An objective evaluation of the clinical potential of low molecular weight heparins in the prevention of thromboembolism.
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Biomedical subjects
Publications and source records attributed to S Haas.
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The various types of meniscal lesion including longitudinal, horizontal and transverse tears, bucket handle tears (displaced or non-displaced) as well as tears of the meniscus base can be visualized in differing sonographic views. Our results on 39 patients, whom we sonographed and then controlled operatively, show that the different meniscal lesions are not reliably differentiated by ultrasound. Depending on the view chosen, similar sonographic displays result for all of the lesions under discussion. Only a smooth reflecting plane in the otherwise homogeneous structure of the meniscus is proof of the existence of a meniscal lesion.
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Population-based analysis of cesarean section rates within 172 geographic areas in the Commonwealth of Massachusetts during fiscal year 1985 revealed a nearly normal distribution of observed-to-expected rates, implying that the forces that compel obstetricians to perform this surgical procedure are pervasive. However, a small number of areas were identified in which the number of procedures performed was significantly different from the state mean. During fiscal years 1982 to 1985, certain geographic subgroups consistently demonstrated incidence rates significantly greater than the state mean. Although variation (either overutilization or underutilization) from the state rate is not synonymous with inappropriate care, those physicians within the identified geographic areas must take responsibility for ascertaining the explanation for the variance.
The so-called heparin level in the plasma of patients or healthy volunteers should be determined using only those methods which correspond to the test standard used by the producer of the heparin applied or which approach the corresponding test principle. The correlation of the ex vivo findings gained through biochemical and functional methods to the physiological effect is, as far as possible, only then guaranteed when methodical influences can be excluded. The data obtained through these test series do not, however, allow a transference to the physiological effect of the corresponding heparin preparations regarding anticoagulant as well as antithrombotic efficacy.
In numerous clinical studies, the antithrombotic effect and tolerance of low-molecular-weight heparins (LMWHs) were compared to those of unfractionated heparin (UFH). Based on our own experience and on a review of the literature the following conclusions can be drawn. In the field of prophylaxis of thromboembolism, including high-risk patients with major bone surgery, the antithrombotic efficacy of a single daily dose of LMWH is at least equivalent to two or three injections of UFH per day. It should, however, be noted that the margin between thromboembolic and bleeding complications has not become bigger, although this had been derived from experimental results. In order to avoid bleeding complications, it is absolutely necessary to take note of the manufacturers' recommendations. This is particularly important when a change of various preparations is considered, because the standardization of LMWH preparations is different and the units are not comparable. The main advantage of LMWH results from an improved practicability. The single daily dose leads to an improved compliance of patients and the nursing staff is spared a great deal of work.
Seventeen healthy postmenopausal women who had subjectively noted eight or more hot flashes per day and who objectively demonstrated four or more vasomotor flushes of 1.0C or more during eight hours of continuous thermography were studied. They were randomly allocated in a double-blind fashion to either 50 micrograms/day of transdermal estradiol (E2) patch or placebo. Application of the first patch was followed immediately by repeat eight-hour thermography, with hourly measurements of E2 and luteinizing hormone (LH). In the transdermal E2 group only, significant elevations of E2 (mean 91 pg/mL) were noted at two hours, and LH was suppressed after eight hours (P less than .05). There was no immediate effect on vasomotor flushes. Treatment was continued for six weeks, with daily subjective recording of hot flash frequency. Patients on transdermal E2 reported a significant (P less than .001) fall in hot flashes over four weeks, after which the rate stabilized. An initial decline in the placebo group was not statistically different from baseline. Eight-hour thermography was repeated after six weeks of treatment. Patients on transdermal E2 demonstrated an 85% decrease from baseline in vasomotor flushes (P less than .01). No effect on total cholesterol or its subfractions, renin substrate, or aldosterone was found. Serum E2 levels fell by 50% in 24 hours after patch removal. Endometrial histology and vaginal cytology showed an estrogen effect.
By means of a catamnestic study diagnostic evidence, number of complications and examination-conditioned stress of the patient caused by needle biopsy of the synovial membrane were tested. 4-11 years after a blind biopsy of the synovial membrane carried out on account of rheumatological indication 80 patients (48 males, 32 females) were examined and the results of the preliminary examination and the secondary examination were compared with the findings of the needle biopsy of the synovial membrane. While the needle biopsy of the synovial membrane in rheumatoid arthritis has a high diagnostic value in comparison to clinical and paraclinical findings, in the histomorphological ascertainment of the uric arthritis the catamnestic study shows the limits of the method due to place-depending differences of the findings of the crystalline deposit in the synovial membrane. The number of complications of the investigation technique was insignificant and had no influence on the duration of the inability to work. As a highly specialised diagnostic method the blind biopsy of the synovial membrane may contribute to the clarification of problem cases in institutions with rheumatological profile without possibility of arthroscopy.
The unusual finding of an abnormal seasonal distribution of schizophrenic births, showing an excess of 10% in the winter or spring months and an equal deficit in the summer or autumn months, cannot be explained by artefacts. It has not yet been established whether the finding is specific to schizophrenia. We observed an excess of schizophrenic births of some 10% in March to May, significant at the 5% level, and a deficit of approximately the same size in June to August on the birth data of first-admission patients with the clinical diagnosis of schizophrenia. The data, obtained from the Mannheim Psychiatric Case Register, were compared with those of the Mannheim population and a control group matched by birth year and sex. The total population of mentally retarded children aged 7 to 16 years from the Mannheim population showed an excess of some 20% in April to June and an equal deficit in the last two quarters of the year, compared with the Mannheim population of the same birth years. The finding was not significant, but allowance must be made for the low case number of 415. We also compared 3409 first-admission patients with depressive syndromes (ICD 296 and 300.4) and 5615 first-admission patients with the diagnosis of "neurosis and personality disorders" (ICD 300-302, except 300.4, and 305-309) from the Mannheim Case Register with a control population and a parallel control group. Depressed males showed an excess of births in March to May, which was significant at the 1% level; the birth peak for females was smaller and not significant. The same findings were obtained for the category of neurosis and personality disorders, i.e. an excess of about 10% in March to May for males, significant at the 1% level, and a non-significant excess for females. Our findings are awaiting replication. Causal explanations will be discussed with great reservation. The procreational hypothesis, assuming those factors that lead to an equidirectional seasonal pattern of births with a slight deviation from the average of a year in the general population, to be reinforced in the disease categories mentioned, is regarded as the most simple and plausible explanation. It is based on the assumption that some of the parents of individuals suffering from schizophrenia, mental retardation or probably also some other mental disorders running from generation to generation, have a higher threshold in partner-seeking behaviour, which is overcome more easily in the summer months with the consequence of increased pregnancies.
In 160 high risk patients with total hip replacement the antithrombotic efficacy and tolerance of a single daily injection of 1500 aPTT-U (aPTT = activated partial thromboplastin time) low molecular weight heparin plus 0.5 mg dihydroergotamine (HNMD; Embolex NM) was compared with a twice daily application of 5000 IU of the heparin-dihydroergotamine combination Heparin-Dihydergot in a double-blind study. Deep vein thrombosis measured by means of the radiofibrinogen uptake test occurred in 20.5% of patients in both groups. In addition, intra- and postoperative blood loss and the development of hematoma were similar in both groups. Thus, on account of the "once-daily" application HNMD offers some substantial advantages: The stress of the patient in the postoperative convalescence phase can be appreciably lowered and thereby the nursing staff are spared a great deal of work.
Physical methods of prophylaxis against deep vein thrombosis aim to counteract the stasis of venous blood flow that occurs during immobilisation. Prospective randomized studies have documented that perioperative electrical calf stimulation, intermittent pneumatic compression, and graduated compression stockings effectively reduce the frequency of post-operative deep-vein thromboses. However, up to date it has not been proved that they also reduce the incidence of fatal pulmonary embolism, and so these physical methods represent no valid alternative to the pharmacological methods of prophylaxis against thromboembolic events. Their use is justified, however, when the pharmacological agents are contraindicated, and as an adjunct to the pharmacological methods.
Psychiatric emergencies and life crises are located at opposite ends of a broad scale of stages requiring acute help: Emergency cases need immediate medical care in order to prevent danger to life. For the same reason, immediate hospital admission and additional treatment of risks of internal medicine have to be provided, if necessary. Crises often have not only mental but also social aspects. The immediate urgency of treatment is determined by the psychiatric (suicidal) or the physical risk. Emergency cases and severe crises require a 24-hour medical service. Social aspects cannot be settled in the night-time, even if they are urgent. Emergency and crisis intervention services with a multidisciplinary staff therefore ascribe different roles to physicians, nurses and social workers. Since 1976, the Central Institute of Mental Health provides a 24-hour crisis intervention and emergency service both at the Institute and at the emergency ward of the Mannheim University General Hospital. Within few years, the number of treated episodes has increased to 1,800-1,900 per year. The distance between the place of work or residence is a decisive factor of service utilization. Over 50% of the users of the emergency and crisis intervention service are mentally ill. Only a small part are contacts for crises without psychiatric disorder. Suicidal attempts or intentions account for about 30% of the service users, marriage crises for about 25% and alcohol problems also for about 25%. The development of complementary care in Mannheim has led to a parallel increase in the proportion of chronically mentally ill living in complementary facilities. This clearly indicates that a 24-hour emergency and crisis intervention service is a compulsory prerequisite for the implementation of an efficient system of complementary care for the mentally ill.
Previous studies have suggested that dopamine is the major catecholamine in the amniotic fluid; however, there are few data available concerning the metabolism of this hormone in the amniotic fluid compartment. With the use of acute 3H-dopamine injection studies into the amniotic sac of pregnant rhesus monkeys, the dopamine half-life was observed to be 29 minutes, the amniotic fluid volume was 113 ml, the metabolic clearance rate was 164 ml/hr, and the calculated production rate was 436 ng/hr. The biphasic pattern of dopamine clearance from this compartment suggests that it is cleared from the amniotic sac by mechanisms similar to those used in the intravascular compartment.
Auditory cortical evoked potentials of 20 schizophrenic patients with an acute exacerbation of the illness were investigated before neuroleptic medication and after remission of the acute symptoms, and compared with healthy controls matched for sex and age. Additionally, tests were conducted in 40 healthy volunteers to ascertain whether psychoticism or other personality factors were correlated with evoked potentials. The aim of the study was to test the overarousal hypothesis of schizophrenia and to control the effects of clinical state, neuroleptic medication and personality factors. Acutely ill schizophrenic patients had a shorter evoked potential N1 latency (Table 1). After remission of the symptoms under haloperidol N1 latency of the patients was no longer different from that of the controls. Patients after remission and on medication, however, had longer P2 and N2 latencies and a greater P2-N2 amplitude (Table 2). Psychoticism and extraversion were correlated negatively with amplitude data of components N1 and P2 in healthy volunteers. The results favor the overarousal hypothesis of schizophrenia. Haloperidol normalizes N1 latency in acutely ill patients. It's effect on later components of the evoked potentials seems comparable to a reduction in vigilance. Auditory evoked potentials might allow to follow up the effect of neuroleptics in acute schizophrenia. It seems necessary to consider personality factors when comparing patients with healthy controls in evoked potential studies.
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In 14 schizophrenic patients, treated with neuroleptic drugs, and in 7 patients, treated with high-dosage diazepam, beta-endorphin-like immunoreactivity in plasma has been measured by use of a highly sensitive and relatively specific radioimmunoassay. Neuroleptic treatment induced a significant increase of beta-endorphin-like immunoreactivity (beta-ELI). The pharmacological and clinical implications of this finding are discussed. High-dosage diazepam treatment induces a slight reduction of plasma beta-ELI, a finding which is attributed to antistress effect of diazepam.
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