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Br J Sports Med 2004;38:55-59. doi: 10.1136/bjsm.2002.003707 Objectives: To analyse the heart rate (HR) response and estimate the ultraendurance threshold--the optimum maintainable exercise intensity of ultraendurance cycling--in ultraendurance elite cyclists [...]

Dank moderner Therapien sinkt die Mortalität vieler Krebserkrankungen kontinuierlich. Neben den bekannten weisen auch viele der neuen Therapeutika potenziell kardiovaskuläre Nebenwirkungen auf. Diese können akut während der Behandlung klinisch bedeutsam sein und im schlimmsten Fall einen Abbruch der onkologischen Therapie erfordern. Darüber hinaus werden aber auch chronische Nebenwirkungen wie Herzinsuffizienz, Klappenerkrankungen und koronare Herzerkrankung bei steigender Lebenserwartung der Betroffenen relevant und stellen bereits jetzt die häufigste nichttumorbedingte Todesursache dar. Für viele der kardiovaskulären Erkrankungen existieren effektive, präventive und prognoseverbessernde Behandlungsmöglichkeiten. Die Kenntnis spezifischer kardiovaskulärer Nebenwirkungen onkologischer Therapien und Diagnosemöglichkeiten ist deshalb essenziell, um Menschen mit Stellung der Krebsdiagnose und Planung der onkologischen Therapie auch strukturiert kardioonkologisch zu betreuen und so die Morbidität und Mortalität weiter zu verbessern.

Aufgrund eines akuten Koronarsyndroms erlitt ein 52-jähriger Patient ein therapierefraktäres Kammerflimmern. Es wurde unmittelbar mit einer Laienreanimation begonnen. Unter Fortführung der kardiopulmonalen Reanimationsmaßnahmen sowie nach repetitiven Defibrillationen und intravenöser Gabe von Amiodaron konnte temporär eine Wiederherstellung der Kreislaufverhältnisse etabliert werden. Bei persistierendem Kammerflimmern wurde die Indikation zur mechanischen Reanimation mittels LUCAS®-Device gestellt und der Patient nach insgesamt 90-minütiger Reanimationsdauer zur Notfallkoronarangiographie vorgestellt. Es zeigte sich eine ausgeprägte Laktatacidose mit einem pH-Wert von 6,7 in der initialen Blutgasanalyse (BGA), weshalb im multiprofessionellen Team die Entscheidung gegen eine extrakorporale Membranoxygenierung getroffen wurde. Nach Mehrfachstenting der rechten Koronararterie (RCA) und der linksseitigen Koronararterie (LAD) unter fortlaufender mechanischer Reanimation sowie anschließender therapeutischer Hypothermie konnte der Patient rasch extubiert werden. Der Patient wies im Verlauf keinerlei neurologische Defizite auf. A 52-year-old man suffered an out-of-hospital cardiac arrest (OHCA) and bystander reanimation was immediately started. The initial electrocardiogram indicated ventricular fibrillation. After repetitive defibrillations as well as intravenous administration of amiodarone, a temporary return of spontaneous circulation (ROSC) could be established. Due to unstable cardiovascular conditions with recurrence of ventricular fibrillation, mechanical resuscitation with the help of the LUCAS™ device was initiated, and the patient was admitted to our hospital for emergency coronary angiography after a cumulative period of approximately 90 min. The initial blood gas analysis displayed a significant lactate acidosis with a pH value of 6.7. Therefore, in a multidisciplinary team, the decision was made against an extracorporeal membrane oxygenation and for a coronary angiography under continuation of mechanical resuscitation. After multiple stenting of the right coronary artery and left anterior descending coronary artery, permanent ROSC could be established. The patient was admitted to our intensive care unit, where he was further treated according to the S3-guideline for infarct-related cardiogenic shock. In the course of time, the patient was quickly extubated without any neurological deficits.

Ultraschall ist ein wichtiges diagnostisches Mittel in der Notfall- und Intensivmedizin. Jederzeit am Patientenbett verfügbar verkürzt Ultraschall die Zeit bis zur Stellung der richtigen Diagnose. Daher ist Ultraschall in vielen Fachbereichen im Sinne einer erweiterten körperlichen Untersuchung in die diagnostischen Algorithmen eingebettet. Viele Differenzialdiagnosen lassen sich mittels einer fokussierten Sonographie schnell ausschließen und erlauben somit eine schnellere Einleitung einer zielgerichteten Therapie. Daher ist die fokussierte Sonographie von größter Bedeutung für den Notfall- und Intensivmediziner. Die Integration der Ausbildung in das Studium wird zunehmend häufiger, es existieren jedoch keine einheitlichen strukturierten oder universitätsübergreifenden Standards. Ultrasound is an important diagnostic tool especially in emergency and intensive care medicine. It is always available at the bedside and shortens time to diagnosis. Many specialties have integrated ultrasound into diagnostic algorithms as part of the extended physical exam. Numerous differential diagnoses can be easily excluded using point-of-care ultrasound and therefore adequate treatment is initiated faster. Emergency or focused ultrasound is therefore of outstanding relevance to any emergency or critical care physician. Integration into medical school curricula is becoming more common tough no nationwide standards are in place yet.

Current international and national guidelines promote the use of emergency echocardiography in patients with cardiogenic shock. We assessed whether these recommendations are followed in clinical practice of infarct-related cardiogenic shock patients. For this purpose we conducted a web-based survey among all members of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN); 40% of the DGIIN members completed the survey. Participants reported that in their department emergency echocardiography/ultrasound is performed on most patients in infarct-related cardiogenic shock presenting to the emergency department/chest pain unit or intensive care unit (58.6% versus 81.4%). Only 33% stated that on patients admitted directly to the catheterization laboratory emergency ultrasound/echocardiography is applied in their institution. Local availability of a standardized algorithm was lacking in the majority of departments (77.2%). A great proportion (38.3%) of participants stated that they personally had no formal training in emergency ultrasound. In order to meet the demands of the current guidelines, in addition to integration of ultrasound examinations into diagnostic algorithms, a structured training of all emergency and intensive care physicians is necessary. Aktuelle nationale und internationale Leitlinien empfehlen den Einsatz der Notfallechokardiographie bei Patienten mit kardiogenem Schock. Ob diese Empfehlungen in der täglichen Praxis bei Patienten mit infarktbedingtem kardiogenem Schock (ikS) umgesetzt werden, ist unklar. Dies wurde in einer webbasierten Umfrage unter allen Mitgliedern der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN) überprüft. Insgesamt nahmen 40 % der Mitglieder an der Umfrage teil. Die Mehrzahl der Befragten gab an, dass in ihrer Abteilung eine Notfallsono‑/Echokardiographie bei Patienten im ikS durchgeführt wird, sobald diese in der Notaufnahme bzw. Chest Pain Unit oder auf der Intensivstation aufgenommen werden (58,6 % versus 81,4 %). Wird ein Patient direkt über das Herzkatheterlabor aufgenommen, berichteten nur 33 % der Befragten, dass in ihrer Abteilung eine Notfallsono‑/Echokardiographie vor der Intervention durchgeführt wird. Ein standardisierter Algorithmus zur Integration des Ultraschalls fehlt in den meisten Abteilungen (77,2 %). Eine große Anzahl an Teilnehmern berichtet, dass sie persönlich keine Ausbildung im Bereich der Sonographie genossen haben. Um den Forderungen der aktuellen Leitlinien gerecht zu werden, ist neben der Integration von Ultraschalluntersuchungen in die diagnostischen Algorithmen eine strukturierte Ausbildung aller Notfall- und Intensivmediziner notwendig.

Ein 47-jähriger Patient stellte sich mit pektanginösen Beschwerden in der Chest Pain Unit vor. Aufgrund einer Psoriasis und Psoriasisarthritis erhielt er seit 4 Jahren eine systemische Therapie. Bei erhöhtem kardiovaskulärem Risikoprofil und Verdacht auf eine koronare Herzerkrankung (KHK) erfolgte eine invasive Koronardiagnostik. In der Herzkatheteruntersuchung konnte eine KHK nachgewiesen und in der gleichen Sitzung behandelt werden. Bedingt durch die erhöhte Inzidenz von kardiovaskulären Risikofaktoren und durch die Grunderkrankung selbst besitzen Patienten mit Psoriasis ein erhöhtes Risiko für das Auftreten einer KHK. Patienten mit Psoriasis sollten daher regelmäßig kardiovaskuläre Screeninguntersuchungen erhalten. A 47-year-old man presented with angina pectoris complaints in the chest pain unit. Due to psoriasis and psoriatic arthritis he had been systemically treated for 4 years. Because of an increased cardiovascular risk profile, coronary heart disease (CHD) was suspected and an invasive coronary diagnosis was performed. In the cardiac catheterization, CHD could be detected and treated in the same session. The risk of CHD in patients with psoriasis is increased due to a higher incidence of risk factors but also the disease itself. Patients with psoriasis should regularly undergo cardiovascular risk screening.

Die Etablierung der primären Koronarangioplastie in der Breitenversorgung von Infarktpatienten, zunehmend komplexere, auch nichtkoronare Katheterinterventionen an schwer kranken Patienten sowie demographisch getrieben steigende Herzkatheteruntersuchungszahlen an älteren und morbiden Patienten führen dazu, dass Intensivmediziner sowohl bei der Primärversorgung kritisch kranker Patienten als auch bei Komplikationen im Herzkatheterlabor zunehmend hinzugezogen werden müssen. Im Rahmen des Komplikations- bzw. Risikomanagements sollten daher alle Herzkatheterlabore eine Checkliste zusammen mit dem zuständigen Notfallteam entwickeln. Ein teamorientiertes interdisziplinäres Management durch Standardisierung von Notfallszenarien bleibt trotz jeglichen Fortschritts weiterhin der Schlüssel zum Erfolg. The establishment of primary percutaneous interventions for the treatment of myocardial infarction, increasingly complex coronary and noncoronary interventions in severely ill patients, and the increasing rise in the number of catheter examinations in elderly and morbid patients due to demographics frequently necessitates involvement of intensive care physicians for primary care of unstable patients and management of complications within the cath lab. In the context of complication and risk management, therefore, all cardiac catheter labs should develop a checklist in collaboration with the respective emergency/intensive care team. Team-oriented interdisciplinary management through standardization of emergency scenarios remains the key to success, despite all progress.

Die fokussierte Echokardiographie besitzt einen zunehmenden Stellenwert zur bettseitigen Diagnostik in der Akutmedizin. Anhand der fokussierten Echokardiographie können verschiedene kardiale Pathologien, wie z. B. ein Perikarderguss, eine linksventrikuläre Dysfunktion, eine Rechtsherzbelastung, relevante Herzklappenfehler sowie eine Dissektion der Aorta ascendens, in Kürze ausgeschlossen bzw. nachgewiesen werden. Die Interpretation der echokardiographischen Befunde sollte stets im klinischen Kontext erfolgen. Focused echocardiography has become increasingly important for bedside diagnostics in acute medicine. Focused echocardiography can detect various cardiac pathologies, such as pericardial effusion, left ventricular dysfunction, right heart strain, relevant heart valve defects and dissection of the ascending aorta. Echocardiographic findings should be interpreted in the clinical context.

Eine 81-jährige Patientin wurde im infarktbedingten kardiogenen Schock zur Herzkatheteruntersuchung übernommen. In der Koronarangiographie zeigte sich ein Verschluss des Ramus interventricularis anterior. Bei unvollständigem Fluss nach perkutaner Koronarintervention mit Implantation von 3 Koronarstents und erhöhter Thrombogenität erfolgte die Gabe von Tirofiban. Im Rahmen der anschließenden Anlage eines zentralvenösen Venenkatheters (ZVK) via V. jugularis interna kam es zu einer arteriellen Fehlpunktion der A. carotis communis mit der Folge von akuter Dyspnoe und eines hämorrhagischen Schocks bedingt durch ein massives zervikales Hämatom. Obwohl die ZVK-Anlage eine häufig angewandte Intervention in der Intensivmedizin darstellt, birgt der Eingriff dennoch ein gewisses Risiko iatrogener Verletzungen. Die Kenntnis über das Notfallmanagement von ZVK-assoziierten Komplikationen ist daher unabdingbar. An 81-year-old woman with infarct-related cardiogenic shock was admitted to the cardiac catheterization laboratory. Coronary angiography revealed an occlusion of the ramus interventricularis anterior. Due to incomplete flow after the percutaneous coronary intervention with implantation of three coronary stents and high thrombus burden, tirofiban was given as a bail out therapy. A central venous catheter (CVC) aimed at the internal jugular vein was incidentally inserted in the common carotid artery, resulting in acute dyspnea and a hemorrhagic shock due to a massive cervical hematoma. Although the CVC is a frequently used intervention in critical care, the procedure still carries some risks of iatrogenic injury. Knowledge about the emergency management of CVC-associated complications is therefore essential.

Die extrakorporale kardiopulmonale Reanimation („extracorporeal cardiopulmonary resuscitation“, eCPR) kann als Rettungsversuch für hoch selektierte Patienten mit refraktärem Herz-Kreislauf-Stillstand und potenziell reversibler Ätiologie erwogen werden. Aktuell fehlen randomisiert-kontrollierte Studien zur eCPR und es existieren keine validen Prädiktoren für Nutzen und Risiko, die bei der Indikationsstellung hilfreich sein könnten. Die bisherigen Selektionskriterien und Abläufe sind klinikspezifisch und ein (nationaler) standardisierter Algorithmus fehlt. Das vorliegende Konsensuspapier bietet basierend auf einer konsentierten Expertenmeinung den Vorschlag für ein standardisiertes Vorgehen bei eCPR. Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

Ein 94-jähriger Patient mit infarktbedingtem kardiogenem Schock wurde über die Notaufnahme eingeliefert. Es erfolgte eine Anfrage bezüglich einer notfallmäßigen Koronarangiographie und intensivmedizinischen Versorgung. Eine Pflegebedürftigkeit aufgrund einer Demenz war bekannt. Nach interdisziplinärer Fallbesprechung im multiprofessionellen Behandlungsteam wurde unter Berücksichtigung der Krankengeschichte, der aktuellen Situation und des mutmaßlichen Patientenwillens im Konsens noch in der Notaufnahme für ein Palliative-Care-Konzept im Sinne einer Symptomkontrolle entschieden. Die Integration von medizinethischen Aspekten und Palliativmedizin in die „geriatrische Notfallmedizin“ stellt zukünftig eine Herausforderung dar. A 94-year-old patient with cardiogenic shock due to myocardial infarction was admitted via the emergency room. A coronary angiography and intensive care were requested. The need for care due to dementia was known. After case discussion in the interdisciplinary and multiprofessional treatment team, the decision for a palliative care concept in the form of symptom control was made in the emergency room, taking into account the patient’s medical history, the current situation, and the presumed patient consent. The integration of medical ethics aspects and palliative medicine into “geriatric emergency medicine” will present a challenge in the future.

Hypothermieinduzierte J‑ bzw. sog. Osborn-Wellen lassen sich unter therapeutischer Hypothermie in 20–40 % der Fälle nachweisen. Das Auftreten von J‑Wellen im Rahmen des zielgerichteten Temperaturmanagements nach kardiopulmonaler Reanimation ist charakteristisch, jedoch nicht pathognomonisch für eine Hypothermie. Eine elektrokardiographische Diagnosestellung unter Hypothermie nach Kreislaufstillstand sollte aufgrund der vielfältigen hypothermieassoziierten elektromechanischen Veränderungen des Myokards stets mit Vorsicht erfolgen. Hypothermia-induced J‑ or so-called Osborn waves can be detected under therapeutic hypothermia in approximately 20–40% of cases. The occurrence of J‑waves in the context of the targeted temperature management after cardiopulmonary resuscitation is characteristic, but not pathognomonic for hypothermia. An electrocardiographic diagnosis under hypothermia after cardiac arrest should always be done with caution due to the various hypothermia-associated electromechanical changes of the myocardium.

The heart rate (HR) response to ultraendurance cycling is poorly understood. This case report describes the exercise intensity of ultraendurance cycling by means of HR monitoring in a well trained [...]

Der sog. Point-of-care-Ultraschall (POCUS) besitzt einen zunehmenden Stellenwert zur Diagnostik und Therapiesteuerung in der Intensivmedizin. Anhand der fokussierten Thoraxsonographie, Echokardiographie und Abdomensonographie können die wichtigsten Arbeits- und Differenzialdiagnosen in Abhängigkeit des führenden Leitsymptoms nachgewiesen bzw. ausgeschlossen werden. Sonographiebasierte Algorithmen erlauben eine strukturierte Evaluation speziell von Patienten mit den häufigen Leitsymptomen Dyspnoe und Thoraxschmerzen. The so-called point-of-care ultrasound (POCUS) is of increasing importance for diagnostics and therapy control in intensive care medicine. Based on focused thorax sonography, echocardiography, and abdominal sonography, the most important working and differential diagnoses can be demonstrated or excluded depending on the leading symptom. Sonographic-based algorithms allow a structured evaluation especially of patients with the common leading symptoms dyspnea and thoracic pain.

Die Sterblichkeit bei Patienten mit kardiogenem Schock nach Herzstillstand bleibt trotz der Fortschritte bei den Wiederbelebungsmaßnahmen und der frühen Revaskularisierung sehr hoch. Gegenwärtig wird der Einsatz der milden therapeutischen Hypothermie (MTH) zur Verbesserung des Überlebens und neurologischen Outcomes bei diesem Patientenkollektiv neu diskutiert. Detektion von Einflussfaktoren auf Morbidität und Mortalität bei Patienten nach präklinischer Reanimation [„out-of-hospital cardiac arrest“ (OHCA)] unter MTH im kardiogenen Schock. Retrospektive Analyse von 80 konsekutiven Patienten (mittleres Alter 60 ± 3,2 Jahre) im kardiogenen Schock. Alle Patienten wurden mithilfe eines endovaskulären Kühlkatheters für 24 h gekühlt. Das neurologische Outcome der Patienten wurde 2 Monate nach OHCA basierend auf der Glasgow-Pittsburgh Cerebral Performance Category (CPC) erhoben und mit verschiedenen Blutwerten korreliert. Zwei Monate nach Indexereignis zeigten 31 Patienten (39 %) eine gute neurologische Erholung (CPC 1–2), 20 Patienten (25 %) wiesen ein schlechtes neurologisches Outcome (CPC 3–4) auf. 29 Patienten (36 %) waren verstorben (CPC 5). Bei den Patienten mit schlechtem neurologischem Outcome fanden sich signifikant höhere Laktat-, Kreatinin- und Harnstoffwerte. Zudem kam es bei diesen Patienten, im Gegensatz zu den Patienten mit gutem neurologischem Outcome, zu einem kontinuierlichen Anstieg der neuronenspezifischen Enolase (NSE; ∆ NSE, Ankunft zu Tag 1, CPC 1–2: − 10,6 ± 3 µg/l; CPC 3–5: 33 ± 12 µg/l; p= 0,02). Der Verlauf von Kreatinin, Harnstoff und NSE im Serum innerhalb der ersten 72 h nach OHCA könnte bei Patienten unter MTH wertvolle ergänzende Informationen zur frühzeitigen Beurteilung der neurologischen Prognose bieten. The mortality in patients with cardiogenic shock after out-of-hospital cardiac arrest (OHCA) remains high despite advances in resuscitation and early revascularization strategies. The use of mild therapeutic hypothermia (MTH) for improvement of survival and neurological outcome in patients with cardiogenic shock is currently subject to renewed discussion. The aim of this study was the detection of risk factors for mortality and morbidity in patients under MTH in cardiogenic shock following preclinical resuscitation for OHCA. A total of 80 consecutive patients in cardiogenic shock after successful resuscitation (mean age 60 ± 3.2 years) treated with MTH were retrospectively analyzed. Patients were cooled to 33 °C for 24 h using an endovascular cooling device. Neurological outcome was assessed after 2 months based on the Glasgow-Pittsburgh cerebral performance category (CPC) and correlated with various blood parameter values. After 2 months 31 patients (39 %) showed a good neurological recovery with CPC scores of 1–2, 20 patients (25 %) had a poor neurological outcome with CPC scores of 3–4 and 29 (36 %) patients enrolled in the trial died (CPC 5). Patients with a poor outcome showed significantly higher mean serum levels for lactate, creatinine and urea. In addition, these patients showed a continuous increase of serum neuron-specific enolase (NSE) values in contrast to patients with a good outcome (∆ NSE from admission to day 1, CPC 1 and 2: − 10.6 ± 3 µg/l and CPC 3–5: 33 ± 12 µg/l, p= 0.02). Changes in the course of serum creatinine, urea and NSE levels within the first 72 h after OHCA could provide valuable additional information for the early assessment of the neurological prognosis in patients treated with MTH.

Controversy still exists regarding inpatient monitoring of patients exposed to electrical injuries. In a monocentric retrospective study, we evaluated the medical records of 169 patients admitted to the University Hospital of Cologne from January 2000 to January 2014 because of electrical trauma. The electrocardiogram (ECG) data of 40 patients were missing. Patients in our collective were predominantly young men (60 %) with an average age of 17.5 ± 17 years (1 year to 73 years). The electrical trauma occurred occupational (20 %), domestic (65 %), and during leisure time (15 %). In the high-voltage (≥ 1000 V) group (n= 7; 71 % male; 40.0 ± 19.4 years) one death was reported, related to an open intracranial injury and cardiac arrest. Of the six surviving patients five showed normal ECGs and one a sinus tachycardia. In the low-voltage (< 1000 V) group (n= 162, 56 % male; 5.0 ± 4.3 years) the ECG findings were as follows: 104 normal, 5 sinus tachycardia, 3 sinus arrhythmia, 6 ST segment changes, 3 premature atrial contraction, 1 premature ventricular contraction, 1 atrio-ventricular (AV)-Block and 1 delta wave. In all, one patient showed a self-limiting supraventricular tachycardia. Asymptomatic and stable patients without any risk factors and with a normal initial ECG need no inpatient cardiac monitoring after an electrical injury. Bezüglich der kardiologischen, stationären Überwachung von Patienten nach Stromunfällen existieren weiterhin kontroverse Meinungen. In einer monozentrischen retrospektiven Studie erfolgte die Auswertung der Elektrokardiogramme (EKGs) von 169 Patienten, welche im Zeitraum von Januar 2000 bis Januar 2014 aufgrund eines elektrischen Stromschlages in das Universitätsklinikum Köln aufgenommen wurden. Die EKGs von vierzig Patienten fehlten. Das Durchschnittsalter der überwiegend männlichen (60 %) Patienten betrug 17,5 ± 17 Jahre (1 bis 73 Jahre). Die Unfälle ereigneten sich bei der Arbeit (20 %), bei der Hausarbeit (65 %) und während des Spielens zu Hause (15 %). In der Gruppe der Hochspannungsunfälle (≥ 1000 V; n= 7; 71 % männlich; 40,0 ± 19,4 Jahre) trat ein Todesfall aufgrund eines offenen Schädel-Hirn-Traumas und Herzstillstandes auf. Fünf der sechs überlebenden Patienten zeigten normale EKGs und ein Patient eine Sinustachykardie. In der Niederspannungsgruppe (< 1000 V; n= 162, 56 % männlich; 5,0 ± 4,3 Jahre) zeigten sich folgende EKG-Befunde: 104 Normalbefunde, 5 Sinustachykardien, 3 Sinusarrhythmien, 6 ST-Streckenveränderungen, 3 supraventrikuläre Extrasystolen (SVES), 1 ventrikuläre Extrasystole (VES), 1 atrio-ventrikulärer (AV)-Block und 1 Deltawelle. Ein Patient präsentierte eine selbstlimitierende supraventrikuläre Tachykardie (SVT). Bei asymptomatischen, stabilen Patienten ohne jegliche Risikofaktoren und mit einem normalen initialen EKG ist keine stationäre kardiale Überwachung notwendig.

Ein hämodynamisches Monitoring gehört zum Standard in der Intensiv- und Notfallmedizin bei Patienten im Schock. Sowohl die klinische Untersuchung wie auch nichtinvasive Verfahren können hierzu genutzt werden. Insbesondere bei der Volumentherapie und dem kardiogenen Schock ist eine bettseitige Ultraschalluntersuchung bereits in den Leitlinien implementiert. Zur Differenzierung der Ursache und zur Steuerung der Therapie ist ein Monitoring unerlässlich. Die vorliegende Übersichtsarbeit zeigt die Möglichkeiten der Integration von klinischen und sonographischen Untersuchungstechniken auf und vergleicht diese mit invasiven Monitoringverfahren. Hemodynamic monitoring is required in critically ill patients presenting with circulatory shock. Besides the clinical evaluation, noninvasive technologies can be used. Guidelines on volume resuscitation and cardiogenic shock already recommend bedside ultrasound as a diagnostic tool. To differentiate the cause of circulatory shock and monitor the effects of therapies, hemodynamic monitoring is necessary. This review discusses possibilities of the different invasive and noninvasive monitoring tools with a focus on the integration of clinical and sonographic parameters.

Long QT syndrome (LQTS) can lead to ventricular arrhythmia, especially torsade de pointes (TdP) tachycardia and/or ventricular tachycardia (VT). The aim of this study is to characterize patients with life-threatening cardiac arrhythmias associated with drug-induced LQTS and to identify risk factors of distinct presenting arrhythmias. In this retrospective study, we present 33 consecutive cases of life-threatening cardiac arrhythmias associated with drug-induced long QT, which were direct admitted as emergency to a medical intensive care unit (MICU) during an observational time of 6 years. Of 33 identified cases, 55 % presented with TdP with the need of resuscitation and 45 % showed nonsustained VT, respectively. In the total cohort the mean corrected QT interval (QTc) was 532 ± 29 ms, with 530 ± 31 ms (n= 14) in men and 533 ± 28 ms (n= 19) in women (p= 0.80), respectively. Cardiac drugs with QTcinterval prolonging effect were reported in 24 % of cases, and the other 76 % involved noncardiac medications. Although hypokalemia is the most common risk factor for drug-induced malignant arrhythmias, a QTcinterval of at least 500 ms seems to be the major determinant of the risk of drug-induced proarrhythmias. Interestingly, patients with TdP exhibit more bradycardia as such with VT. This is the first study of patients with drug-induced life-threatening cardiac arrhythmias who were admitted as a case of emergency to a MICU. Physicians should be aware of drug-induced LQTS and be able to identify patients at risk and avoid specific drugs in such patients. Das verlängerte QT-Syndrom (LQTS) kann mit ventrikulären Arrhythmien, insbesondere Torsade de pointes (TdP) und/oder ventrikuläre Tachykardien (VT), einhergehen. Das Ziel dieser Studie war es die patientenspezifischen Charakteristika und Risikofaktoren von lebensbedrohlichen kardialen Arrhythmien bedingt durch ein Medikamenten-induziertes LQTS zu identifizieren. Anhand dieser retrospektiven Studie über 6 Jahre präsentieren wir 33 Fälle von lebensbedrohlichen kardialen Arrhythmien beruhend auf ein Medikamenten-induziertes LQTS, welche als Notfall über die internistische Intensivstation aufgenommen wurden. Von den 33 Fällen mit einem Medikamenten-induziertem LQTS präsentierten sich 55 % mit einer TdP-Tachykardie und 45 % mit einer nicht-anhaltenden VT. Die korrigierte QT-Zeit (QTc) betrug im Mittel 532 ± 29 ms (Männer: 530 ± 31 ms, n= 14; Frauen: 533 ± 28 ms, n= 19; p= 0,80). Kardiaka führten in 24 % und nicht-kardiale Medikamente in 76 % der Fälle zu einer QTc-Zeit Verlängerung. Obwohl die Hypokaliämie den häufigsten Risikofaktor für Medikamenten-induzierte maligne Arrhythmien darstellt, so ist eine QTc-Zeit von über 500 ms für derartige Arrhythmien prädisponierend. Bradykardien konnten insbesondere im Zusammenhang mit Medikamenten-induzierten TdP-Tachykardien beobachtet werden. Diese Studie präsentiert erstmalig eine Risikoanalyse von Patienten mit Medikamenten-induziertem LQTS, welche notfallmäßig aufgrund von malignen Arrhythmien auf eine internistische Intensivstation aufgenommen wurden. Die Bedeutung eines Medikamenten-induzierten LQTS sollte allen Ärzten vertraut sein, um spezifische QT-verlängernde Medikamente im Zusammenhang mit patientenspezifischen Risiken zu vermieden.

Eine 34-jährige Patientin wurde nach erfolgreicher kardiopulmonaler Reanimation im kardiogenen Schock vorstellig. Fremdanamnestisch wurde eine Migräne angegeben. Die Notfallechokardiographie zeigte eine eingeschränkte linksventrikuläre Pumpfunktion mit basomittventrikulärer Hypokinesie und apikaler Hyperkontraktilität. Die kraniale Computertomographie ergab den Hinweis auf eine stattgefundene massive Subarachnoidalblutung (SAB), sodass unter Berücksichtigung der Fremdanamnese (stärkste Kopfschmerzen) die Diagnose einer SAB-assoziierten umgekehrten Takotsubo-Kardiomyopathie gestellt werden konnte. Im Rahmen einer SAB sollte stets an die Assoziation von extrazerebralen Organdysfunktionen, wie das Auftreten einer invertierten Takotsubo-Kardiomyopathie, gedacht werden. We present a case of a 34-year-old woman with cardiogenic shock after successful resuscitation. In the medical history migraine was known. Emergency echocardiography demonstrated left ventricular dysfunction with hypokinetic basal and midventricular segments and hyperkinetic apex. Cerebral computed tomography suggested a massive subarachnoid haemorrhage (SAH) with transtentorial herniation, so that taking into account the clinical history (severe headache) the diagnosis of a SAH-associated inverted takotsubo cardiomyopathy could be made. In the case of subarachnoid haemorrhage it should be noted that extracerebral organ dysfunction, e.g. inverted takotsubo cardiomyopathy, frequently occurs.

Dysphagietherapeuten gehören heutzutage zum Repertoire in der modernen Intensivmedizin. Eine Langzeitintubation führt häufig zu einer aspirationsassoziierten Schluckstörung. Ein frühzeitiges und standardisiertes Schluckmanagement sollte daher bereits während des Aufenthalts auf der Intensivstation initiiert werden. Die optimale Betreuung von Intensivpatienten mit Dysphagie erfordert eine interdisziplinäre Zusammenarbeit verschiedener Fachdisziplinen. Der Intensivmediziner sollte daher im Rahmen der schluckrehabilitativen Betreuung von Intensivpatienten mit den Grundkenntnissen der Dysphagiologie vertraut sein. Physicians specializing in dysphagia are needed in modern intensive care medicine. Long-term intubation is associated with aspiration and swallowing disorders. Early and standardised dysphagia management should be initiated during a patient’s stay on intensive care unit. A clinically experienced, interdisciplinary team is required to provide optimal care for critically ill patients with dysphagia. Intensive care physicians should therefore know about basics in dysphagiology.

Eine 52-jährige Frau wurde über den Notarzt unter der Verdachtsdiagnose thorakolumbaler Bandscheibenvorfall bei neuen stärksten bewegungs- und lageabhängigen Schmerzen des linken Hemithorax vorstellig. In der transthorakalen Notfallechokardiographie zeigten sich eine Aortenklappeninsuffizienz, eine erweiterte Aortenwurzel und eine Dissektionsmembran der Aorta ascendens. Eine sofortige Angio-CT-Untersuchung des Thorax konnte eine akute Aortendissektion Typ Stanford A bestätigen, sodass die Indikation zum notfallmäßigen operativen Ersatz der Aorta ascendens gestellt wurde. In der Notaufnahme ermöglicht die transthorakale Notfallechokardiographie die rasche und bettseitige Evaluation wichtiger Differenzialdiagnosen des Leitsymptoms Thoraxschmerz. A 52-year-old woman was admitted to our emergency department with a suspected diagnosis of a thoracic disc prolapse. She presented with acute thoracic and vertebral pain of sudden onset that increased on movement and change of body position. An emergency echocardiography that was performed at the bedside showed aortic insufficiency, dilation of the aortic root, and membrane dissection in the ascending aorta. A thoracic contrast-enhanced CT angiogram verified acute aortic dissection Stanford type A, which resulted in immediate referral to the department of cardiothoracic surgery for an emergency replacement of the ascending aorta. In the emergency department, emergency bedside echocardiography facilitates the rapid evaluation of potential differential diagnoses in patients presenting with acute thoracic pain.

Background: A single measurement of glycated hemoglobin (HbA1c) is a weak predictor for cardiovascular events in patients without Type 2 diabetes mellitus. We hypothesized that dynamic changes in HbA1c(Delta-HbA1c) would better predict cardiovascular outcome than a single value. Methods: In 99 consecutive patients with stable coronary artery disease (CAD) and without diabetes mellitus who were seen twice in our outpatient clinic (4–6 months apart) in 1998, Delta-HbA1c(follow-up HbA1c–baseline HbA1c) was assessed. Between August and September 2007 (mean observation period 9.1 yr), patients and their physicians were contacted by telephone to evaluate the incidence of cardiovascular endpoints. The combined primary endpoint of our study was defined as the incidence of myocardial infarction, stroke or death from any cause. The endpoints were validated by chart review. Results: Multivariate analysis demonstrated that the change of HbA1cbetween first and second examination in 1998 was the most powerful parameter for prediction of the combined primary endpoint in the next 9 yr. The hazard ratio was 5.03 [95% confidence interval (CI) 1.4–17.9] for any increase in HbA1cand 1.99 (95%CI 1.3–3.0) for an HbA1cincrease of 0.3%. In addition, Kaplan-Meier survival analysis showed a significant association between endpoint-free survival and dynamic changes in HbA1c. Conclusions: Hence, changes in the glucometabolic milieu within 4–6 months calculated by the difference of two values of HbA1caffect the long-term prognosis of patients with CAD but without diabetes mellitus.

The Grenoble Hybrid magnet is a modular platform using resistive and superconducting technologies to produce various continuous high magnetic field and flux configurations for the scientific community. They range from 43 T in 34 mm diameter with 24 MW electrical power to 9 T in 800 mm diameter when the superconducting coil is used alone. Thanks to the ongoing upgrade of the electrical power installation of LNCMI-Grenoble up to 30 MW and possibly to 36 MW, the possibility to increase the total field up to 45-46 T in the near future is foresee and deeply studied. The key design parameters will be briefly recalled including the specifically developed Nb-Ti/Cu conductor, the large bore outsert superconducting coil, the magnet cryostat with its structure including the eddy-current shield, the cryogenic line for the interconnection with the cryogenic satellite and the fully dedicated 150 l/h He liquefaction plant. All components of the hybrid magnet platform have been built, tested and delivered to LNCMI-Grenoble, where integration and assembly are ongoing. The status of the project will be given with focus to the recent commissioning tests of the cryogenic satellite producing the pressurized superfluid He at 1.8 K as well as to the successful powering tests of the specially developed current leads at ultimate current and under fully degraded cooling conditions simulating the worst-case accidental scenario.

AbstractBackground: Circulating magnesium exists in the bound and in the free ionized form, that is biologically active. In kidney disease the relationship between ionized and total circulating magnesium is often altered. Little information is available on the influence of hemodialysis on the relationship between ionized and total circulating magnesium in end-stage kidney disease. Methods: Plasma total and ionized magnesium and the plasma ionized magnesium fraction were assessed before and after hemodialysis (dialysate magnesium content 0.75 mmol/l) in 46 patients with end-stage kidney disease and in a control group of 25 healthy subjects. Results: In patients plasma total (from 1.19 [1.05–1.33] to 1.10 [1.02–1.16] mmol/l; median and interquartile range) and ionized (from 0.71 [0.66–0.78] to 0.65 [0.63–0.69] mmol/l) magnesium significantly decreased during dialysis (control subjects: 0.82 [0.80–0.92], respectively, 0.57 [0.54–0.59] mmol/l). The plasma ionized magnesium fraction was significantly lower in patients both before (0.61 [0.58–0.64)] and after (0.60 [0.56–0.62]) hemodialysis than in controls (0.68 [0.65–0.70]). Conclusion: The study demonstrates a tendency towards a reduced circulating ionized magnesium fraction in end-stage kidney disease that is not corrected by hemodialysis.Copyright © 2002 S. Karger AG, Basel

Zusammenfassung: Als Hashimoto-Enzephalopathie wird eine steroid-sensitive, schubförmig oder stetig progrediente Enzephalopathie bezeichnet, welche mit einer Hashimoto-Thyreoiditis assoziiert ist. Charakteristische klinische Befunde sind Verwirrtheit, epileptische Anfälle, Vigilanzminderung, schlaganfallähnliche Episoden, Myoklonien und Tremor. Die Liquordiagnostik zeigt meist eine Proteinerhöhung ohne Pleozytose, das EEG generalisierte und umschriebene Verlangsamungen, seltener triphasische Wellen und epilepsietypische Potentiale; die zerebrale Bildgebung mittels CT oder MRT sowie die zerebrale Angiographie sind in der Regel normal. Wir stellen 2 Patientinnen im Alter von 55 und 77 Jahren vor, bei denen die Symptome einer Hashimoto-Enzephalopathie gut auf eine Behandlung mit Steroiden ansprachen, und geben einen Überblick über die Literatur.

Catalyzing the first step in the de novosynthesis of adenylmonophosphate, adenylosuccinate synthetase (AdSS) is a known target for herbicides and antibiotics. We have purified and crystallized recombinant AdSS from Arabidopsis thalianaand Tritium aestivum, expressed in Escherichia coli. The structures of A. thalianaand T. aestivumAdSS in complex with GDP were solved at 2.9 Å and 3.0 Å resolution, respectively. Comparison with the known structures from E. colireveals that the overall fold is very similar to that of the E. coliprotein. The longer N terminus in the plant sequences is at the same place as the longer C terminus of the E. colisequence in the 3D structure. The GDP-binding sites have one additional hydrogen-bonding partner, which is a plausible explanation for the lower Kmvalue. Due to its special position, this partner may also enable GTP to initiate a conformational change, which was, in E. coliAdSS, exclusively activated by ligands at the IMP-binding site. The dimer interfaces show up to six hydrogen bonds and six salt-bridges more than in the E. colistructure, although the contact areas have approximately the same size.

The cockroachesBlatella germanica andSupella longipalpa can act as intermediate hosts ofTrichospirura leptostoma as demonstrated by experimental infestation. The parasite developed from the embryonated egg into the infective larval stage (L3) in cockroaches within 5–6 weeks. After experimental infection of marmosets (Callithrix jacchus), eggs were first found in faecal samples (prepatency) at 8–9 weeks post-infection. Patency last about 2 years. Despite the presence of living adult worms in the marmosets' pancreas, no additional eggs were observed in their faeces after the patent period.

Abstract: Percutaneous ultrasonic lithotripsy of upper urinary tract lithiasis is a well-established procedure in adults. We successfully applied this technique to completely remove symptomatic renal calculi in two children with idiopathic hypercalciuria. The procedure was well tolerated and no complications occurred. Both patients were discharged within 4 days of the lithotripsy. This method is an alternative to surgery for the removal of large or impacted calculi from the upper urinary tracts of pediatric patients.

Summary Twenty-six tributyltin (TBT)-resistant bacterial strains isolated from sediments were examined for the presence of plasmids. Plasmids of the size reported to carry metal resistance genes were not found in 15 of the strains, indicating that resistance does not have to be plasmid-mediated. Attempts to cure plasmid-containing strains using acridine organge, ethidium bromide, novobiocin or sodium dodecylsulfate, or by growth at elevated temperature were not successful, nor were plasmids transferred from TBT-resistant strains into TBT-sensitive organisms by electroporation. In a broth mating experiment however, plasmid pUM505, a conjugative plasmid known to encode chromium resistance inPseudomonas aeruginosa PAO1, was introduced into TBT-sensitiveBeijerinckia sp. MC-27 isolated from freshwater sediment. The TBT tolerance of theBeijerinckia sp. increased 100-fold, from 8.4 µM TBT inBeijerinckia sp. MC-27 to 840 µM TBT inBeijerinckia sp. MC-27 (pUM505) on solid medium. The plasmid was transferred at a frequency of approximately 6×10-4. TBT-resistant transconjugants grew faster in media containing TBT and lost their enhanced TBT tolerance and the plasmid upon serial transfer in medium without TBT. Spontaneous mutants of the donorP. aeruginosa lost both TBT resistance and the plasmid. Therefore, TBT resistance in bacteria can be plasmid-mediated. To our knowledge, this is the first report that resistance to a tin compound can be plasmid-mediated.

Formation of exospores in Methylosinus trichosporium was examined by electron microscopy; serial sectioning was used to visualize the shape and location of the developing exospore in relation to the vegetative cell. The initial stage was the formation of a budlike enlargement on one end of the vegetative cell. The enlargement was surrounded by the exospore capsule, and the cell wall was continuous around both the cell and the developing exospore. A constriction occurred in the area where the budlike structure was attached to the vegetative cell, and the constriction continued to form until the immature exospore was detached from the vegetative cell. The cup-shaped immature exospore was surrounded by the exospore capsule, which appeared to hold the exospore close to the vegetative cell. After separation from the vegetative cell, the immature exospore developed further by forming the exospore wall and by becoming spherical.

Background: Intrinsic asthma is characterized by an increased number of activated eosinophils and macrophages and an increased expression of the hematopoietic growth factor granulocyte-macrophage colony-stimulating factor (GM-CSF) in the bronchial mucosa. Objective: This study was carried out to investigate the expression of @aGM-CSF receptor (@aGM-CSFr) messenger RNA and protein in the bronchial mucosa of patients with intrinsic or atopic asthma and of control subjects and to correlate the expression of @aGM-CSFr to the number of EG2^+ cells (eosinophils) and CD68^+ cells (macrophages) and pulmonary function. Methods: Nineteen patients with stable asthma (9 with atopic and 10 with intrinsic asthma) and 22 normal control subjects (12 atopic and 10 nonatopic subjects) were recruited, and FEV"1 (percent predicted) and PC"2"0 were measured before bronchoscopy. Endobronchial biopsy specimens were obtained and examined for membrane-bound @aGM-CSFr by using in situ hybridization and immunocytochemistry. Results: @aGM-CSFr mRNA- and protein-positive cells were identified in biopsy specimens from all four groups studied. There was no significant difference in the number of cells expressing @aGM-CSFr mRNA and protein in patients with atopic asthma compared with atopic and nonatopic control subjects. However, the numbers of @aGM-CSFr mRNA- and protein-positive cells were significantly higher in nonatopic patients with asthma compared with atopic patients with asthma and atopic and nonatopic control subjects (p < 0.001). In the patients with intrinsic asthma, the number of @aGM-CSFr mRNA-positive cells per millimeter of basement membrane correlated with numbers of CD68^+ cells (r^2 = 0.87, p < 0.001) but not with EG2 ^+ cells, and colocalization studies demonstrated that 80% of the cells expressing @aGMCSFr mRNA were CD68^+. The expression of GM-CSF was also significantly increased in patients with intrinsic asthma compared with those with atopic asthma and control subjects ( p < 0.05). In addition, in intrinsic asthma, there was a correlation between @aGM-CSFr mRNA and FEV"1 ( r^2 = 0.61, p < 0.05). Conclusion: These results demonstrate that elevated numbers of cells expressing @aGM-CSFr can be detected in nonatopic asthma but not in atopic asthma and suggest that this increased expression is predominantly macrophage-associated and may play an important pathophysiologic role in intrinsic asthma. (J Allergy Clin Immunol 1997;99:666-72.)

Local secretion of cytokines by T cells within the bronchial mucosa, with consequent selective eosinophil influx, has been implicated in the pathogenesis of bronchial asthma. The cytokine IL-13 exhibits activities (selective eosinophil vascular adhesion by very late antigen-4/vascular cell adhesion molecule-1 interaction and promotion of IgE synthesis and ''T"H"2-type'' T cell responses) that may be relevant to this process. We hypothesized that, compared with conditions in control subjects, elevated expression of messenger ribonucleic acid (mRNA) encoding IL-13 is a feature of the bronchial mucosa of both atopic (positive skin prick test result to at least one of a range of common aeroallergens) and nonatopic (negative skin prick test results and serum total IgE concentrations within the normal range) subjects with asthma. With use of a semiquantitative reverse transcriptase-polymerase chain reaction technique, we measured the quantities (relative to @b-actin) of IL-13 mRNA in bronchial mucosal biopsy specimens from atopic and nonatopic subjects with asthma and atopic and nonatopic control subjects. Biopsy specimens from the subjects with asthma, whether the subjects were atopic or nonatopic, had statistically equivalent quantities of IL-13 mRNA relative to @b-actin, and these quantities were significantly elevated compared with those in specimens from both the atopic and nonatopic control subjects ( p @? 0.02 in each case), in which the quantities of IL-13 mRNA relative to @b-actin were also statistically equivalent. The quantities of IL-13 mRNA reflected the numbers of EG2+ eosinophils per unit area of submucosa in the biopsy specimens as determined by immunohistochemistry, which were statistically equivalent in the atopic and nonatopic subjects with asthma and significantly elevated as compared with those in both the atopic and nonatopic control subjects without asthma (p @? 0.007 in each case). Taking the subjects with asthma as a group, no correlations were observed between the quantities of IL-13 mRNA (relative to @b-actin) and several measures of disease severity. These data are consistent with the hypothesis that IL-13 plays a role in the pathogenesis of both atopic and nonatopic asthma, at least partly through promoting recruitment of eosinophils to the bronchial mucosa, although other factors may be more important in regulating the severity of the disease. (J Allergy Clin Immunol 1997;99:657-65.)

The presence of a specialized terminal region in Mycoplasma pneumoniae was seen in thin sections viewed in an electron microscope. Actively growing cells were examined by the freeze-fracture technique in the absence of fixation to further establish the core as a significant structural entity. Cross fractures revealed a cytoplasmic matrix surrounding a central core structure of about 54 nm. This structure disappeared rapidly in aging cells. The convex protoplastic faces of the membrane around the core had characteristic 5- to 10-nm intramembrane particles evenly distributed across the cell surface, with no apparent difference in the region of the specialized tip. A periodicity previously noted in negatively stained preparations was clearly defined here in thin sections. Attachment of actively growing cells to sheep erythrocytes was seen primarily as a side attachment rather than attachment at the tip alone. This association between the mycoplasma and the sheep erythrocytes seriously deformed the sheep erythrocytes, but no membrane fusion could be detected.

Mycoplasma pneumoniae was grown on Formvar- and carbon-coated electron microscope grids and treated with the nonionic detergent Triton X-100 to gently remove the membrane and cytoplasm. The detergent mixture was composed of 0.5% Triton X-100 in SSR-2 broth base. After this treatment, the grids were rinsed in a mixture of 0.1 M KCl, 5 mM MgCl2, and 6 mM potassium phosphate buffer (pH 7.05) and negatively stained with uranyl acetate. The Triton X-100-resistant remains of M. pneumoniae after gentle removal of the membrane and cytoplasm consisted of fibrous structures oriented similarly to the undisrupted cells. The thin fibers displayed a negative staining quality and diameter analogous to that of rabbit muscle F-actin. The fibrous moieties ended in rodlike condensations which appeared striated in negatively stained and shadowed preparations. These striations were regular, and the majority of rod structures had lengths of 220 to 300 nm and widths of 50 to 80 nm. Specific antibody to rabbit muscle actin, produced in guinea pigs, was used in indirect immunofluorescence of the M. pneumoniae colonies. Fluorescence was detected, with concentrations at the colony center and at the tips of filamentous cells.

This study aimed to investigate high molecular weight surface glycoprotein (S-GP) patterns on various types of human leukocytes. S-GP were externally labelled by the Galactose-oxidase-NaB3H4 technique. Results based on the analysis of 120 samples derived from different types of normal and malignant leukocytes indicate that (i) the relative expression of high molecular weight S-GPs changes during haemopoietic cell differentiation and (ii) to some extent these changes enable the classification of human leukocytes.

Reversible contractures can be induced in slow mammalian muscles by manipulations that probably generate a long-lasting alkalinization of the muscle cell interior. Such contractures reach about 1/4 of the tetanic force, P0, and last 10 times longer than potassium contractures. While in contracture, the muscle fibers have high resting potentials so that they can be electrically stimulated. Tetanic force is then increased and added to that of the contracture so that total force may reach 2 P0. This level of potentiation has not been reached by any previously-known method.

Background: Recent studies have provided evidence for increased IL-4 expression in the airways of atopic and nonatopic asthmatic subjects. IL-4 is believed to perform important regulatory roles in asthma; however, the expression of the IL-4 receptor has not been investigated. In this study we examined the mRNA and protein expression of the specific @a-subunit of the IL-4 receptor (@aIL-4R) in bronchial biopsy specimens obtained from atopic and nonatopic asthmatic subjects. Methods: Asthmatic subjects and nonasthmatic control subjects were recruited, and lung function measurements were performed before bronchoscopy. Endobronchial biopsy specimens were examined for the presence of @aIL-4R mRNA and immunoreactivity by using in situ hybridization and immunocytochemistry, respectively. Results: @aIL-4R mRNA-positive and immunoreactive cells were detected in the epithelium and subepithelium in biopsy specimens from all subjects. Expression of @aIL-4R mRNA and protein was significantly increased in the epithelium and subepithelium of biopsy specimens from atopic asthmatic subjects compared with atopic control subjects (P < .05 and P < .001, respectively). Epithelial @aIL-4R mRNA expression and immunoreactivity did not differ significantly between nonatopic asthmatic subjects and nonatopic control subjects. Although the numbers of @aIL-4R mRNA-positive cells were augmented in the submucosa of intrinsic asthmatic subjects compared with nonatopic control subjects (P < .05), @aIL-4R immunoreactivity did not differ significantly between these groups. Increased @aIL-4R immunoreactive signals were also detected in the endothelial cell layer in both atopic and intrinsic asthmatic subjects compared with atopic and nonatopic control subjects, respectively (P < .05). Combined in situ hybridization immunocytochemistry performed on biopsy sections from asthmatic and control subjects demonstrated @aIL-4R mRNA expression in CD3-positive T cells and tryptasepositive mast cells, with T cells comprising the larger proportion of @aIL-4R mRNA-positive cells. Numbers of @aIL-4R mRNA-positive or immunoreactive cells did not correlate with CD3-positive cell numbers, numbers of IL-4 mRNA-positive cells, or indices of pulmonary function. Conclusion: These results demonstrate constitutive @aIL-4R expression in normal airways and enhanced expression in airway tissue from asthmatic individuals. (J Allergy Clin Immunol 1998;102:859-66.)

Methylosinus trichosporium exospores did not display a well-defined cortex or an exosporium. A thick, electron-dense exospore wall was characteristic of the exospores. Located on the exterior of the exospore wall was a cell wall to which a well-defined capsule was attached. An extensive lamellar intracytoplasmic membrane system characteristic of the kind in vegetative cells of this bacterium was present along the interior periphery of the exospore wall. Upon germination of M. trichosporium exospores, the thick exospore wall gradually disappeared and a germ tube formed. The intracytoplasmic membranes of the exospores extended into the germ tube which did not possess the extensive fibrillar capsule observed on the dormant exospore. Cup-shaped exospores which have an ultrastructure similar to that of mature exospores except that they are invaginated also germinated upon exposure to methane.

Preliminary experiments on the photoelectric detection of Raman spectra are described making use of commonly available spectroscopic equipment in conjunction with the new RCA-931 photomultiplier tube. A more eleborate experiment is described using a large planegrating monochromator as the dispersing device. The photoelectric current was suitably amplified and continuously recorded making use of a galvanometer and photographic galvanometer deflection recorder. The limit of detection set by the thermionic emission at room temperature of the photomultiplier has been reached. It is shown that the minimum intensity observable photoelectrically compares favorably with the minimum commonly observed photographically in Raman spectra. A rough order of magnitude experiment was performed with the photomultiplier to ascertain the feasibility of the photoelectric method for measuring intensities in arc and spark spectra under high dispersion. An arrangement of apparatus for quantitative spectroscopic analysis photoelectrically is suggested.