache or cancer pain. Distribution of accepted guidelines and standards by means of the internet in order to make this knowledge known among general practitioners and to give patients better access to this information. We have built an internet manual about the treatment of chronic headache and cancer pain. About 9100 readers accessed the manual during a period of 33 months. The manual has been completely downloaded 279 times. Physicians and patients very often used search engines to access the manual in their search for information about headache. The terms "migraine" and "tension type headache" were looked up the most. It is worthwhile editing medical information for use on the internet and thus making it available to the public.

Ambulant rehabilitation of patients with gastrointestinal and metabolic diseases

For the following reasons it has, despite plausible different opinions, seldom been possible realize ambulant rehabilitation offers:For historical reasons gut rehabilitation centers lie outside of conurbations. A model of gastrointestinal-oncologic rehabilitation supports developing an entirely new concept for ambulant treatments, instead of merely copying the presently in-patient rehabilitation therapy. In the exemplary thoughts of the GRVS, which were already presented five years ago, quantitative factors have not been taken into consideration satisfactorily. Considering this the following three diagnosis groups become relevant - diabetes m. - obesity - gastrointestinal cancer. The needed ambulant rehabilitation concepts are to be connected to the long-term ambulant treatment, available close to the patient's home city.

Integrated rehabilitation of patients with hand injuries--a model of cooperation between acute and rehabilitation clinics

Close cooperation between acute and rehabilitation clinics are an exception even today. Although operative reconstruction may have been successful, hand injuries will have poor functional results if rehabilitation is insufficient. With the establishment of multi-disciplinary intensive rehabilitation of patients with complex hand injuries under inpatient conditions, a close cooperation of the Clinic of Plastic and Hand Surgery, Klinikum Wuppertal, and the Orthopaedic Clinic, Rhein-Sieg-Klinik Nümbrecht, was created. A good functional outcome of the injured hands with a low percentage of remaining invalidity and an early return to work of the affected patients are the dominant aims of this rehabilitation model. When the initial and reconstructive treatment is finished in the Clinic of Plastic and Hand Surgery, inpatient rehabilitation by an experienced rehabilitation team starts immediately. Clinical control of all patients with complex hand injuries is performed in a weekly consultation hour by the hand surgeons and the rehabilitation team. Weekly reports guarantee close and timely documentation of the clinical course. After the end of inpatient rehabilitation, patients return to work, take part in vocational rehabilitation or, if necessary, continue with ambulant treatment organized and controlled by the acute clinic.

The fibrin-stabilizing factor as a topical means for leg ulcer healing: Biochemical and experimental properties and clinical results

The topical application of factor XIII (Fibrogammin HS) is a new concept in the treatment of ulcerative leg disease. In addition to the mode of application, the utilization of a fibrin-stabilizing effect in ulcer treatment is a completely different strategy, since many other medications used for local wound treatment contain a fibrinolytic component. Of the 29 inpatients treated topically during the last 3 years, 17, 12 female and 5 male averaging 60.8 ± 13.6 years, suffered ulcerative leg disease due to a postthrombotic syndrome. The average period since first clinical manifestation of venous ulcer was 3.5 ± 2.1 years. Thirteen patients (76.4%) with chronic ulceration showed such a distinct improvement of topical site after an average period of 3.02 ± 1.05 weeks with topically applied factor XIII (Fibrogammin HS) combined with compression bandaging that they were discharged for further ambulant treatment. Apart from a wound surface reduction and a clinical improvement of granulation, we observed a marked reduction of bleeding and secretion tendency within the ulcus area, especially in patients with severe venous insufficiency. Our hypothesis was that high doses of topically applied factor XIII could improve barrier function of endothelial cells in the wound area. For experimental investigation, porcine aortic endothelial cells were cultured on filter membranes to confluent monolayers. To monitor the barrier function, permeability of the monolayer was continuously measured as flux of trypan blue-labeled albumin. Confluent endothelial monolayers exposed to factor XIII (Fibrogammin HS) showed a significant (n=8, p < 0.05) reduction of albumin flux compared with controls. After induction of hyperpermeability in endothelial monolayers by incubation with potassium cyanide (KCN) and 2-deoxyglucose (2-DG), we found a significant increase (up to 250%) in albumin flux compared with controls (n=8, p < 0.05). This hyperpermeability was significantly reduced to 50% (n=8, p < 0.05) in monolayers that had been preincubated with Fibrogammin HS. We conclude that F XIII reduces permeability of endothelial monolayers. This effect is due to the stabilization of the endothelial barrier function and likely caused by cross-linking of suitable substrates from endothelial cell membrane or extracellular matrix. Because of our good clinical results in improvement of granulation and reduction of secretion during topical treatment of venous ulcer and the demonstrable effect on endothelial permeability, F XIII may play an important role in wound healing of chronic ulcerative leg disease.

CPT-11. The European experience.

CPT-11 is a derivative of camptothecin, which has a broad spectrum of antitumor activity, both in vitro and in vivo. Like camptothecin, CPT-11 is a selective inhibitor of the DNA enzyme topoisomerase I. Phase I trials were conducted in Europe with the aim of determining the recommended CPT-11 dose and schedule for evaluation in phase II trials. The phase I trials assessed the toxicity of CPT-11 in 235 patients and tested three different administration schedules. CPT-11 was administered as a single infusion once every three weeks, as a weekly infusion for three weeks out of every four, and as a daily infusion for three consecutive days every three weeks. The maximum tolerated dose (MTD) was 115 mg/m2 in the daily schedule and 145 mg/m2 in the weekly schedule. When the drug was administered once every three weeks, diarrhea became the dose-limiting toxicity at doses above 350 mg/m2. This schedule allowed the highest dose intensity to be obtained, was the best tolerated, and allowed ambulant treatment. Finally, using this schedule, a combination of CPT-11 with high doses of loperamide allowed the dose of CPT-11 to be increased to 750 mg/m2. An ongoing phase I trial is investigating the combination of CPT-11 and 5-fluorouracil (5-FU) in various solid tumors. Although the MTD has not yet been reached, preliminary results have not demonstrated any pharmacokinetic interaction between the two drugs, contrary to the findings of a previous Japanese study. Based on the results of the three phase I trials, CPT-11 administered at a dose of 350 mg/m2 as an intravenous infusion over 30 minutes once every three weeks has been recommended for assessment in phase II trials. The phase II trials started in Europe at the beginning of 1992. To date, CPT-11 has showed remarkable efficacy in colorectal cancer, even in patients resistant to 5-FU. Interesting results have also been obtained in pancreatic, cervical and lung cancer. Future trials will make it possible to assess whether there is a place for CPT-11 in combination with other cytotoxic agents or radiotherapy.

Liability immunity as a legal defense for recent emergency medical services system litigation.

Although many emergency medical services (EMS) providers are concerned about liability litigation, no comprehensive, national studies of EMS appelate cases have been published. Information about these cases and the use of liability immunity (sovereign immunity, emergency medical care immunity, or Good Samaritan immunity) as a defense could be used for EMS risk management and better patient care. To review recent EMS system civil litigation cases to determine their common characteristics and the number that used liability immunity as a legal defense. An observational study of the WESTLAW computerized database of legal cases from all state and federal appellate courts. All legal cases that named a member of the EMS system as a defendant, involved either a patient-care incident or ambulance collision, and received an appellate court opinion from 1987 through 1992, were studied. Eighty-six cases were identified and analyzed. Most cases (85%) were related to a patient-care incident, and 71% of the cases involved a death or significant physical injury. More than 49% of the patient cases alleged inadequate assessment or treatment, and 27% alleged delay in ambulance arrival or no ambulance arrival. There were 11 cases (15%) that alleged no transport of the patient to the hospital. Liability immunity was used as a defense in 53% of the cases. The appellate courts ruled in favor of 68% of the defendants that did not use an immunity defense and in favor of 72% of those that did use liability immunity. There have been a large number of recent appellate cases involving EMS systems. The common characteristics of many of these cases demonstrate the need for providing rapid ambulance arrival, proper assessment and treatment, and rapid patient transportation to a hospital. Although liability immunity was used as a legal defense by most EMS system defendants, the appellate court outcome was similar regardless of its use.

The Tower of Babel or uniform reporting of cardiac arrests?

ABSTRACTObjectives: To assess the uniformity of reporting and data collection for cardiac arrests in Australia.Methods: Twenty seven Australian teaching hospitals were surveyed. They were asked whether they used specific CPR/arrest forms and their content.Results:: The survey showed only 12 of 27 hospitals had specific forms recording cardiac arrests. Nine of 27 captured 25% or more of essential data as defined by the “Utstein” conferences. A CPR/arrest form is presented which is based on a form that has been successfully used by major hospitals for over four years and incorporates the major Utstein data required for meaningful review and research.Conclusion: Uniformity of data collection on CPR/cardiac arrest has been agreed to internationally. In order to assess, compare and improve our results in Australia, such a format is needed A suggested data collection form is presented. At present the information chain from the time of a collapse to a cardiac arrest, through bystander CPR, general practitioner treatment, ambulance treatment, in hospital management and outcome is not usually, let alone uniformally, recorded. This is a vital step in order to improve patient care and effectively allocate resources.

Elderly patients with hip fractures: improved outcome with the use of care maps with high-quality medical and nursing protocols.

In a prospective cohort study, 51 patients were treated with standard nursing and medical treatment after sustaining a hip fracture. A second group of 55 patients was treated with high-quality medical and nursing protocols outlined on our care map. The patient groups showed no significant differences preoperatively in terms of the important variables of age, mental status, marital status, accommodation, ambulation, fracture type or fracture treatment. Postoperatively the patients were followed for a 6-month outcome. The outcome of return to their place of accommodation and their previous level of function was considered grade 1. In grade 2, the patients lost one level of function or one level of accommodation. In grade 3 they lost one level of accommodation and one level of function. In grade 4 they were dead. Overall we were able to show that the patients in the study group had a statistically significantly better outcome (p = 0.036). In addition, they had significantly fewer postoperative complications (p = 0.01) and a significantly greater number of the patients returned home within 14 days of their admission. We feel that the medical and nursing protocols outlined are generally applicable and could significantly improve the outcome overall for elderly patients with fractured hips.

Ambulante rückenmarksnahe Morphinanalgesie über einen transkutan ausgeleiteten Spinalkatheter

This report deals with a patient suffering from recurring rectum carcinoma infiltrating the lumbosacral plexus who received ambulant treatment with spinal opiate supply by a pump device, using a transcutaneous spinal catheter over a period of 12 weeks. The catheter turned out to be simple to implant. During the whole period no malfunctions occurred. This form of spinal analgesic treatment allowed the patient a relatively pain-free life outside the hospital.