JEMSA 2006 Spring Edition by Konstantinos Roditis

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Journal of EMSA on Medical and Scientific Affairs

Contents Journal of EMSA … Editor’s Introduction III Samuel Ribeiro, Davor Lessel One Europe, One Voice: EMSA’s Mission 1 Emon Farrah Malik

… And Scientific Affairs Acute Myocardial Infarct—a view on pathophysiological processes, current therapy and ischaemia/reperfusion injury-prevention 16 Sajjad Muhammad, Saba Sajjad The Morphometric Characteristics of Myocardial Bridges

Ivan Stankovic, Milica Jesic

… On Medical … Alcohol Abuse – Its Role in Intensive Care Patients 4 Christoph Kiblb ck HIV/AIDS in Europe 7 Julia Hezoucky Evaluating our Sleep 10 Daniil Charalambos Aptalidis Human Experimentation— a Historical and Bioethical Perspective 13 Alexandre Santos, Anniina Palm

Clinical and Epidemiological Aspects of Human Leptospirosis in Georgia 24 Nickoloz Tchankoshvili, Givi Koberidze, Davit Butkhusi Development of Protocols for the Treatment of Common Cold 28 Conrad Buttigieg-Scicluna

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Chief Editors:

Disclaimer:

Samuel dos Santos Ribeiro (Portugal), Davor Lessel (Austria)

EMSA (European Medical Students’ Association), Thieme Publishing Group and the editor do not hold themselves responsible

Editorial Board:

for the statements made, or the views put forward in the vari-

Georg Dimou (Austria), Matthias Behrends (Germany),

ous articles and papers. Medical knowledge is constantly chang-

Natalia Romero Martinez (Spain-Catalonia)

ing. The authors and the editor, as far as it is possible, have taken care to ensure that the information given in this text is ac-

Cover illustration:

curate and up-to-date. However, readers are strongly advised to

Cristina Ioana

confirm that the information is correct. Despite judicious efforts

Special thanks to:

errors may have crept in and EMSA, the editor and the publisher do not accept responsibility for this.

Doris Pecival, Elisabeth Russe, Georg Dimou, Katharina Erb, Mischa Wejbora, Stefan Dallinger (Austria)

Divo Ljubicic (Croatia)

This journal, including all individual contributions and illustra-

Christiane Sherman, Simon Rieder (Germany)

tions published therein, is legally protected by copyright for the

Christos Kalitsis (Greece)

duration of the copyright period. Any use, exploitation or com-

Ruth Maria dos Santos Ribeiro (Portugal)

mercialisation outside narrow limits set by copyright legisla-

Emon Farrah Malik (United Kingdom)

tion, without the publishers’ consent, is illegal and liable to criminal prosecution. This applies in particular to photostat re-

Thieme Publishing Group R digerstraße 14, D-70469 Stuttgart Phone: + 49/ 0711/ 8931-0, http://www.thieme.com Printed in Germany

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ISSN: 0779-1577

itor, the article writers and the EEB (EMSA European Board).

III

JEMSA â&#x20AC;&#x201C; Journal of EMSA on Medical and Scientific Affairs 2006

Dear readers,

Message from the past...

It is an honour to release my first issue of JEMSA. As the nulli-

Dear readers,

parous Editor, I required much support and guidance so that this edition could see daylight. I would like to express my sin-

I hope that reading our journal will increase your interest in fol-

cere gratitude to all the help I received, namely from the former Editor, Davor Lessel, whose spontaneous co-operation has been

lowing (bio-)medical research. We have chosen a profession where studying is, and will remain, part of our lives. As we live

unique and continuous, making him a clear co-editor of this is-

in a time where new research is being published almost every

sue.

single day, I find it extremely important to incorporate the read-

JEMSA has gone through some adjustments since the last time it was published. To begin with, the sophisticated new design is a tribute of the recent collaboration with Thieme Publishing Group. Secondly, due to many requests by student-researchers, we intend to publish this Journal twice a year, having spring and

ing of various journals and magazines in our every day life. On the other hand, I hope that while reading this edition you will gain the courage to publish your own work either in JEMSA or in any other medical journal. Last but not least, my great appreciation goes to my colleagues,

autumn editions. As the subscription list increases, standards

members of EMSA European Board and members of Austrian

must raise, so we also intend to reformulate JEMSA's structure

Medical Students Association, whose support played an impor-

and distribution.

tant role: this edition would have been harder to accomplish without this help.

Now that all the first edition's struggles are surpassed, the JEMSA 2006 Spring Edition aims to be all what the 2005 issue was intended to be. I would specially like to thank the writers of the articles for their patience, since a few of them have waited for some time to see their articles published. I thank their reliance and hope all expectations have been achieved. This issue of JEMSA seeks to increase scientific awareness in the heart of all medical students in Europe and I hope that we are now one step closer to do so.

Best Regards, Samuel Ribeiro JEMSA Spring 2006 Editor

Best Regards, Davor Lessel JEMSA Spring 2006 Editor

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Journal of EMSA

One Europe, One Voice: EMSA’s Mission EMON FARRAH MALIK

The European Medical Students’ Association (EMSA) seeks to

the opportunities provided by the role of CPME Trainee who

improve the health and quality of care of the citizens of Europe, by acting as a conduit for increased interaction and sharing of

also acts as “EMSA Permanent Officer”, in Brussels. On a European level, EMSA is governed by an executive body, the EMSA

knowledge between European medical students in the fields of

European Board, which is responsible for the daily management

medical education, ethics and science. EMSA currently has ac-

of the Association.

tive Faculty Member Organisations in countries across the European Union and geographical Europe and is also proud to have

The European Medical Students’ Council is a politically neutral

working collaborations with many other institutions, including

body created by EMSA, with the aim of working towards the

the International Federation of Medical Students’ Associations

common goals of medical students throughout geographical Eu-

(IFMSA), the American Medical Students’ Association, the Asian Medical Students’ Association, the Permanent Working Group

rope. Common priorities identified include student welfare and the possibility of future standardisation of protocols in Euro-

of European Junior Doctors (PWG), the European Forum of Med-

pean medical schools, as well as the ever-changing medical cur-

ical Associations, the World Health Organisation and the

ricula in individual nations.

CPME—or the Standing Committee of European Doctors—and Associated Organisations. EMSA’s activities as an institution

The February 2005 meeting of the EMS Council in Warsaw,

pioneered by the medical students for medical students have

brought together the leading medical student representatives

further been endorsed by the European Commission in 2005

from across Europe to debate the feasibility of “Opt-out” from

and 2006. These activities extend from locally-based projects to those on national and European levels, which has enabled the

the European Working Time Directive and implementing the Bologna Process in medical education. The “Quality Assurance”

development of a diverse spectrum of young individuals to de-

Workshop, held in Copenhagen last July, co-hosted by the Dan-

vote their energies to the activities to which they believe they

ish Medical Students’ Association (FADL), EMSA and the IFMSA

can contribute most productively.

carried the debate further and comprehensively clarified the expectations of the medical student in achieving quality assurance

EMSA Faculty Member Organisations actively recruit young vol-

and quality control. Now, in these next stages, EMSA and the

unteers at their medical schools—individuals who can be at any

EMS Council hope to establish what the newly graduated doctor

stage of their medical education, be it first year to final year. Once a faculty joins EMSA, every medical student in that faculty

should be proficient at and whether a previously proposed “Core Curriculum” could be standardised/harmonised through-

has the right to actively engage in the EMSA networks and to

out Europe. Further issues of concern include plans to push for

jointly maximise the influence of the voice of youth in medical

changes in medical school policies regarding applicants with

and social affairs. This network expansion enables integration

disabilities (including learning disabilities) and it has been pro-

and harmonisation between medical students and also allows

posed that European-wide standardisation of admissions proce-

mobility within Europe, especially since students on the Eras-

dures can be a solution for this. Although facilitating this kind

mus or other exchange programmes are able to participate and

of change can be a slow and arduous process, the CPME and the

contribute in their own manner. Certain students may also choose to take time out of their official medical studies to spend

Associated European Medical Organisations are committed to quality assurance as a united European goal in the medical field

time focusing on another initiative—one such example of this is

and EMSA, as the representative in Brussels for the medical stu-

Fig. 1 3rd EMS Council 2006, Albufeira.

Journal of EMSA

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

amongst others. This widespread publicity and coverage has maximised interest from youth, enthusiastic to contribute and participate; it has been invaluable in promoting awareness of the importance of education in young children. The Teddy Bear Hospital scheme is a joint project of the IFMSA and EMSA. The Anti-Tobacco Campaign is fully backed by EMSA, especially with respect to educating young people about the dangers and health risks of smoking; this project is a theme that runs as a thread through all of EMSA’s flagship projects, even to the extent that all statutory meetings, workshops and work programmes are conducted in a strictly smoke-free environment. The Global Health Professionals Survey (GHPS) is also one of EMSA’s biggest priorities at this time, with members such as Austria, Malta, Croatia and Germany, already committed to the goals, with more countries starting to set up the means to parFig. 2.

dent sector, is determined to lead the way in assuring that the student voice is heard and actively consulted on progress.

ticipate, as well. GHPS was developed by World Health Organisation (WHO), the U.S. Centers for Disease Control and Prevention (CDC), the Canadian Public Health Association (CPHA), and the American Cancer Society (ACS) in 2004 to collect information from 3rd year health professionals attending dental, medical, nursing, and pharmacy schools. The European participation

At the last meeting of the EMS Council (January 2006), in Albu-

in GHPS is coordinated by EMSA. After having been highly in-

feira, Portugal, the BMA Medical Students’ Committee, as a

volved in the Tobacco Action Group of the European Forum of

member of the EMS Council, was actively represented in the de-

Medical Associations and WHO (EFMA-WHO), EMSA was ap-

bate on equal opportunities and EMSA and the BMA hope to use the outcomes of the meeting to facilitate future discussion in

proached by the WHO Europe Regional Office (WHO-EURO), since it is already working on the development of methodology

the student sector and draft guidelines which can be used to

to assess smoking habits and attitudes among medical students

lobby for policy changes and clarifications across European medical schools in the European Higher Education Area, partic-

in Europe.

ularly with regard to the idea of National and European Licens-

Furthermore, one of EMSA’s themes, together with the Anti-To-

ing Examinations, on a post-graduate level.

bacco Campaign and HIV/AIDS awareness, is sport and sports medicine, inspired by EYES—the European Year of Education

Follow-up workshops on “Patient Safety” are also aims for 2006 and the World Healthcare Students’ Symposium (formerly the

through Sport 2004, together with education and awareness training on exercise and healthy eating aimed specifically at

World Medical and Pharmaceutical Students Scientific Sympo-

youth in Europe, in conjunction with the EMSA series on Diabe-

sium) also aims, in cooperation with medical, nursing and pharmaceutical student organisations, to strengthen and highlight

tes and Obesity, in the field of medical science. With regard to

the inter-professional cooperation between medicine and phar-

process of construction on a range of topics, including euthana-

macy, with a special regard to public health and patient safety.

sia, access to healthcare for minority populations and the man-

This is scheduled to take place in 2007, thus requiring tremen-

agement of suspected domestic or non-domestic violence. Work-

dous input and resources in 2006, in preparation.

ing group members include representatives from some EU Member States, as well as an EU Candidate country (Romania)

Further support and integration with young people is provided

and a potential EU Candidate country (Croatia), to cover a di-

by projects such as the EMSA “Substance Misuse Support (SMS) Project”, aimed at educating and supporting young people, in

verse geographical and political spectrum. Keeping in line with

realising and appreciating the dangers of substance misuse. The

tient Safety (a continuing priority of the EU), the medical ethics

EMSA “Best Buddy” project is a mentoring scheme, allowing

sector will also focus heavily on medical error and the ethical

medical students to team up with younger people, who may

implications. It is expected that an ethically-based system for re-

have fewer opportunities, disabilities or confidence issues.

porting such error will be constructed and proposed, as a followup to former EMSA and EMS Council policies on Patient Safety.

medical ethics, a series of youth-led working groups are in the

the lead that EMSA has taken in the student perspective on Pa-

Moreover, the highly acclaimed “Teddy Bear Hospital” scheme is EMSA’s most successful and widespread project to date, benefiting thousands of very young children every year, in teaching the

And so the struggle continues. There has never been a greater

benefits of healthy eating, safety in the home and, ultimately,

the European Union’s influence continues to expand exponen-

reducing “White Coat Anxiety”, i.e. fear of the doctor and hospi-

tially and certainly, medical students simply cannot afford to lag

tal environment. Teddy Bear Hospital is run in almost every

behind, especially in times of educational and health reforms.

EMSA Faculty Member Organisation and has been featured in national television specials and countless publications across

This Association is only 15 years old—such a tender age for an organisation which is only just spreading its wings—and already

Europe, including the Student British Medical Journal (sBMJ),

those luxuries of open debate, dialogue and freedom of expres-

the Journal of EMSA on Medical and Scientific Affairs (JEMSA)

sion are slowly becoming realities throughout the continent.

need for the student voice to be heard in unity, particularly as

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Journal of EMSA

This Journal itself is an excellent example of the way students

The time for medical students—the doctors of tomorrow—to

and young professionals can express their knowledge and growing expertise in a range of fields and sow the seeds of education

lead the way is now. In the words of Theodore Hesburgh, “The very essence of leadership is that you have a vision”.

for the next generation of healthcare professionals and scientists. We all have the tremendous honour (and responsibility) of

We have a vision.

moulding something timeless and it would be reckless for us in

“One Europe, One Voice”.

the 21st century to forgo this opportunity.

Contact Emon Farrah Malik President 2005–6 European Medical Students’ Association president@emsa-europe.org www.emsa-europe.org

Medical Affairs

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Alcohol Abuse—its Role in Intensive Care Patients: a Review CHRISTOPH KIBLB CK

Medical University of Vienna, Austria

Introduction

al. found no difference in the average age (mean 56 years) the alcohol-related patients in the study of Uusaro et al. were 12

Alcohol abuse is a major health problem in many countries. It

years younger than the other group (48 vs. 60 years). Mostafa et

has been estimated that in the UK at least 25 % of emergency ad-

al. classified the patients into three groups according to their

missions and 15 % of all hospital admissions can be attributed to

history of alcohol intake and diagnosis. Those in whom the con-

alcohol abuse [1]. Alcohol is a contributory factor in 25 % of all

dition that necessitated admission was directly associated with

deaths in road traffic accidents, 40 % of all deaths from fall, 40 %

alcohol consumption and who consumed > 21 units per week

of all deaths in fires and 15 % of all deaths from drowning [2]. In

for males and > 14 units per week for females constituted Group

Austria estimates based on data from hospital discharges assume that 5 % of the population over 16 years are chronic alco-

1. Group 2 were those who described themselves as “social drinkers” or consumed less than that given amount. Group 3

holics. With 6,65 mill people in that group the total number is

comprised patients that denied any alcohol intake. Those were

330 000. 20 % of which are women. With an average alcohol

the diagnostic categories they found:

consumption of 226 g/d for men and 130 g/d for women those 5 % consume 1/3 of the total alcohol consumption in Austria. The number of alcohol-related deaths in Austria reaches 8000 a year and the expectency of life in chronic alcoholics is 20 years below average [3]. In Finnland, for example, a thesis has shown that in the < 50-year age group, 40 % of all deaths amongst men and 15 % amongst women are related to alcohol [4].

Table 1. Mostafa et al. patient classification according to alcohol intake and diagnosis. Group 1: more then 21 units per week for males or more then14 units per week for females. Group 2: those who described themselves as “social drinkers” or consumed less than that given amount. Group 3: comprised patients that denied any alcohol intake Diagnosis

Group 1

Group 2

Group 3

(n = 89)

(n = 35)

(n = 87)

Cancer

Cirrhosis

Pneumonia

During a clinical elective at the intensive care unit at the Foothills Medical Centre in Calgary (Canada), a 22 bed mixed unit in tertiary care center, I was astonished about how many of our patients seemed to have a history of either acute or chronic alcohol abuse. Therefore I decided to go into that problem on a more scientific basis. My main interest was on the proportion of intensive care unit admissions related to alcohol abuse and if

Trauma

there are any differences between that group and non-alcohol

Overdose

Miscellaneous*

related admissions regarding the number and severity of complications, lenght of stay (LOS) and the mortality rate.

* Pancreatitis, perforated doudenal ulcer, alcoholic cardiomyopathy, thrombosis of mesenteric vessels, subarachnoid haemorrhage

Methods My findings are based on a literature research and comparison

As you can see above Group 1 amounted for 17 out of 24 trauma

on medline. There are only three studies explicitly dealing with

admissions (= 70 %) of whom 11 were pedestrians. This is higher

that topic [5, 6, 7]. All of them are prospective cohort studies with either 317 [5], 893 patients [6] or 200 patiens [7]. At the

than figures found in previos studies that stated that the prevalence of chronic alcoholics in traumatized patients is between

time of admission patients were distributed into three different

50 and 60 % [11, 12].

groups whether there was a definte history of alcohol abuse and relationship to the patient¢s illness, whether this relationship was likely or there was no relation. No biochemical markers

A paper [8] dealing with intercurrent complications of chronic

concentrations were used.

trauma showed that the rate of major complications was 196 %

alcoholic men admitted to the intensive care unit following in the chronic alcoholic vs 70 % in the non-alcoholic group. The

Results

diagnoses of alcohol abuse and alcohol dependence were made following the DSM-III-R and ICD-10 criteria based on the CAGE questionaire and laboratory markers such as mean corpuscular

Researchers found a definite relationship between alcohol and

volume (MCV), aspartate amino-transferase (ASAT), gamma-

ICU admission in 17,5 % of 893 admissions in Kupio [6], in 21 % of 200 consecutive admissions in Detroit [7] and in 28 % of 311

glutamyl-transferase (GGT) and carbohydrate-deficient transferrin (CDT).

admissions at an ICU in Liverpool [5]. In further 11,1 % [5] and 6,6 % [6] alcohol use was likely to contribute to the admission.

As you can see complications such as alcohol withdrawal syn-

Males amounted over 75 % of the alcohol-related admissions [5, 6]. Whereas the ratio was 60:40 % and 52:48 % (males:females)

drome (AWS) and pneumonia significantly differed between the two groups, whereas sepsis, bleeding disorders, and the mortal-

[5,6] in the nonalcohol-related admissions. Whereas Mostafa et

ity differed in tendency, but were not significantly different [8].

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Medical Affairs

Table 2. Spies CD et al. results on the complications in chronic alcoholic men admitted to the intensive care unit following trauma Major complications

Chronic alcoholics (n = 69)

Non-alcoholics (n = 39)

in total

135/69 (196 %)

23/33 (70 %)

Death

16/69 (23 %)

4/33 (12 %)

AWS

42/69 (61 %)

0/33 (0 %)

P = 0.0000

Pneumonia

31/69 (45 %)

8/33 (24 %)

P = 0.0454

P = 0,0001

Organisms isolated Pseudomonas aeruginosa

Staphylococcus aureus

Sepsis

19/69 (29 %)

4/33 (12 %)

Cardiac complications

11/69 (16 %)

4/33 (12 %)

Bleeding disorder

16/69 (23 %)

3/33 (9 %)

A higher incidence of pneumonia was also demonstrated in

was significantly higher than in other patients with one of seven

Group 1 (29,2 %) compared to Group 3 (21,8 %) [5].

at-risk diagnoses for the development of ARDS (43 vs 22 %, P < 0.001). In the subset of the patients who developed ARDS, the

Alcohol has been recognised as a direct risk factor for pneumonia [13]. Alcohol adversely affects both the respiratory and the

in-hospital mortality rate was 65 % in the chronic alcoholics group compared to 36 % (P = 0.003) in patients without a history

immune system [14,15]. Alcohol abuse is associated with greater

of alcohol abuse [21].

colonization of the oral cavitiy with gram-negative flora, impaired respiratory clearance mechanisms, inlcuding depressed

Regarding the lenght of stay (LOS) the research shows different

glottal reflexes, cough reflex, ciliary action and a risk of altered consciousness and vomting with aspiration [14, 16]. Further-

results. Whereas in one study no difference in the LOS (4 days

more, granulocyte numbers and function can be adversely af-

with a median difference of 8 days or even up to 13–14 days if

fected by alcohol [17].

patients developed AWS [8, 9]. Uusaro et al. [6] on the other

on average) is found [5], others state that the LOS was prolonged

hand found a slightly shorter LOS (median 0,6 days) in the paDespite of its role as a risk factor for the development of pneu-

tients with a history of alcohol abuse.

monia it has been shown that alcohol abuse also is a prognostic factor for resource utilization. Resulting in a 60 % higher use of intensive care, a 0,6 day longer lenght of stay and therefore

Discussion

$ 1200 higher charge per hospitalization, although there was no difference in mortality [18].

It is rather surprising that there are only three studies assessing the proportion of alcohol-related admissions to intensive care

This is consistent with the findings of Uusaro [6]. Another study

treatment [5–7]. Their samples with 200 and 893 patients are

showed that chronic alcohol abuse has no addittional adverse

rather small. Furthermore they were done in different countries

effect on the function of extrahepatic organs and ICU mortality

with different drinking habits and may not be representativ for

in patients with liver cirrhosis [19]. This is in contrast to other

other nations, such as Austria. If you look at the number of

data that shows a significant difference in the mortality of the

deaths from liver cirrhosis for men you will find low figures for

alcohol-related and nonalcohol-related admissions [5, 9, 20].

England and Wales and the US (10,2 and 14,7 out of 100 000 in-

The mortality rate in Group 1 with 41.6 % was significantly

habitants) compared to Austria with 32,7 out of 100 000 [22].

higher compared to that of Group 3 (18,4 %, P < 0.001) or the entire sample studied (23,7 %, P < 0.001) [5]. Another study dealing with the severity of illness and outcome of treatment in alco-

All of them address the difficulty to categorize the patients and to define the possible relationship between alcohol misuse and

holic patients in the intensive care unit found alcoholics to be

ICU admission. While moderate alcohol consume may also pre-

significantly sicker and had a higher mortality (50 % compared

dispose to illnesses or injuries, it is logical that ICU admission

to 26 %) than other critically ill patients [20]. Spies et al. have

may not be related to alcohol use even in chronic alcoholics.

showed that only the chronic alcohlics died during a subsequent

Mostafa’s classification into the three groups is completely

ICU stay following tumor resection of the upper digestive tract

based upon the amount of alcohol consumption obtained when-

(9 patients = 7 % vs 0 %, P = 0.0438). Major surgical complications such as anastomotic leakage or necrosis of the transplant

ever possible directly from the patient, their relatives or the

only occured in chronic alcoholics aswell. Subsequently the

case history. Uusaro admits that it may be viewed as a weakness of the study that it was the subjective judgment of the admit-

number of operations secundary to complications and bleeding

ting physician to asses the possible relationship between alco-

disorders were increased in that group [9].

hol use and admission [6].

In a related study the incidence of acute respiratory distress

Naturally this is not only of scientific interest. One of the major

syndrome (ARDS) in patients with a history of alcohol abuse

life-threatening complications associated with alcohol depend-

Medical Affairs

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

ence is AWS, which can be prevented by pharmaco-prophylaxis.

adult intensive care unit: an audit. Eur J Anaestesiol 2002;

However recognition and management is often delayed in ICU patients because the differential diagnosis includes a broad

6. Uusaro A, Parviainen I, Tenhunen J, Roukonen E. The pro-

spectrum of common complications, e.g., infection, hypoxemia,

portion of intensive care unti admissions related to alcohol

bleeding, metabolic and electrolyte disorder or pain [8]. There-

use: a prospective cohort study. Acta Anaesthesiol Scand

fore it is essential to routinely determine alcohol dependent pa-

19: 193–6

2005; 49: 1236–1240

tient in the ICU setting. In reality only 16 % of chronic alcoholics

7. Marik P, Mohedin B. Alcohol-related admissions to an inner

are detected preoperatively [23]. The sensitivity and specificity

city hospital intensive care unit. Alcohol Alcohol 1996; 31: 393–6

of laboratory markers such as CDT (58 % and 90 %) or GGT (59 % and 72 %) are limited. Only a combination of those parameters and the CAGE questionaire increased the rate of detecting alco-

8. Spies CD, Neuner B, Neumann T, Blum S, M ller C, Rommels-

hol-dependent patients up to 72 % [23] or even 91 % [8]. This

Striebel HW, Schaffartzik W. Intercurrent complications in

seems to be a reliable and practicable way to categorize patients

chronic alcoholic men admitted to the intensive care unit

in groups for further research and for the timely risk assessment of other complications such as ARDS or pneumonia as well.

pacher H, Rieger A, Sanft C, Specht M, Hannemann L,

following trauma. Int Care Med 1996; 22: 286–293 9. Spies CD, Nordmann A, Brummer G, Marks C, Conrad C,

As shown above there are different answers concerning the

Berger G, Runkel N, Neumann T, M ller C, Rommelspacher H, Specht M, Hannemann L, Striebel HW, Schaffartzik W.

question if alcohol abuse leads to an increased mortality rate

Intensive care unit stay is prolonged in chronic alcoholic

during an ICU stay. Whereas some studies [6, 18] did not find

men following tumor resection of the upper digestive tract.

any difference [2] others found a mortality rate that significantly differed [5, 9, 20]. It certainly does if the patient developes a ma-

10. Ewing JA. Detection alcoholism, The CAGE Questionaire.

jor complication such as ARDS, which may be more likely in

Acta Anaesthesiol Scand 1996; 40: 649–656 JAMA 1984: 252: 1905–1907

chronic alcoholic patients [21]. The studies [6, 20] agree that

11. Herve C, Gaillard M, Roujas F, Huguenard P. Alcoholism in

there is no difference to be found in the intensity of the treatment between the different groups measured by the Thearpeutic

polytrauma. J Trauma1986; 26: 1123–1126 12. Soderstrom CA, Dischinger PC, Smith GS, Mc Duff DR, Hebel

Interventions Scoring System (TISS). Regarding the lenght of stay

JR, Gorelick DA Psychoactive substance dependence among

Uusaro et al. admit that their case mix with twice as many gas-

trauma center patients. JAMA 1992; 267: 2756–2759

troenterological patients in the alcohol-related group compared with twice as many patients with the diagnostic category “res-

13. Fernandez-Sola J, Estruch R, Monforte R, Torres A, Urbano-

piratory failure” and “circulatory failure” in the other may have

factor for community aquired pneumonia. Arch Intern Med

caused the discrepancy between their results of a shorter LOS for the chronic alcoholic group and previous findings. Recapitulatory the authors come to the conclusion that alcohol plays a major role in the admission of ICU patients. That those patients may be considered as high-risk patients for the developement of life-threatening or prolonging complications and that further investigations are warranted to ascertain the magnitude of the problem. Finally, it has to be stressed that in chronic alcoholic patients the ICU stay is everything but curative.

Marquez A. High alcohol intake as a risk and prognostic 1995; 155: 1649–1654 14. Krumpe PE, Cummiskey JM, Lillington GA. Alcohol and the respiratory tract. Med Clin North Am 1984; 68: 201–209 15. Glassman AB, Bennett CE, Randall CL. Effects of ethyl alcohol on human peripheral lymphocytes. Arch Pathol Lab Med 1985; 72: 40–51 16. Berkowitz H, Reichel J, Shim C. The effect of ethanol on the cough reflex. Lin Sci Mol Med 1973; 45: 527–531 17. Ballard HS. Hematological complications of alcoholism. Alcohol Clin Exp Res 1989; 13: 706–720 18. Saitz R, Ghali WA, Moskowitz MA. The impact of alcoholrelated diagnoses on pneumonia outcomes. Arch Intern Med 1997; 157:1446–1452

Acknowledgements

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This paper was written during a course on Lifestyle Medicine in

abuse has no additional adverse effect on the function of

Public Health given by Prof. Dr. Anita Rieder at the Medical Uni-

extrahepatic organs and ICU mortality in patients with liver

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2. Department of Health, The Health of the Nation. Key Area

21. Moss M, Boucher B, Moore FA, Moore EE, Parsons Pe. The

Handbook: Accidents. London, UK: HMSO 1993 3. BM f r soziale Sicherheit und Generationen, A. Uhl et al. (Hrsg.): Handbuch Alkohol – sterreich 2002 – Zahlen, Daten, Fakten Trends

15(1):19–22 role of chronic alcohol abuse in the developement of acute respiratory distress syndrome in adults. JAMA 1996; 275(1): 50–54 22. Jahrbuch Gesundheitsstatistik, Statistik Austria, 2002

4. M kela P. Alcohol related deaths. Incidence and association

23. Verner L, Voß A. Die Bedeutung des Parameters Geschlecht

between gender and socio-economic status. Academic Dissertation. Helsinki: University of Helsinki, 1999

im Umgang mit alkoholisierten PatientInnen in der An s-

5. Mostafa SM, Murthy BVS. Alcohol-related admissions to an

thesie und Intensivmedizin. Wien Med Wochenschr 2004; 154/17–18: 433–438

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Medical Affairs

HIV/AIDS in Europe General epidemiology and an overview of the students work in Austria JULIA HEZOUCKY

Medical University of Vienna, Austria; National Officer on Reproductive Health incl. HIV/AIDS, AMSA-Austria

39.4 million people, worldwide, are infected with HIV, the Hu-

than 3000 people living with HIV are currently receiving anti-

man Immunodeficiency Virus. In 2004, 4.9 million people were

retroviral medication, less than 5 % of them are injected-drug

HIV infected, including 640 000 children under 15 years. World

users in remission. There are several reasons for this, including

wide, 17.6 million women and girls live with HIV and 2.2 million

high antiretroviral drug costs, despite ongoing efforts to negoti-

children under 15 years. Extremely shocking is the fact that

ate lower prices, as well as discrimination and marginalisation

daily there are 14 000 newly infected people; only in Europe

of the group of citizens in need: injecting-drug users.

30 000 to 40 000 people get newly infected per year. The number of people who died of AIDS (Acquired Immune Deficiency

In North America, Western Europe and Central Europe some

Syndrome) since the first diagnosed HIV case in 1982 is increas-

64 000 new infections occurred in 2004, raising the number of

ing every day, only in 2004 3.1 million died, including 510 000

people living in these countries to 1.6 million. The number of

children under 15 years.

women and girls living with HIV in 2004 rose to 420 000. In Western Europe, thousands of new infections are occurring

By the end of 2004, in Eastern Europe and Central Asia the num-

every year and an astonishing large number of HIV-infected

ber of people living with HIV had risen, in just a few years, to

people are unaware of their HIV status. A large share of new HIV

1.4 million. This is an increase of more than nine-fold in less than ten years. About 210 000 people were newly infected with

diagnoses is in people originally from countries with serious epidemics. The highest risk in getting an HIV-infection is still

HIV in the past years, while about 60 000 died of AIDS. Among

increasing among male homosexuals, with a prevalence of 10–

young people, aged between 15 and 24 years, 0.8 % of women

20 % or higher, and drug users. But also the HIV diagnoses in

and 1.7 % of men were living with HIV at the end of 2004.

people who were infected through heterosexual contact increased by 122 % between 1997 and 2002. A large share of those

The most serious and firmly-established epidemic is in the Uk-

diagnoses are in people originally from countries with serious

raine, while the Russian Federation is home to the largest epi-

epidemics, principally countries in sub-Saharan Africa and the

demic in all of Europe. Surprisingly the vast majority of people living with HIV in this region are youngsters. More than 80 % of

English-speaking Caribbean. Due to the increasing number of HIV infections transmitted through heterosexual intercourse,

the reported infections are being found among people below

the proportion of women among people newly diagnosed with

the age of 30 years, while in comparison, in Western Europe

HIV-infection increased as well, from 25 % in 1997 to 38 % in

only about 30 % of people with HIV fall in this age group. The

2002. In France about 66 % of the newly diagnosed people with

reason is the large number of young people injecting drugs and

HIV were infected during heterosexual intercourse in 2003 and

having active and unprotected sex lives. Between 1.5 and 3 mil-

in Germany 41 %. A significant number of female sex workers

lion Russians are believed to inject drugs (1–2 % of the entire

are still being infected in some countries, such as the Nether-

population), and estimated 30–40 % use non-sterile needles or syringes. For example, about 65 % of street injecting-drug users

lands, where a 2002–2003 study found 7 % of sex workers in Rotterdam were HIV positive.

in Irkutsk were HIV-positive, 90 % of them still in their teens. The majority of male drug users do not use condoms consis-

In the countries of central Europe, including Czech Republic and

tently; hence the proportion of new reported HIV infections ac-

Hungary, numbers of new HIV infections have stabilised since

quired during heterosexual intercourse has grown steadily and dramatically from 5.3 % in 2001 to almost 15 % in 2002 and just over 20 % in 2003. The number of women living with HIV has increased to 38 % in 2003. Reported cases of pregnant women with HIV have increased in the past six years from 125 in 1998 to 3531 in 2003. The total number of children born with the virus has risen to more than 9000. Drug abuse and commercial sex is one of the highest risk factors for women. 81 % of the surveyed said they injected drugs, 65 % of them had used non-sterile injecting equipment. 48 % of them were HIV positive; among those aged 20–24 years, 64 % were infected. Also, the number of commercial sex partners was found as a reason for higher risk. The HIV prevalence among sex workers with 2–4 partners was 30,8 %, with 20 or more partners, 66,7 %. Russian law assures free, universal access to antiretroviral drugs for all citizens. However, current estimates suggest that fewer

Fig. 1 Open-line-radio show.

Medical Affairs

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

the late 1990 s, with most of the new infections being reported

team is trained in workshops by professional sexual peda-

in Poland. In the Czech Republic, the Slovak Republic, Hungary and Slovenia, male homosexual intercourse is known to be the

gogues, as well as by experienced peer educators themselves. Once a year a three-national workshop takes place together

predominant mode of HIV transmission. Unlike elsewhere in

with similar and linked education projects in Switzerland and

the world, a large majority of people from most countries in this

Germany, as well as a national workshop. Regularly there are

region who need antiretroviral treatment actually do have ac-

methods-training-days held by the own experienced peer-edu-

cess to it. As a result, AIDS deaths have been remarkably low

cators. The training basically focuses on “how to answer black-

after being very high in the mid-to-late 1990 s.

box-questions correctly” (anonymous posed questions by the pupils) and “which methods” should be used in different situa-

In Austria 1–2 people are HIV infected every day and about 430 people are newly infected per year (58 people/1 million),

tions, depending on the age and the boys-girls distribution, as well as on the cultural background in classes. There is an actual-

whereas the rate in Germany is only half, 2000 per year,

isation of knowledge and facts on topics like STI’s or contracep-

(24 people/1 million). From 1983, when the first HIV case in

tion as well.

Austria was diagnosed, till April 2005, 2416 people were HIV infected, 1393 of which died of AIDS. One third of all AIDS cases

There is always a team of one female and one male student in a

were infected by injecting drugs, about half were through male

classroom, while the teacher is absent. For four hours the ach-

homosexual encounters. At the moment, about 13.500 people

tung liebe team talks with the class about relationships, friend-

are living with an HIV infection, 1022 people with AIDS. The highest transmission rate is 35,1 % due to homosexual and bi-

ship, sex, STD’s HIV/AIDS etc. Several methods are used to facilitate the pupils’ participation. As all classes are quite different,

sexual intercourses and 14,5 % due to injecting-drug use. Unex-

the main focus differs, being set up, sometimes, more on rela-

pectedly the transmission at heterosexual intercourse is raising

tionships or on sex. A “black-box” is placed in the classroom

to 18,5 %. Hence already one third of the HIV infected people in

where anonymous questions are thrown in during the whole

Austria are women. The major newly infections may be attrib-

workshop. At the end all questions are read out loud and an-

uted to heterosexual contacts. Yearly over 1,2 million people are

swered by the team.

tested on HIV antibodies, that means every seventh person in

unsafe sex. Especially in young peoples minds, HIV and AIDS are

Frequent “Black-box”-questions: Q “is it possible to fuck yourself to death?” Q “how large is a penis?”

not so extraordinary anymore. They seem to be annoyed by this

Austria, 0,5 million of whom are blood donors. In short, the major reasons are injecting-drug use with non-sterile needles and

people often get a wrong idea of HIV/AIDS since surveys show

“my friend already has her period. I haven’t. Is that a problem?”

topic and see condoms just as a means of contraception. Young Q

“is it possible to get HIV-infected by swallowing sperm?”

how they think HIV positive people can be recognised by their ill appearances. Hence, the most important way to reduce HIV/

Other activities are to organize the World AIDS Day. On Decem-

AIDS is education and raising awareness which was enabled with the AIDS-law from 1985, which declares that informational

ber 1st, 2004, there was a big action in Vienna at the UEFA-Cup match FK Austria Magna : FC Br gge in the Ernst Happel sta-

campaigns have to be organised for the public regularly.

dium. A Red Ribbon made out of 75 m cloth was placed on the football pitch before the start of the match. The stadium speaker

Given the high incidence of HIV, Austrian Medical Students (attention Association started a project for pupils,

read out facts about HIV/AIDS to the fans while on the stadium

love) which is being organized in Vienna and Graz. This

to the officials and the trainers. There was an article about it in

project focuses on peer-education and sexual education in

“Die Presse”, Austrian newspapers, and on an internet maga-

schools with pupils aged between thirteen and seventeen, involving medical and psychology students. The achtung liebe

zine. We were able to reach over 25 000 people!

Fig. 2 Peer-education.

Fig. 3 World AIDS Day 2004.

screen “Welt AIDS Tag” appeared. Red Ribbons were handed out

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Medical Affairs

general and it’s juridical issues, for instance, what happens if a student or a physician gets HIV infected. Since spring 2005 achtung liebe is invited, on a monthly basis, to the national radio station, FM4, to create an open-line radio show. Topics about sex including HIV/AIDS and relationships are discussed with the moderator and the audience. It is a great success and further open-line radio shows are being planned. In June 2005 a huge achtung liebe party with 600 people took place, organised to raise some money and for public relations work. This year’s winter term started very successfully. Beside lots of peer-education in schools and in youth centres achtung liebe won the second place at the “Vienna Health Award”. In December the AMSA and achtung liebe joined the Austrian AIDS Campaign. Far more activities are being planned, hoping fund Fig. 4 World AIDS Day 2005.

support.

In 2005 we decorated an ice hockey stadium with eight Red Rib-

In conclusion, it is important to say that everyone is responsible for their own life and health, which is the most valuable thing

bons and again the speaker gave factual information about HIV/

we have. In order to be able to help and teach others we have to

AIDS. We reached more than 4000 fans. The WAD was also an-

keep this concept clear in our minds. Love and be loved but, at

nounced at the club’s homepage. Both events were broadcasted

the same time, live and let live!

live at Premiere Austria. With love and condom, Further in Innsbruck Red Ribbons were given to professors at

Julia

the Teaching Hospital and a workshop for students was held. In Graz a big party was organized with 600 guests.

References: 1. UNAIDS (www.unaids.org)

In all three cities Red Ribbons were handed out to bar-keepers

2. WHO (www.who.int)

and waiters and questions were posed to people about HIV/

3. BMGF (www.bmgf.gv.at)

AIDS. For each correct answer they got a condom or a ginger-

4. AIDS-Hilfe Wien (www.aids.at)

bread-sperm. One of the highlights was an open-line radio show about contraception, HIV/AIDS. Contact In April 2005 SCORA and achtung liebe did a workshop for med-

E-mail: julia.hezoucky@amsa.at

ical students during the “Med Success”, which is a weekend

www.achtungliebe.at

filled with workshops and talks by professors and several NGOs

www.amsa.at

at the Medical University of Vienna. The topic was “HIV&Job” and this work shop was filled with facts and cases about HIV in

Medical Affairs

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Evaluating Our Sleep DANIIL CHARALAMBOS APTALIDIS

Have you ever woken up in the morning feeling really tired re-

responsible for lob impairment and motor vehicle crashes. For-

gardless the fact that you have slept all night and at least eight hours? Are you feeling without any energy at all through out

tunately, sleep apnea can be diagnosed and treated. Several treatment options exist, and research into additional options

the day? Is it hard to concentrate and memorize things as you

continues.

used to? Don’t be scared. You are not the only one. Millions of people are suffering from the same symptoms as well. It is a

Sleep apnea can be diagnosed through a very simple procedure

common thing for people to feel tired after a night’s sleep and

called polysomnography.

very often this occurs due to the bad quality of their sleep. To find out whether it is really like that and what the solution to

Polysomnography (PSG) is a diagnostic test during which a

this problem is, all you have to do is book an appointment at your nearest sleep disorder center.

number of physiologic variables are measured and recorded during sleep. Physiologic sensor leads are placed on the patient in order to record:

There you will be tested to see whether you suffer of sleep ap-

nea or any other sleep disorders. How you will be diagnosed/

2. Eye and jaw muscle movement

tested and what exactly are these disorders is about to be ex-

3. Leg muscle movement

plained. But before that we have to understand that by saying

4. Airflow

sleep we are actually referring to all three stages that consists of

5. Respiratory effort (chest and abdominal excursion)

a night’s sleep.

6. Electrokardiogram (EKG) 7. Oxygen saturation

Brain electrical activity

These stages are: –

Wake

How does it work?

–

Stages 1—4 (NREM sleep)

Information is gathered from all leads and fed into a computer

and outputted as a series of waveform tracings which enable

–

transition from wake to sleep

2. light sleep

the technician to visualize the various waveforms, assign a score

3. transition into REM sleep

for the test, and assisting the diagnostic process.

4. deep sleep REM sleep

Electroencephalogram (EEG) Six electrodes (labeled C3, C4, A1, A2, O and O2) and one ground

But what is this sleep apnea? The Greek word “apnea” literally

electrode are placed around the cranium to record electrical ac-

means “without breath”. There are three types of apnea: ob-

tivity across the brain. These leads are used to determine the

structive, central and mixed; of these three, obstructive is the

stage of sleep the patient is in during any given period of the

most common. Despite the difference in the root cause of each

night.

type, in all three, people with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times during the night and often for a minute or longer.

Electrooculogram (EOG) One electrode is placed above and to the outside of the right eye, and another electrode is placed below and to outside of the

Obstructive sleep apnea (OSA) is caused by a blockage of the air-

left eye. These leads record the movements of the eyes during

way, usually when the soft tissue in the rear of the throat col-

sleep and serve to help determine sleep stages.

lapses and closes during sleep. In central sleep apnea, the airway is not blocked but the brain fails to signal the muscles to

Electromyogram (EMG)

breathe. Mixed apnea, as the name implies, is a combination of

Three leads are placed on the chin (one in the front and center

the two. With each apnea event, the brain briefly arouses people with sleep apnea in order for them to resume breathing, but

and the other two underneath and on the jawbone) and two are placed on the inside of each calf muscle 2–4 cm apart. These

consequently sleep is extremely fragmental and of poor quality.

leads serve to demonstrate muscle movement during sleep. This is helpful in documenting a wake period, an arousal, or just a

Sleep apnea is very common, as common as adults’ diabetes.

spastic movement.

Risk factors include being male, overweight, and over the age of forty, but sleep apnea can strike anyone at any age, even chil-

Electrokardiogram-Electrocardiogram (EKG/ECG)

dren. Yet, still because of the lack of awareness by the public

Two electrodes are placed on the upper chest near the right and

and healthcare professionals, the vast majority remain undiagnosed and therefore untreated, despite the fact that this serious

left arms. These record the heart rate and rhythm. They also demonstrate whether apneic desaturation leads to arrhythmias

disorder can have significant consequences.

or not.

Untreated sleep apnea can cause high blood pressure and other

Airflow (thermistor or thermocouple sensor)

cardiovascular disease, memory problems, weight gain, impo-

A device similar to a nasal cannula is secured just under the pa-

tency, and headaches. Moreover, untreated sleep apnea may be

tient’s nose. It senses the amount of air moving into and out of

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Medical Affairs

the airways and sends a signal to a physiological recorder. This

is attached to a supply of continuously flowing air via a flex-

tracing is used to determine the presence and extent of apneic episodes.

ible plastic hose from a medical air pump that sits on the floor or bedside table. The flow of air goes into the mask through the nose into the upper airway. This positive pres-

Respiratory effort (piezo crystal effort sensor)

sure dilates the upper airway so the breathing is not inter-

Two Velcro bands, one placed around the chest under the

rupted. When a sleep apnea patient no longer has obstruc-

breasts and one around the abdomen, serve to determine chest

tive breaths they are able to sleep continuously and hence

wall and abdominal movements during breathing. Each band is

their quality of sleep improves dramatically. An added bene-

joined together by a piezo crystal transducer. The force of chest/

fit is that when the upper airway is dilated sufficiently there

abdominal expansion on the bands stretches the transducer and alters the signal to a physiological recorder. These leads, com-

shouldn’t be any further snoring. The amount of airflow and hence the amount of pressure is determined by your doctor.

bined with the airflow sensor, are how apnea is demonstrated

To date this has been the most successful and well studied

and categorized during the test.

treatment for sleep apnea. It is usually well tolerated and does not have any serious side effects.

Oxygen Saturation (Pulse oximeter)

2. One of the reasons for the upper airway to become nar-

The O2 saturation is measured by a pulse oximeter probe placed

rowed at night is because the tongue falls posteriorly, espe-

on the patient i.e. finger, earlobe etc.

cially in the supine position. Since the tongue is attached to

If the sleep disorder center is equipped with video cameras in

mandible this can be a significant problem in people with retrognathia and/or large tongue. It is possible to use a den-

the patient’s room, the patient can be filmed while sleeping.

tal splint at night which effectively prevents the jaw and

This allows the technician to review the tape at any time during

tongue from moving back when someone lies down and

the test and verify whether strange looking waveforms were

goes to sleep. There has been less experience with this type

caused by an actual arousal, a period of wake, or normal patient

of treatment compared to CPAP, since the upper airway can

movement in bed.

be narrowed for different reasons, this approach may not work for all patients. This splint may put some strain on the

Interpretation of the test results

temporal mandibular joint, causing some discomfort. Patients should consult dentists or orthodontists that are knowledgeable about sleep apnea.

Each sleep study is scored epoch by epoch both for stages of

3. A surgical operation on the back of the throat to remove re-

sleep and any abnormalities that can be seen. An epoch is a con-

dundant soft tissue in an attempt to increase the size of the

venient time interval, usually equal to one page record. Epoch

upper airway can be performed. It usually involves removal

durations should be 20–30 sec. respectively depending on

of the part of the soft palate that hangs down in the back of

whether the recommended 15 or 10 mm/sec paper sheets are

the throat, as well as the tonsils if present, and other soft tis-

used. In the tracing on the right, nasopharyngeal pressures (Pn) of zero mark an apneic event. Q Obstructive sleep apnea is labeled and marked anytime

sue if felt to be excessive. The operation is referred to as uvulopalatopharyngoplasty (UPPP) and was initially de-

there is greater than a 50 % decrease in airflow with contin-

ally quite successful for patients at decreasing the loudness

ued efforts to breathe lasting over 10 seconds in duration.

of snoring but it is not always successful at improving sleep

Central sleep apnea is marked when there is a cessation in

apnea. There is currently no method that is widely available

airflows as well as respiratory effort lasting at least 10 sec-

to predict which patients stand to benefit from this surgery.

onds in duration.

It is likely to be less successful for patients with retrogna-

Mixed sleep apnea is labeled if you see at least 10 seconds of central sleep apnea followed by an obstructive compo-

thia. The surgery should not be considered as an option for patients with severe sleep apnea. Like dental appliances

nent.

there should be some follow-up after surgery to ensure

scribed as an operation to improve heavy snoring. It is usu-

there has been a significant improvement in the severity of the sleep apnea. This surgery can be performed traditionally Sleep apnea therapy

under general anesthesia in a hospital operating theatre. Short term results suggest a 50 % chance of improvement

Currently there is no proven drug therapy for sleep apnea. How-

(defined as a 50 % reduction in the AHI). Longer term studies

ever, there are four basic approaches to treatment which are mutually exclusive. Modification of circumstances which may

suggest that some patients relapse and their sleep apnea is no longer controlled. Part of the reason for this may be

be causing sleep apnea or making it worse. This would include

weight gain. More recently this type of surgery is being of-

weight loss, avoidance of alcohol and sedative drugs, trying to

fered to patients in an outpatient setting using local anes-

sleep only on one side and stopping smoking. It would also help

thesia and laser assistance. While this looks like a promising

to improve nasal breathing if this problem exists; sometimes

treatment for snoring there are no well controlled, long

this can be done with some simple medication and occasionally

term studies that can demonstrate a role for it in patients

it requires an operation. Finally, it is important to avoid sleep

suffering from significant sleep apnea. One would expect

deprivation. 1. The use of Continuous Positive Airway Pressure (CPAP) in

the results might be similar to the standard UPPP. Currently neither types of operations should be considered as an op-

the upper airway to support and hold the airway open. This

tion for treatment unless patients are unable or unwilling to

involves wearing a closed-fitting mask over the nose which

tolerate CPAP.

Medical Affairs

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

However obstructive sleep apnea can strike adults, as well as in-

Evaluating sleep in older infants, toddlers, children and pre-ado-

fants and children. It is not necessary for us to mention what is the importance of diagnosing OSA in early stages of children’s

lescents is very difficult. First the nervous system as well as other physiologic processes dynamically, functionally, and ana-

lives.

tomically change during this period of life. Attempting to define cross-sectional criteria for evaluation and comparison is quite

The most common indications that polysomnography is re-

difficult because of significant internal variability. Ranges of

quired to children 5–10 years old are: Q Obstructive sleep apnea syndrome

“normal” may be quite broad. External reliability and validity is

Sleep-related diurnal seizures

pare each individual child at several points in time (longitudinal

Q Q

Frequent/injurious sleepwalking Rhythmic movement disorders

evaluation or developmental polysomnography) to assure normal progression of maturation, rather than evaluating a single

S/P tonsillectomy/adenoidectomy

physiologic polysomnographic study at a single point. Because

Excessive day-time sleepiness

of these difficulties, little information has been available to

Unexplained drop attacks

provide accurate normative data, despite the evidence that

Hypotonic syndromes

sleep and its normal structure has far-reaching implications on

Uncontrolled diurnal seizures

growth, development, and learning.

Possible UARS

Indicated under certain circumstances Q Unexplained attention deficits

often difficult to establish. It may be more appropriate to com-

As you have realized it is sad to suffer from the symptoms of sleep apnea when it is so easy to be diagnosed and treated. As soon as we realize that by sleeping we spend 1/3 of our lives,

Development delays

we will see the importance of evaluating our sleep and keeping

Frequent sleepwalking

it in a good condition. Let’s also not forget that sleep is giving us

Enuresis resistant to traditional treatment/diurnal sleep-re-

the energy to keep-on going every single day.

lated symptoms Q

Nightmares with agitation and bed displacement

Q Q

Unexplained CHF Periodic/rhythmic limb movements

References 1. ASAA: American Sleep Apnea Association 2. www.medscape.com 3. http://classes.kumc.edu

Potential indications Q Behavioral problems

4. The Lung Association http://www.sleep-apnea.ab.ca

Unexplained school-learning problems

Possible PTSD

Contact

Unexplained sleep-maintenance insomnia

E-Mail: danos_aptalidis@yahoo.gr

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Medical Affairs

Human Experimentation—a Historical and Bioethical Perspective ALEXANDRE SANTOS, ANNIINA PALM

Quoting Prof. von Engelhardt: “Even in our day, history affects

In the same year the world saw the Manchuria invasion, in

the conscience of man, because historical wisdom is needed to understand the present and to influence the future [1].”

which Dr. Shiro Ishii and his famous unit, no. 731, were responsible for incalculable biological war experiments. These tests included the induction of diseases to prisoners of war, followed

Knowledge of history should be used as a means to comprehend

by a dissection and cremation of test subjects while still alive

the present and foresee the future. Understanding history is a

[9].

way of building a wisdom that helps us to avoid the mistakes made in the past.

In 1940, new medications were tested on 400 prisoners from the prison of Chicago [10].

We will talk about the abuses of the experimental method. Because of the nature of this paper, we will not cover the totality

From the onset of the Second World War, human experimenta-

of the 20th century cases but will only give examples to illustrate

tion reached levels never seen before. Most of these experi-

our approach.

ments were conducted in the concentration camps of the Nazi regime, and examples will be listed below.

Experimental method is a very old way of verifying a given hypothesis. In the 1st century B.C., Cleopatra wanted to prove the

Dr. Rascher conducted experiments concerning the physiologic

theory that forty days were necessary for the development of a

effects of high altitudes. In Dachau, Holzlohner, an eminent pro-

male embryo and eighty for the development of a female one. When her handmaids were sentenced to death, Cleopatra had

fessor of physiology, conducted several studies related to human resistance to cold [11, 12]. Other experiments were made

them impregnated and subsequently had their wombs opened

using artificial hormones, poisons, blood transfusions, forcing

at specific times in order to confirm the hypothesis.

people to drink only sea water as well as induction of diseases such as typhoid fever and malaria [13].

This event is similar to many cases that have occurred in the 20th century: the experimentation is carried out on prisoners

In 1944, American soldiers were subjected by their own govern-

without their permission, the only purpose being the satisfac-

ment to an experiment in which they were injected with 4.7 mg

tion of scientific curiosity [2, 3].

of plutonium. This test was a part of a programme called The Manhattan Project.

In 1900, the Royal Minister for Religion, Education and Medical Affairs of Prussia approved a code that guaranteed the follow-

Soon after, in November 1944, the Nuremberg trial began. As a

ing: “Medical intervention with a purpose other than diagnosis,

result, a code was created which stated voluntary consent to be

treatment or immunization, even with legal or moral authoriza-

absolutely necessary for scientific experimentation on human

tion, is forbidden if the patient is underage or handicapped. The

subjects [14].

same applies if the patient has not given consent in an explicit way. The patient should also be informed of the possible negative consequences [4].”

To those who think the experiments mentioned earlier were conducted by isolated scientists working alone, unsupported by national institutions, it must be told that even after the Nurem-

In 1906, Prof. Richard Strong conducted experiments on war

berg trial CIA carried out studies on brainwashing with the drug

prisoners from Philippines. Thirteen of these eventually died [4,

LSD. The name of the project was MK-ULTRA [15].

5]. We could now continue on describing many other examples like In 1931, Germany changed its laws concerning therapy and ex-

the previous ones, but we have chosen as a subject to analyse

perimentation to decree that human experiments should be preceded by testing on animals. This new law was valid during

the reaction of the American scientific community to these events. The reason for this choice is simple: United States is the

the Nazi regime [6].

country with the largest scientific output.

The same year Dr. Cornelius Rhodes injected cancer cells in

Let us now analyse the intellectual environment in the United

some of his patients. Later on he directed radiation experiments

States after the Second World War.

on war prisoners, patients and soldiers. Afterwards, he received a prize from the American Association for Cancer Research [7].

The post-war period was a time of great prosperity and opti-

One year later, in 1932, began the famous study in Tuskegee, in

mism in science, which, among other things, had given United States the victory in the recent war. At the time, science was

which 400 syphilitic patients received no medical treatment for

seen as the main axis of progress. What place, then, did ethics

their illness in order to find out the natural outcome of non-

occupy? In order to answer this question, let us quote Hubert

treated syphilis. Strangely enough all of the test subjects were

Doucet: “If morals were, in the fifties, very important in the reg-

Afro-American [8].

ular American life, the intellectual and academic circles had little interest in ethics. These circles identified ethics and mor-

Medical Affairs

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

ality with religion, which was considered “depass ”, therefore

In this reformed environment began the first multidisciplinary

ethics were naturally outdated too [16].”

studies on research ethics, conducted in working groups containing philosophers, sociologists, anthropologists and law spe-

Until the mid-sixties, there was a general disinterest in medical

cialists. Examples are the Hastings Center in 1969 and the Ken-

ethics except in certain catholic and medical circles, even if the

nedy Institute of Ethics in 1972. At the same time, the so-called

two had a very different way of seeing the issue. At that time,

Institutional Ethics Committees appeared. The world finally saw

medical ethics were comparable to norms of etiquette. More

the beginning of bioethics [20].

importance was given to “concealing the error of a colleague than protecting the patient” [16]. Medical ethics were seen as

Senator Mondale had subsequently the idea of creating a multi-

the property of the medical community, and only doctors, because of their experience in the matter, were considered author-

disciplinary commission named “Health, Science and Society”. This initiative raised anger in many doctors, who believed that

ities.

the duty of the Congress was merely to provide sufficient funding for progression of scientific research. Concerning the rest,

The catholic circle was nearly the only one with ethical con-

they should trust experts.

cerns. They found their ethical principles in God’s commandments and in the sacred character of each human life [16]. This

Senator Kennedy was responsible for the elaboration of the law.

ethical view on medicine caused various reactions, such as Paul

Once it was shown that doctors were unable or unwilling to de-

Blanchard’s accusation against the Catholic Church of them stripping all freedom from doctors, nurses and even patients.

termine their own ethical limits alone, an external commission named “National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research” was established

In 1954, Joseph Fletcher published a book named “Morals and

in 1973.

Medicine”, which had a different approach to the doctor-patient relationship; the book considers it from the patient’s viewpoint.

The most important contribution of this commission was the

However, the work was not very well received [16].

“Belmont Report” that presented the basic ethical principles for human experimentation. Another Commission was founded—

In 1964, the World Medical Association adopted the Declaration of Helsinki on ethical principles for medical research involving

“President’s Commission for the Study of Ethical Problems in Medicine”, responsible for treating new questions raised by sci-

human subjects, which states: “Considerations related to the

entific progress [21].

well-being of the human subject should take precedence over the interests of science and society [17].” This message seems to

From a background of these commissions, work groups and dec-

have been unheard by some scientists.

larations, we can conclude that the purpose of research on human subjects must be the well-being of the individual, which

In 1966, an event that we may truly regard as a historical mark

must always precede the interests of science and society. There-

occurred. Henry Beecher, a professor in Harvard, published in the New England Journal of Medicine an article named “Ethics

fore, sacrificing an individual for a supposed higher purpose or benefit for mankind cannot be considered ethical.

and Medical Research”, in which he described 22 different experiments he considered unethical [18].

Doctors, however, may sometimes want to defeat illnesses and achieve the cure so desperately that the human being is left

Beecher’s article caused debate and even some anger in the sci-

aside from the treatment and healing processes, seemingly as if

entific community, but a corporative morality continued to rule.

the patient had to be methodologically discarded in order to at-

Quoting Dr. Jay Katz: “In the first public conference that I gave

tain the goals of medical progress [22].

in Yale’s Medical School, a year and a half before Beecher’s article, I defended the position that medical schools should take the lead in the study of problems posed by human experimenta-

But did 20th century doctors learn the lessons of past mistakes? We cannot give a definite answer, but we continue to see alarm-

tion. The conference wasn’t well received. I was criticised for

ing signals, for instance, from a current theme—cloning.

having spoken of things that should not be discussed publicly. I understood then that regulation was inevitable [19].”

In 1993, professors Hall and Stillman from the George Washington University in USA announced they had managed to clone

All of these things, mainly Beecher’s article, raised some politi-

successfully human embryos through embryo splitting [23]. The

cal questions. The National Institute of Health could not see how it might limit scientists’ autonomy without delaying scien-

research was done despite a general disapproval of human cloning by most of the scientific society, and furthermore the uni-

tific progress. As a consequence, the Institutional Review Board

versity’s institutional review board had not approved the study.

was then created, a group composed of researchers and non-scientists that evaluated projects investigated by institutions.

The same Dr. Hall said in an interview that he thought all of these ethical themes should be investigated by ethics specialists

Finally came the late sixties and the seventies, rich in civil rights

and lawyers, after which the scientist should be able to choose

movements, which brought with them a new attitude and rela-

whether or not to follow their suggestions [24]. In this state-

tionship between the general society and the institutions that served it.

ment we can clearly see the lack of the historical wisdom of which Prof. von Engelhardt spoke.

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Medical Affairs

But how is it possible, as Umberto Eco once said, that “people

8. Jones JH. Bad blood: the Tuskegee syphilis experiment. New

who loved Brahms and Goethe planned concentration camps”? What could have been the motives, the reasons, the purposes of

9. Harris, Sheldon H. Factories of Death: Japanese Biological

medical professionals who participated in such atrocities?

York: Free Press, 1981 Warfare 1932–45 and the American Cover-up. London: Routledge, 1994

We cannot give a final answer, but we agree with Dr. Walter

10. Lederer, Susan E., Idem

Osswald on what he said about a study concerning euthanasia

11. Angell, Marcia. “The Nazi Hypothermia Experiments and

in the Nazi regime: “What we tried to show was how theoret-

Unethical Research Today,” in New England Journal of Medicine, 322(20), May 17, 1990, 1462–1464

ical visions, sustained by a scientific or medical foundation (whether correct or not) can have perverse consequences, when one loses the firm support of radical commitment to individual solidarity and respect for life, all life, any life [25].”

12. Berger R. L. “Nazi Science–the Dachau Hypothermia Experiments.” The New England Journal of Medicine 322 (May 17 1990): 1435–40 13. Centre d’Etudes Laennec, L’Experimentation humaine en

We know that relations between scientists and experts of bio-

Medecine, Ed. P. Lethielleux, 1952, Paris

ethics are sometimes difficult. The former believe that ethicists

14. Faden RR, Beauchamp TL. A history and theory of informed

are conservative, while the latter think scientists have a limited perspective of the human being. This perspective is well illus-

consent. New York: Oxford University Press, 1986 15. Mark Jenkins. Mk Ultra, The Washington Post, September

trated by the words of Professor Albert Kligman, a famous dermatologist, about his first visit to a prison where he was going

16. Cf. HUBERT, Doucet, Au pays de la bio thique – l’ thique

to start his experiments: “All I saw was acres of skin [26].”

25, 1998 biomedicale aux Etats-Unis, Labor et Fides, 1996, G n ve, p. 14

It is necessary to subject scientific research to a multidiscipli-

17. World Medical Association Declaration of Helsinki - Ethical

nary approach in order to see how it may effectively serve man-

principles for Medical Research Involving Human Subjects,

kind. On the other hand, ethics must be prevented from declining into a hermetic speech or a closed dialogue, so that it might

June 1964 18. Beecher, H. K., Ethics and Clinical Research, NEJM, 274

positively contribute to the discussion. By following this path, may medicine reach its Hippocratic ideal of service.

19. Katz, Jay, ed. Experimentation with human beings; the

(1966), p.1354–1360 authority of the investigator, subject, professions, and state

References 1. Engelhardt, Dietrich von, Euthanasie in historischer Perspektive, Zeitschr. Med, Ethik, 39, 1993, pp. 15–25 2. Centre d’Etudes Laennec, L’Experimentation humaine en Medecine, Ed. P. Lethielleux, 1952, Paris 3. Beauchamp, Tom. L., and Walters, LeRoy. Contemporary Issues in Bioethics. Belmont, CA: Wadsworth Publishing Company, 1978

in the human experimentation process. New York, Russell Sage Foundation 1972 20. Rothman, D. J., “Human Experimentation and the Origins of Bioethics in the United States, in WEISZ, ed. Social Science Perspectives on Medical Ethics, Dordrecht, Kluwer Academic Publishers, 1990, p.190 21. Archer, Lu s, Bio tica: avassaladora, porquÞ?, Brot ria 142 (1996) p. 450

4. BMJ 1996; 313: 1445–1447

22. Jaspers, Karl, O M dico na Era da T cnica, Ed. 70, Lisboa

5. JAMA 1991; 16: 492

23. Kathy A. Fackelmann, Science News, Feb 5, 1994

6. BMJ 1996; 313: 1445–1447

24. Hubert Cf., Doucet, Au pays de la bio thique—l’ thique

7. Lederer, Susan E. Subjected to science : human experimen-

biomedicale aux Etats-Unis, Labor et Fides, 1996, G n ve 25. Osswald, Walter, ExperiÞncia nazi da eutan sia: mem ria e

tation in America before the Second World War. Baltimore: Johns Hopkins University Press, 1995

lic¸¼o, Brot ria 142 (1996) 519–542 26. Min Med 1999, Jul: 82 (7): 53–4

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JEMSA â&#x20AC;&#x201C; Journal of EMSA on Medical and Scientific Affairs 2006

Acute Myocardial Infarct A view on pathophysiological processes, current therapy and ischaemia/reperfusion injury-prevention SAJJAD MUHAMMAD

Department of Neurology, University of Heidelberg, Germany/Faculty of medicine, University of Heidelberg, Germany SABA SAJJAD

Department of Environmental Sciences, University of Punjab, Pakistan

Abstract

Pathophysiology

Acute myocardial infarct is the leading cause of death in the

Formation of atherosclerotic plaques and change in macro- and

world. Coronary bypass surgery, PTCA and thromobolysis are the only possibilities of therapy. Coronary reperfusion therapy

micro-vascular structures due to above-listed factors, play a basic role in the pathophysiology of MI.

is being used over last twenty years. The reperfusion therapy can itself cause damage called ischaemia/reperfusion (IR)â&#x20AC;&#x201D;in-

The external triggers provoke activation of sympathetic compo-

jury by disturbing the endothelial function that can lead to mi-

nent of the autonomic nervous system which causes increased

cro vascular dysfunction. In this review, the authors want to

arterial blood pressure, heart beat and myocardial contractility

highlight the risk factors, diagnosis, acute management and

with the consequent increase of myocardial oxygen utilisation.

therapy of MI. Another aspect of this review is to highlight the

Atherosclerotic plaques, especially in the coronary arteries, can

current strategies for the ischaemia reperfusion injury protection.

disrupt due to high blood pressure and coronary vasoconstriction. An arterial thrombus can develop on the site of plaque disruption, due to increased aggregability of platelets and lower fi-

The up regulation of NO synthesis, neutralisation of free radicals

brinolytic activity. All these mechanisms cause the formation of

and prevention of inflammation and apoptosis could be the pos-

thrombosis in coronary arteries which can lead to an acute myo-

sible strategies helpful to reduce IR-injury. Recently some com-

cardial infarct.

pounds like cariporid, vitamin E, allopurinol, and erythropoietin have confirmed protective effects against IR-injury.

After deprivation of oxygen, myocardial cells undergo necrotic

Key words

or apoptotic cell death. The inflammatory cells and inflammatory cytokines play an important role in the in these mecha-

Acute myocardial infarct, perfusion, micro vascular dysfunction,

nisms.

NO, free radicals, apoptosis. Diagnosis, therapy Introduction History of the patient, the ECG and enzymes (markers) help to Cardiovascular diseases like Myocardial Infarct, Heart failure, atherosclerosis and Coronary heart diseases are the most com-

diagnose the MI. A persistent ST elevation is helpful, but not sensitive enough for diagnosis of acute myocardial infarct in pa-

mon cause of mortality in developed countries. According to

tients with concomitant ST segment elevation. Extended prae-

World Health Organisation (WHO) [1] alone the acute coronary

cordial chest leads only marginally increase the sensitivity of

occlusion will be the major cause of death till 2020 (Lopez AD).

the ECG diagnosis of AMI.

[2] Acute myocardial infarct (AMI) is a serious sudden heart condition due to obstruction of blood flow, characterised by chest pain, discomfort, weakness, sweating, nausea and vomiting. Acute myocardial infarction can lead to death or it leads to several deadly complications like heart failure, arrhythmias, aneurysm, acquired ventricle septum defect, etc. MI is multifactorial and polygenic and is thought to result from genetic predisposition and environmental factors. Hypertension, atherosclerosis, high lipids in blood, nicotine abuses and diabetes are the well known risk factors of cardiovascular disease, including acute myocardial infarct (WHO) [3]. Factors like heavy physical activity, emotional stress, sexual activity, meteorological stress and feeding behaviour are the external triggers of acute myocardial infarct (Viktor C et al., 2004) [4]. Fig. 1 Triggers of MI.

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Scientific Affairs

The clinical manifestations of IR-injury include myocardial necrosis, arrhythmia, myocardial stunning, endothelial dysfunction and micro-vascular dysfunction. High cytosolic calcium (Brooks WW) [6], an overproduction of oxygen-derived free radicals (Zweier JL) [7] and low concentration of ATP could be important factors involved in the pathological mechanism of IR-injury. However, there are some other factors of importance in the pathogenesis of IR-injury—these include neutrophil-mediated injury (Dryer WJ) [8], platelet mediated injury (Devis MJ) [9], activation of renin-angiotensin system (Nevis LA) [10] and activation of complement.

Treatment of IR-Injury There are three possible pharmacological strategies to prevent Fig. 2 An overview of MI processing.

the ischaemia induced injury. These include L-arginine supplementation, Temperature modulation and Na+/H+ exchange inhibitors. The prevention is possible if the treatment is initiated at least at the onset of reperfusion. The reperfusion injury can be prevented at three moments: 1.

Phase I Therapy: Acute reperfusion therapy generally given in first minutes.

2. Phase II Therapy: Anti inflammatory and anti apoptotic therapy in the first hours. 3. Phase III Therapy: Anti-remodelling therapy days and months after AMI. Here are some the strategies that have proved their cardioprotective effects during ischaemia reperfusion injury.

Fig. 3 Pathogenesis of micro vascular dysfunction.

Oxygen derived free radical (ODFR)-scavenger/antioxidantia Many ODFR-scavengers and antioxidantia like superoxide dismutase, allopurinol, feroxamine, vitamin C, and vitamin D have

Until 1980, CGOT and LDH were used as markers to assess the

been tested. The beneficial effects of intracoronary administra-

cardiac injury. Later on, MB-CK and, presently, troponin T and troponin I were considered to be the most sensitive.

tion of vitamin E (100 mg) during coronary artery surgery has been reported (Canbaz S et al.) [11]. The beneficial effects of allopurinol (400 mg) on IR-injury after PTCA has also been re-

The initial management of AMI should be nasal oxygen supply,

ported (Guan W) [12]. An oral administration of 400 mg allopuri-

sublingual application of trinitroglycerin, analgesia (mepridine),

nol one hour before reperfusion effectively inhibits the generation of oxygen derived free radicals.

aspirin (160–325 mg) and fibrinolysis or PTCA if the ST elevation > 1 mv. In the first 24 hours, the patient should get TNG, BetaBlocker, ACE inhibitors (see contra-indications), aspirin and

NO-donors

heparin in case of (a) Large anterior MI, (b) LV thrombus, (c) PTCA (d) alteplase. No antiarrythmics should be given in the

Nitric oxide (NO) is an important molecule that has dose-dependent cardio protective effects.

first 24 hours (American college of Cardiology and American heart association, 2000) [5].

Small amounts of NO for short periods are beneficial whereas large amount of NO for sustained periods are harmful. (Jugdutt BI et al.) [13].

Myocardial ischaemia/reperfusion injury There are two major trials concerning use of NO donors during Over the last 20 years, coronary reperfusion therapy has become established for the management of acute myocardial in-

reperfusion but none has shown any beneficial effects (Lancet et

farct. The main goal is to save the myocardium as much as

free radicals and NO. The beneficial effects of folic acid on IR-in-

possible and restore the contractile function of the heart cham-

duced endothelial dysfunction, myocardial necrosis, apoptosis

bers. However, restoration of blood flow to a previously ischae-

and ventricular arrhythmia have also been shown in vitro and in vivo models (Moens A et al.) [15].

mic myocardium results in so-called ischaemia reperfusion injury.

al. 995) [14 a, b]. Folic acid is a regulator of balance between the

Scientific Affairs

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Inhibitors of Na+/H+ exchangers

ythropoietin levels in patients with acute myocardial infarct

ATP depletion in ischaemic cells leads to an inactivation of Na+/ K+ATPase and an accumulation of sodium in cytoplasm that

subjected to primary percutaneous coronary intervention (PCI) can predict a smaller infarct size predicted by creatine kinase

leads to overload of calcium in cell with a consequence of cell

CK release (Namiuchi S et al.) [24].

death. Cariporid is an inhibitor of Na+/H+. It slows down the progres-

Discussion

sion of ischaemic injury during myocardial ischaemia (Rodriguenz-Sinovas A) [16]. An intravenous administration of 120 mg

Acute MI is the leading cause of morbidity and mortality in de-

cariporid initiating shortly before the surgery and continued an administration after every 8 hours reduces 25 % of relative risk

veloped countries. It will be the major cause of death until 2020 (Lopez AD). Coronary bypass surgery, PTCA and reperfusion

(Boyce SW et al., Moens A) [17 a, b].

through thrombolysis are the main possibilities of treatment. However the small health centres do not have the possibility of

Inhibitors of Na+/Ca+2 exchanger can also be helpful in the same

Coronary bypass surgery or PTCA leaving thrombolysis a ther-

way but there are no clinical trials confirming their beneficial

apy of choice. Hence more research is needed to improve partic-

effects.

ularly reperfusion therapy, especially to prevent the reperfusion injury with thrombolytic drugs.

Inhibitors of contractility The prevention of hypercontracture can reduce the necrosis and

Restoring a balance between NO production and O2 radical gen-

infarct size. The only inhibitor (2,3 butane-dione) of actin-myo-

eration or prevention of inflammation and apoptosis could be

sin cycling so far available has many toxic effects. NO-donators

the important strategies to minimise the ischaemia reperfusion

like L-Arginine or Urodilatin are effective to prevent the IR-in-

injury.

jury complications like IR-induced arrhythmias. Recently studies on some agents like cariporide, vitamin E, alloAdenosine receptor agonists

purinol and erythropoietin have shown the protective effects

Adenosine receptors are not only responsible for inhibition of neutrophil function and generation of free radicals (Cronstein

against the reperfusion injury, but that is still not enough to solve the problem of IR-Injury.

BN et al.) [18] but also have an anti-ischaemic effect by opening K+-ATP-channel (Ely SW et al.) [19]. Acknowledgements An adjunctive therapy with adenosine in patients with anterior myocardial infarction with coronary reperfusion reduces the in-

Author Sajjad Muhammad is thankful to Mr. Noor Shamas and

farct size in comparison with patients getting only reperfusion

KAAD for friendly support during studies and thankful to Mr.

(Mahafey KW et al.) [20].

M. F. Kiani for his help in correcting the review.

Application of GIK solution (25 % glucose, 50 IU insulin and

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Contact Sajjad Muhammad, B.Sc., MD (Stud),

cariporid on death or myocardial infarction in high risk

Department of Neurology, University of Heidelberg,

CABG surgery patients: results of CABG surgery cohort of

Im Neuenheimer Feld 400, 69120 Heidelberg, Germany,

the GUARDIAN study. J Thorac Cardiovas Surg 2003; 126(2):

Tel: +49–6221–634684

720–7

E-mail: msajjad51@yahoo.com

Scientific Affairs

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

The Morphometric Characteristics of Myocardial Bridges IVAN STANKOVIC, MILICA JESIC

Institute of Anatomy, School of Medicine, University of Belgrade, Serbia and Montenegro

Abstract

Materials and Methods

The functional significance of myocardial bridges (MB) is either

Twenty three hearts of adults, both sexes (15 males and 8 fe-

emphasised or diminished. Its presence can be asymptomatic,

males), white race, age between 21 and 76 (mean age 48 € 15

but it can also result in the wide range of clinical expressions.

yrs), were included in morphological and morphometric re-

The objective of our research was to define the prevalence, dis-

search. The specimens were obtained from two sources. Fifteen

tribution and morphology of MB. The research was carried out

out of 23 specimens belonged to the Institute of Anatomy, School

on 23 adult hearts, from both sexes, aged between 21 and 76.

of Medicine, University of Belgrade. These specimens were ob-

After anatomical dissection and measurements were done, results were processed by standard methods of descriptive and

tained from the subjects who had donated their body to the Institute. The medical records of donors were not accessible. Other

analytic statistics. 13 out of 23 hearts (57 %) presented with MB.

8 specimens were obtained after the necropsies performed at the

The major number of MB was observed over the branches of the

Institute of Forensic Medicine in Belgrade. They belonged to so-

left coronary artery. The most frequent locations of MB were the

called healthy individuals whose death, caused by an accident,

left anterior descending coronary artery (LAD), the right coro-

was not related to cardiac disease. Detailed morphological exami-

nary artery and the circumflex artery. There were four hearts

nations were carried out at the Institute of Anatomy in Belgrade.

with more than one MB, three hearts with two MB and one

The hearts obtained after necropsies were fixed in 10 % formalde-

specimen with three MB. The MB over the LAD were more frequently observed in the proximal (60 %) than over the middle

hyde solution for two weeks. The specimens from the Institute of Anatomy had been fixed (10 % formaldehyde solution) before the

third of the LAD epicardic path, which was statistically signifi-

beginning of the study. Dissection was done under the stereo

cant (p < 0.05). MB over the distal third of the LAD were not no-

loupe and included the removal of the epicardium and subepicar-

ticed. Its average length showed the great variations—from

dial adipose tissue and the tracing of each artery and its

4.3 mm to 43.5 mm. The results of our research suggest the fre-

branches. The most representative preparations were photo-

quent presence of MB in the human heart. Their location is

graphed. The lengths and diameters of the coronary arteries and

most often detrimental if the visualisation area of the LAD is

MB were measured using a nonius (up to an accuracy of 0.1 mm).

considered. Also, different localisation as well as different length might explain both clinical symptoms of MB and its

The coronary arterial network obtained for each heart was

asymptomatic existence.

drawn as a diagram. The standard methods of descriptive and analytic statistics were used for the statistical evaluation of

Key words:

data—the average value, standard deviation and t-test for small

myocardial bridge, coronary artery, morphology

and non-dependent samples.

Introduction

Results

Myocardial fibres, which cross the epicardic path of the coro-

Myocardial bridges (MB) were found in 13 (56.5 %) out of

nary arteries and their branches as short segments, are consid-

23 hearts included in research. There were 18 MB. A consider-

ered to be myocardial bridges. It is assumed that myocardial

ably large number of MB was observed over the branches of the

bridges belong to physiological variations [1], as well as to con-

left coronary artery (LCA) (Fig. 1). The most of MB were located

genital heart anomalies [2]. The functional significance of myo-

over the left anterior descending artery (LAD), then over the

cardial bridges is still controversial. The presence of myocardial

right coronary artery (RCA) (Fig. 2) and the circumflex artery

bridges can be asymptomatic, but it can provoke cardiac arrhythmias, angina pectoris, myocardial infarction and sudden

(RCx) as shown in Table 1.

cardiac death. These symptoms can occur due to the compres-

The length was similar on the average (Table 1) but it showed

sion of the coronary artery by myocardial bridge during ventric-

great range of values, as shown in Table 2.

ular systole, thus producing myocardial ischaemia distally to the constriction [3, 4] but also due to accelerated atherosclero-

The myocardial bridges were more frequently observed in the

sis caused by the presence of myocardial bridge [5].

specimens that belonged to males (8/13) than to females (5/13), which was statistically significant (p < 0.05).

The direction of the myocardial bridges' fibres was also considered as a possible culprit for the induction of described effects

Four hearts (16.7 %) had more than one MB. There were three

[6]. According to probably great importance of myocardial

hearts (12.5 %) with two MB. In two of them both MB were lo-

bridges in human population, the objective of our research was

cated over the LAD, as shown on Fig. 3. In another specimen,

to define the frequency of myocardial bridges, their location and

one MB was discovered over the RCx and another over the RCA.

to describe its morphology. This could contribute to the better

Three myocardial bridges were discovered in one preparation

understanding of wide range of MB's clinical manifestations.

(4.2 %)—one bridge over the LAD and two over the RCx.

JEMSA â&#x20AC;&#x201C; Journal of EMSA on Medical and Scientific Affairs 2006

Scientific Affairs

Fig. 1 Sternocostal heart surface. Myocardial bridge (MB)

Fig. 2 Right heart margin (lateral view). Myocardial bridge

over the middle portion of left anterior descending artery

(MB) over the proximal part of ramus marginalis dexter

(LAD); TP-truncus pulmonalis.

(RMD) of right coronary artery.

Fig. 3 Sternocostal heart surface. Two myocardial bridges

Fig. 4 Human heart (superior view). Myocardial bridge

(MB) running over the left ascending artery (LAD) of left

(MB) over the third coronary artery (TCA); RCAâ&#x20AC;&#x201D;right coro-

coronary artery.

nary artery.

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JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

[10]. The myocardial bridges over the LAD are located only over Table 1. Distribution and average length of MB over the coronary arteries

its proximal and middle third [11, 12] as well as in our study. Differently from our results, certain authors [11] more frequently found MB over the middle than proximal third of LAD.

coronary artery

number of MB (%)

average length € SD (mm)

LCA

13 (72.2)

12.9 € 4.5

LAD

10 (55.5)

13.1 € 4.2

RCx

3 (16.7)

12.8 € 3.9

Certain authors imply that the thickness of myocardial bridge,

RCA

5 (27.8)

11.9 € 4.4

or its depth [4] as well as the direction of myocardial fibres running over the vessel [4, 6] determines the role of MB in coronary

MB—myocardial bridges; LCA—left coronary artery; LAD—left anterior

The length of the overbridged segment of coronary artery showed the greatest variations: from 4 mm to 51 mm, which resembles our findings.

atherosclerosis more firmly than the presence of MB per se.

descending artery; RCx—circumflex artery; SD—standard deviation.

The bigger incidence of MB in males was reported by certain authors [6, 13] whereas approximately the same incidence of MB Table 2. Variations of length of MB Coronary artery

length variation (mm)

in both sexes was suggested in few studies [8, 9, 14]. The myocardial bridging is not the phenomenon that is noticed only in human heart. It was discovered in high percentage in the monkey heart—about 80 % [15) as well as in the dog heart—

LCA

about 30 % [16].

LAD

from 6.1 to 43.5

RCx

from 12.3 o 17.1

The therapeutic procedures in the symptomatic cases could be

RCA

from 4.3 to 18.2

divided in the conservative and surgical treatment. The conservative therapy suggests the use of the short-acting beta blockers

MB—myocardial bridges; LCA—left coronary artery; LAD— left anterior descending artery; RCx—circumflex artery.

[17, 18, 19] since the use of nitroglycerin is contraindicated [20]. The surgical treatment includes the simple section of MB fibres [21, 22], usually during the by-pass procedure, and suggests the excellent long-term prognosis.

One of the MB was observed over the third coronary (conal) artery (Fig. 4). Conclusion The myocardial bridges over the LAD were more frequently located in the proximal (60 %) than in the middle third of epicardial segment of this artery, which was statistically significant (p < 0.05). The myocardial bridges over the distal third of LAD

The myocardial bridges over the coronary arteries are frequent finding in human heart-more frequent in male than female. Its length shows great variations.

were not noticed. The myocardial bridges over the major branches of RCA were equally presented on its proximal and dis-

The presence of several MB in the same heart is less frequent

tal segments (p > 0.05).

than presence of one MB. The coronary blood vessel that is most often overbridged is LAD, exceptionally over its proximal and middle third. There is no coronary blood vessel spared from this

Discussion

phenomenon. Even coronary anomalies (third coronary artery) can be overbridged.

The incidence of myocardial bridges in human population shows the wide range of values. It depends on both the authors

The extreme variations in morphology of MB could influence its

and the different methods (whether anatomical dissection or

clinical expressions.

radiological evaluation is used). The lowest incidence obtained by dissection is 5.4 % [7], since the greatest is 78 % [8]. Generally speaking, the incidence of myocardial bridging obtained by ra-

Acknowledgements

diological methods is lower than incidence obtained by dissection. Our findings are similar to the results of 55.6 % [4] and 53,7 % [6], but they differ from other studies which covered the

We would like to thank Ass.Prof.Dr. Valentina Nikolic, M.D. for generous assistance during this research.

same population—about 40 % [9). References The most frequently overbridged blood vessel is the LAD, which presents the most detrimental location, regarding the area of myocardium which is vascularised by this blood vessel.

1. Frank RE Jr. Myocardial bridging. J Insur Med 1999; 31(1): 31–4 2. Konduracka E, Piwowarska W, Kitlinski M. Myocardial bridge of the coronary arteries and its clinical significance. Pol Merkuriusz Lek 1997; 3(14):86–8

Our findings considering the MB over LAD (56 %) are in concordance with results related to the same population—about 52 %

3. Berry JF, von Mering GO, Schmalfuss C, Hill JA, Kerensky RA.

[9] but they are bigger when compared to 35.4 % (6) and 22 %

Systolic compression of the left anterior descending coro-

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

nary artery: a case series, review of the literature, and therapeutic options including stenting. Catheter Cardiovasc Interv 2002; 56(1):64–5 4. Ferreira AG Jr, Trotter SE, Konig B Jr, Decourt LV, Fox K, Olsen EG. Myocardial bridges: morphological and functional aspects. Br Heart J 1991; 66(5):364–7

Scientific Affairs

atherosclerosis in the left anterior descending coronary artery. J Pathol 1986; 148(4):279–91 15. Teofilovski G, Filipovic B, Bogdanovic D, Trpinac D, Rankovic A, Stankovic G, DiDio LJ. Myocardial bridges over coronary arteries in Cercopithecus. Anat Anz 1992; 174(5):435–9 16. Tangkawattana P, Muto M, Nakayama T, Karkoura A, Yama-

5. Ishikawa Y, Ishii T, Asuwa N, Masuda S. Absence of athero-

no S, Yamaguchi M. Prevalence, vasculature, and innervation

sclerosis evolution in the coronary arterial segment covered by myocardial tissue in cholesterol-fed rabbits. Virchows

of myocardial bridges in dogs. Am J Vet Res 1997; 58(11): 1209–15

Arch 1997; 430(2):163–71 6. Baptista CAC and DiDio LJA. The relationship between the direction of myocardial bridges and of the branches of the coronary artery in the human heart. Surg Radiol Anat 1992; 14:137–140

17. Nair CK, Dang B, Heintz MH, Sketch MH. Myocardial bridges: effect of propranolol on systolic compression. Can J Cardiol 1986; 2(4):218–21 18. Bestetti RB, Finzi LA, Amaral FT, Secches AL, Oliveira JS. Myocardial bridging of coronary arteries associated with an

7. Edwards JC, Burnsides C, Swarm RL, Lansing Al. Atheroscle-

impending acute myocardial infarction. Clin Cardiol 1987;

rosis in the intramular and extramular portion of coronary arteries in the human heart. Circulation 1956; 13:235–241.

10(2):129–31 19. Schwarz ER, Klues HG, vom Dahl J, Klein I, Krebs W, Hanrath

8. Bezzera AJC, Prates JC, DiDio LJA. Incidence and clinical

P. Functional, angiographic and intracoronary Doppler flow

significance of bridges of myocardium over the coronary

characteristics in symptomatic patients with myocardial

arteries and their branches. Surg Radiol Anat 1987; 9:

bridging: effect of short-term intravenous beta-blocker

273–280

medication. J Am Coll Cardiol 1996; 27(7):1637–45

9. Nikolic Valentina, Teofilovski-Parapid G, Duric-Srejic M,

20. Ishimori T, Raizner AE, Chahine RA, Awdeh M, Luchi RJ.

Rankovic A, Stankovic G, Oklobdzija M. The role of over-

Myocardial bridges in man: clinical correlations and angio-

bridged coronary artery in coronary atherosclerosis. Intercontinental Cardiology 1996; 5:104–108

graphic accentuation with nitroglycerin. Cathet Cardiovasc Diagn 1977; 3(1):59–65

10. Geringer E. The mural coronary. Am heart J 1951; 41:

21. Betriu A, Tubau J, Sanz G, Magrina J, Navarro-Lopez F. Relief

359–368 11. Lima VJ de Melo, Cavalcanti JS, Tashiro T. Arq Bras Cardiol, 2002, 79:219–22

of angina by periarterial muscle resection of myocardial bridges. Am Heart J 1980 A; 100(2):223–6 22. Iversen S, Hake U, Mayer E, Erbel R, Diefenbach C, Oelert H.

12. Harikrishnan S, Sunder KR, Tharakan J, Titus T, Bhat A,

Surgical treatment of myocardial bridging causing coronary

Sivasankaran S, Bimal F. Clinical and angiographic profile

artery obstruction. Scand J Thorac Cardiovasc Surg 1992;

and follow-up of myocardial bridges: a study of 21 cases. Indian Heart J 1999; 51(5):503–7

26(2):107–11

13. Polacek P. Relation of myocardial bridges and loops on the coronary arteries to coronary occlusion. Am Heart J 1961;

Contact

61:44–52

Ivan Stankovic

14. Ishii T, Hosoda Y, Osaka T, Imai T, Shimada H, Takami A, Yamada H. The significance of myocardial bridge upon

ul. Narodnog Heroja 36, 17500 Vranje, Serbia and Montenegro Tel.++381642653257, Email: ivanstankovic@fastmail.fm

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JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Clinical and Epidemiological Aspects of Human Leptospirosis in Georgia NICKOLOZ TCHANKOSHVILI, GIVI KOBERIDZE, DAVIT BUTKHUSI

6th year medical students at Tbilisi State Medical University Tbilisi State Medical University, Department of Infectious Diseases

Abstract

able diseases of Georgian Ministry of Labour, Health and Social Affairs [7].

Introduction Leptospirosis is considered to be the most common re-emerging

Leptospira laboratory in Georgia was established in 1956 under

zoonosis worldwide, under-reported in many countries. In Geor-

the government program for identification infection sources and

gia, leptospiral infection has not been studied for the last three

routes of transmission. A number of works were published about

decades.

the disease in Georgia in the 1950s–1970s. Both sporadic cases

Aim

and small outbreaks were reported from different parts of the country [5, 8, 9]. Analyse of acute cases and retrospective studies

Assessment of severity and epidemiological features of the dis-

revealed that the incidence of the disease was higher in village

ease in Georgia for the period of 2000–2004.

settings than in the inner-city population for the period of 1956– 1966. Inhabitants of the rural areas, especially those at the sea

Methods

coast were predominantly affected (Western Georgia) [10]. 356

Criteria for diagnosis included symptoms and signs, haemato-

human serum samples out of 16 989 were positive with aggluti-

logical studies, blood biochemistry and serological studies (en-

nation-lysis reaction. The results were: L. pomona (89.5 %), L. heb-

zyme-linked immunosorbent assay, microagglutination test). Cases were classified as suspected (clinically compatible case)

domadis (8.7 %), L grippotyphosa (0.8 %), L. icterhaemorrhagiae (0.5 %), L. bataviae (0.5 %) [11]. Other serovars specified from hu-

and confirmed (a suspected case confirmed with serological

mans, some domestic and wild mammals were: L. canicola, L.

studies). According to presentation, cases were categorised in

australis, L. tarassovi, L. sorex [9, 10, 11]. Since then, information

three clinical groups: mild disease; Weil’s syndrome; pulmo-

about the disease in Georgia has been missing. Leptospirosis, as

nary haemorrhage and respiratory failure.

an object of scientific and clinical research, was abandoned.

Results

The aim of the study was assessment of severity and epidemio-

A total of 23 cases were analysed, male to female ratio 17:6, overall incidence—0,458/100 000 inhabitants, mean age 44 €

logical features of the disease in Georgia.

standard deviation 15,82 (range 12–70). Most admissions were from July to October. Suspected cases were 9 and confirmed—

Methods

14. Severe leptospirosis was considered in all cases: Weil’s syndrome—22, pulmonary haemorrhage and respiratory failure alone—1. Chronic viral hepatitis was noted in 6 patients. Persis-

Georgia is situated in South Caucasus; the total area is 69 700 km2, population—5 019 538 (July, 2000). The climate is sub-

tent human leptospirosis was suspected in 2 patients. Three pa-

tropic-to-temperate. Temperature ranges from –2 to 3 C (Janu-

tients died in hospital.

ary) to 26–28 C (August) and rainfall averages 500 to 4500 mm per year. Total number of rivers is 25075. Elevation extremes are

Conclusion

the Black Sea 0 m, as the lowest point and the highest point is

The study revealed that the course of leptospirosis was severe,

5048 m.

but the data was not sufficient to generalise the conclusions. The study was conducted at Infectious Diseases, AIDS and CliniKeywords

cal Immunology Research Center, Georgia from April 1, 2000 to

Leptospira, Weil’s syndrome, Georgia, persistent human lepto-

April 30, 2004. The Vast majority of patients with suspicion of

spirosis, viral hepatitis, emerging zoonosis

leptospirosis are admitted or transferred to the Center. Criteria for diagnosis included:

Introduction

a) Symptoms and signs: fever, headache, myalgia, prostration (weakness), conjunctival suffusion, meningeal irritation, anu-

Leptospirosis has emerged as a globally important infectious

ria or oliguria and/or proteinuria, jaundice, haemorrhages,

disease. It is considered the most common zoonosis in the world

cardiac arrhythmia or failure, skin rash, nausea, vomiting,

[1, 2, 3, 4]. Both rural and many inner-city residents have antibodies to L. interrogans [5, 6]. Morbidity and mortality remains significant related to delays in diagnosis and to other poorly understood reasons that may include inherent pathogenicity of some strains or genetically determined host immunopathologi-

abdominal pain, diarrhoea, arthralgia; b) Haematological studies: haemoglobin, packed cell volume, white blood count, platelet count, erythrocyte sedimentation rate, prothrombin index; c) Blood biochemistry: alanine aminotransferase (ALT), aspar-

cal responses [2]. Mild forms are often misdiagnosed or ignored,

tate aminotransferase (AST), g-glutamyl transpeptidase (g-

and high seroprevalence rates were found in various popula-

GT), total bilirubin, alkaline phosphatase, albumin, serum

tions [3]. Leptospirosis is included in the list of urgently notifi-

creatinine, urea;

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Scientific Affairs

d) Serological studies: Enzyme-Linked Immunosorbent Assay (ELISA) and Microagglutination Test (MAT). Cases were classified as suspected (a case that is compatible with the clinical description) and confirmed (a suspected case that is confirmed with serological studies: ELISA IgM positive in a single sample using leptospira biflexa Patoc, MAT positive in a single sample with diagnostic titre >/= 1 : 160 or a fourfold or greater rise in antibody titre between two samples tested by the same method). Cases were categorised in three clinical groups: a) a mild, influenza-like illness; b) Weil’s syndrome characterised by liver involvement (total

Fig. 1 Admissions for leptospirosis by sex and age groups.

bilirubin > 55 micromol/L and/or aminotransferases > 100 U/ L), renal failure (creatinine > 150 micromol/L, urea > 10,0 micromol/L), haemorrhage and myocarditis with arrhythmias; c) pulmonary haemorrhage and respiratory failure. Detailed epidemiological anamnesis was obtained in all cases to identify presumptive infection source and transmission conditions. Attention was paid to age, sex, occupation, area, the date of onset and causative serovars.

Results A total of 23 cases were analysed, male to female ratio 17:6, overall incidence—0,458/100 000 inhabitants (range 0,079– 0,139/100 000), mean age 44 € standard deviation (SD) 15,82

Fig. 2 Incidence of leptospirosis in Georgia per month, April 2000–April

(range 12–70, median 45) (Fig. 1). Leptospirosis was registered

2004.

throughout a year, except January, March, May and December, but most of admissions were from July to October (17 patients) (Fig. 2). The disease seemed to be linked to occupation (farming) in 6 cases, recreational (swimming, fishing)—6, not applicable— 11. The number of cases considered as suspected was 9 (no serology performed—7, seronegative—1, only ELISA IgG positive—1) and 14 confirmed (ELISA IgM and IgG was positive in 8, MAT positive—4, both ELISA IgG and MAT positive—2). All results were based on the first single serum. In 6 cases, serovar was specified (MAT): L. canicola in 5 patients and L. ballum in 1. Fever, myalgia and weakness were presented in all patients. Severe leptospirosis was considered in all cases: Weil’s syn-

Fig. 3 Number of confirmed and suspected cases in different clinical

drome—22 (Weil’s syndrome alone—16, Weil’s syndrome and

groups

pulmonary complications together—4, Weil’s syndrome and meningitis together—2); pulmonary haemorrhage and respiratory failure alone—1 (Fig. 3).

Discussion

Chronic viral hepatitis was noted in 6 patients (hepatitis B virus

In many respects, leptospirosis may be viewed as a re-emerging

(HBV)—3, hepatitis C virus (HCV)—1, both HBV and HCV—2),

disease, and this has led to an increased interest and demand

and 1 suspected patient had viral markers positive for hepatitis

for information, notably in developing countries [4] and in

A virus. Three patients died in hospital. All of them were

Georgia particularly. Worsening of sanitary conditions, wide-

women. Mortality was associated with severe haemorrhage (pa-

spread poverty and inefficient implementation of preventive

tient’s age 40), septic shock (age 62), meningoencephalitis (age

measures resulted in an increase of incidence of infectious dis-

67). Persistent human leptospirosis (PHL) was suspected in

eases after the Soviet Union collapse in the beginning of the

2 patients. They were re-hospitalised after one week and two months, respectively.

1990s [12]. Despite the most widespread zoonosis, the warm climate and more primitive sanitation conditions in the underdeveloped parts of the country, leptospirosis does not seem to be epidemic in Georgia [5].

Scientific Affairs

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Overall incidence is not high. However, it can be largely attrib-

characterised with headaches, eye problems, fatigue, depres-

uted to the poor health statistics and unavailability of laboratory studies in most cases [12]. A substantial proportion of peo-

sion, psychological changes, parainfectious encephalomyelitis and obsessive-compulsive disorder [15, 16, 17]. Two patients

ple may have subclinical or anicteric disease and do not seek

were opined to have PHL, but definite diagnosis was absent, as

medical attention [2]. The diagnoses such as ‘fever of unknown

it required isolation of Leptospira from clinical specimens.

origin’ or septic shock where causative factor is not specified cannot exclude leptospirosis. Besides, there is no information about the incidence and prevalence of the disease in Abkhazia

Conclusions

and ‘South Ossetia’, the breakaway regions of Georgia. Predominance of males can be explained firstly with more occu-

The study revealed that the course of the disease was severe, but the data was insufficient to draw general conclusions about

pational exposure and secondly males are more likely to take

the clinical and epidemiological aspects of human leptospirosis

part in freshwater-linked recreational activities. However, 1/3 of

in Georgia. This was related to lack of infrastructure and ad-

affected females were elderly women taking part in animal hus-

equate clinical suspicion, due to protean manifestations of the

bandry. Around half of the patients were from the age group

disease.

40–59 due to higher occupational exposure. Cases below the age of 19 and above 65 were uncommon. It has been suggested

Improving information management, updating knowledge in

that children less than 10 years of age show less severe reaction to leptospiral infection [3]. The absence of cases among the eld-

health workers and establishing modern diagnostic laboratory can greatly contribute to better diagnosis, management and

erly can probably also be explained by limited contact with in-

control of the disease in Georgia.

fected soil and water and because they are more likely to have developed immunity. Acknowledgements Seasonal differences could be related to warm climate and increased rainfall, leisure and farming in the period of July–Octo-

Authors wish to thank Department of Infectious Disease of

ber. Although presumptive source of infection was known in around 2/3 of cases, detailed epidemiological investigation for

Tbilisi State Medical University, Head of the department Professor E. Vashakidze, Associate professor T. Megrelishvili for perti-

identification definite sources, area and ways of transmission

nent advices.

were not carried out. References Confirmation of the cases was based on the first single serum

1. Meites E, Jay MT, Deresinski S, Shieh WJ, Zaki SR, Tompkins

test and none of them were supported with the fourfold or

L, Smith DS. Reemerging leptospirosis, California. Emerg

more increase in antibody titre in paired sera, or the recovery of Leptospira from clinical specimens. L. pomona was considered as the most frequent pathogen [10], however L. canicola and L. ballum prevailed in the results of 2000–2004, but it was not known whether Leptospira strains used for antigens were representative of local strains.

Infect Dis. 2004 Mar; 10(3): 406–12 2. Bharti AR, Nally JE, Ricaldi JN, Matthias MA, Diaz MM, Lovett MA. Leptospirosis: a zoonotic disease of global importance. Lancet Infect Dis. 2003 Dec; 3(12): 757–71 3. Yersin C, Bovet P, Merien F, Wong T, Panowsky J, Perolat P. Human leptospirosis in the Seychelles (Indian Ocean): A population-based study. Am J Trop Med Hyg. 1998; 59(6):

Most cases registered in Georgia were severe-to-fatal. Weil’s

933–940

syndrome is the most frequent course of the disease or the most

4. World Health Organisation [homepage on the Internet];

frequently diagnosed clinical manifestation. Weil’s syndrome may be accompanied with pulmonary complications or aseptic

c2003. Human leptospirosis: guidance for diagnosis, surveillance and control. 2003

meningitis. Pulmonary haemorrhage and respiratory failure

Available from: www.who.int/entity/csr/ don/en/WHO_

alone seem to be less common in Georgia. Leptospiral meningitis/meningoencephalitis also appears to be rare, but icteric meningoencephalitis can be fatal.

CDS_CSR_EPH_2002.23.pdf 5. Tchankoshvili N, Mirazanashvili V, Kapanadze L. Clinical study of hospitalised cases of sporadic human leptospirosis. In: Tbilisi State Medical University, Ivane Tarkhnishvili

Platelet count (Plt) below 100 109/L has been suggested as a prognostic factor associated with severe leptospirosis [13, 14]. However, only one fatal case showed Plt 105 109/L and the rest of patient had Plt > 130 109/L.

Students’ Scientific Society. Abstract book. Students’ LXV Scientific Conference; 2002 May 14–18; Tbilisi, Georgia. Tbilisi: TSMU; 2002. p. 36 6. Vinetz JM, Glass GE, Flexner CE, Mueller P, Kaslow DC. Sporadic urban leptospirosis. Ann Intern Med. 1996 Nov 15;

Chronic viral hepatitis, recognised to cause negative changes in

125(10): 794–8

host immunological response, was noted in 6 severe cases. For

7. The Partners for Health Reformplus (PHRplus) [homepage

that reason, viral hepatitis can be considered as one of the fac-

on the Internet]; c2004. Ministry of Labor, Health and Social

tors associated with severity of leptospirosis.

Affairs of Georgia; and National Center for Disease Control.

Persistent human leptospirosis (PHL), poorly recognised seque-

Guidelines for Surveillance and Control of Vaccine Preventable Diseases (July 2003). Available from: www.phrplus.org/

lae of the infection, is thought to develop in around 10 % of pa-

Pubs/Tool004_fin.pdf

tients. PHL is a long-term, but essentially transient condition,

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Scientific Affairs

8. Kvitashvili G.V. [About an outbreak of anicteric leptospiro-

14. Turgut M, Sunbul M, Bayirli D, Bilge A, Leblebicioglu H,

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Contact

with severe leptospirosis. J Med Assoc Thai. 2003 Oct;

Vazha-Pshavela Ave., Block 7, Korp. 15, Apt. 34,

86(10): 925–31

380086 Tbilisi, Georgia E-mail: Nick.1@gmx.co.uk Telephone (home) +995 32 300158

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JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Development of Protocols for the Treatment of Common Cold CONRAD BUTTIGIEG-SCICLUNA B.PHARM (HONS)

Introduction

teen cases were meant to assess the knowledge on treatment of common cold symptoms prior to their reading the protocols

Common cold is one of the most common conditions in the

(Part 1). After two weeks another fifteen cases were collected

world [1]. However, as the illness is self-limiting and the symp-

and these were used to validate the pharmacist’s improvement

toms are generally not too severe or long lasting but simply

after having read the protocols (Part 2). In order to achieve the

tedious, many patients will self-medicate, using products pur-

required amount of cases, the fieldwork was initiated as early as

chased through habit or recommendation from their pharmacist.

possible so as to have ample of time in which to collect the rele-

This project highlights the use of protocols for the symptomatic

vant cases. It was carried out over a period of five months during the 4th year, where a total of two hundred and two observation hours were spent.

treatment of common cold. Disease-specific drug treatment protocols can be important tools for pharmacists and other professionals who participate in the delivery of pharmaceutical care. Protocols are not intended to reduce the pharmacist’s in-

Scoring was made on an all or none basis. The data collected for

teraction with the patient. The goal of the protocols is to break

each case was filled in the respective result sheet. Whenever a

out the management of drug therapy as part of the overall dis-

pharmacist followed a step correctly, as required by the proto-

ease support throughout the evaluation, monitoring and main-

col, the corresponding box in the result sheet was ticked with a

tenance processes needed for the provision of pharmaceutical

very good (3). In cases where the pharmacist omits a step that

care [2].

is required in the management plan, the corresponding box in the result sheet is marked with a cross (7). Whenever a step is omitted as required by the protocol, the corresponding box in

Methodology

the result sheet is marked as not applicable (N /A). Each recorded case was numbered and then this number was attrib-

Two protocols were developed for the treatment of common

uted to a particular case in the statistical analysis.

cold, the first entitled Non-prescription sheet protocol and the other, Prescription sheet protocol for the treatment of common

The Mann-Whitney test and Pearson Chi-Square test were used

cold. The presentation of each protocol consisted of a flowchart and a definition pack, which were intended to be used concur-

for statistical analysis using statistical software BMDP. In both protocols, the Mann-Whitney test was used to determine

rently. The flowchart contains numbered boxes or steps, which

whether it is statistically significant for the twenty pharmacists

correspond to identically numbered sections in the definition

to all the steps. On the other hand, the Pearson Chi-Square test

pack. These boxes were set in a certain order to obtain the re-

was used to determine whether it is statistically significant for

quired information from the patrons of the pharmacy and each

the twenty pharmacists per step. In both tests, a significance

box contained summerised information as to deliver the mean-

level of 5 % was used as a cut-off point for a significant versus a

ing of each step without occupying unnecessary space on a par-

non-significant result (P < 0.05).

ticular page of the flowchart. The Prescription sheet protocol consisted only of six steps,

Results

where as the Non-prescription sheet protocol consisted of thirty-one steps for the management of common cold. The ob-

A total of 600 common cold cases were collected during the ob-

jective of the first six steps in both protocols was to gather infor-

servation hours. Three hundred and eighty-seven cases con-

mation regarding the medication and herbal remedies currently

cerned children, while the remaining cases concerned adults, in

used by the patient, the intended use as well as the length and

which females were more prevalent (n = 145). The Non-pre-

frequency of these products, medical history, age of patient, medication exclusions and precautions, counseling and nonpharmacological treatment. Regarding the Non-prescription sheet protocol, steps seven to thirty-one focus on the symptom(s) that is/are mostly disrupting the patient’s daily routine. A pilot study was conducted to analyse the practicality and applicability of the protocols. It took place in the pharmacy where weekly pharmacy practice required by the course regulations was carried out. During this phase, the required alterations to the protocols were made in order to initiate the actual fieldwork. The fieldwork involved the collection of thirty cases from

Fig. 1 Average percentage compliance to both protocols for all the cases

twenty pharmacies, which were chosen randomly. The first fif-

collected in the twenty pharmacies (n = 600).

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

Scientific Affairs

Table 1. Part of the descriptive statistics of data for both protocols GROUP

Before

After

MEAN

57.9780

82.2856

STD DEV

17.6064

12.1655

1.0165

0.7024

S.E.M. SAMPLE SIZE

TEST STATISTICS

P-VALUE

300

SAMPLE SIZE

300

MAXIMUM

100.0000

MINIMUM

16.6670

40.0000

Z MAX

2.39

1.46

Z MIN

–2.35

–3.48

MANN-WHIT.

13 104.0

(RANK SUMS

5 254.0

CASE (MAX)

124

CASE (MIN)

240

417

0.0000 122 046.0)

scription sheet protocol was followed in most cases in the com-

The protocols were found to be sufficiently detailed to manage

munity pharmacies (n = 361). Of the five common cold symptoms, nasal symptoms (n = 350) and cough (n = 290) were the

the conditions included in them. Details included were all evidence based and none of the steps were considered to be un-

most frequent. On the other hand sore throat (n = 190) and

necessary. The Mann-Whitney test was used to determine

headache (n = 158) were less frequent and relatively very few

whether there was a statistical significance between Part 1 and

patients complained of fever (n = 18). Out of 290 cough cases,

Part 2 mean compliance scores. Table 1 shows that the P-values

productive cough (n = 157) is more prevalent when compared to

is equal to zero and that the sum of ranks are significantly

dry cough (n = 133).

higher in Part 2 than in Part 1. Since P-value was sufficiently

The two protocols had a general compliance ranging from 16 percent to 100 percent for all the cases collected in Part 1 and

conclusion was that the two means do indeed differ significantly. The change between before and after reading the proto-

from 40 percent to 100 percent for all the cases collected in Part

cols was of 24 percent, which in turn implies that the difference

2. The average compliance with which these cases were man-

in the mean scores between Part 1 and Part 2 was statistically

aged was of 58 percent (n = 300) and 82 percent (n = 300) re-

significant and hence it can be generalized since it was not at-

spectively. Figure 1 graphically portrays the average percentage

tributed to chance.

small (P < 0.05), the null hypothesis (H0) was rejected and the

compliance of the twenty pharmacists to the two protocols. The Mann-Whitney test indicates that there was a statistical significance between Part 1 and Part 2 mean compliance scores. Table 1 shows the sum of ranks, which is significantly higher in Part

Discussion

2 than in Part 1. Since P-value is sufficiently small (P < 0.05), the

The findings indicate that the protocols play a significant role in

null hypothesis (H0) is rejected and the conclusion is that the

the management of common cold symptoms through giving ad-

two means do indeed differ significantly.

vice and recommending appropriate non-prescription medicines. The protocols were found to be practical to use and applicable. However it is still up to the pharmacist to apply steps

Conclusion

highlighted in the protocols in a manner which best suits indi-

Generally adults will have between two to four colds per year,

vidual patients. A statistically significant increase in compliance was observed after the dissemination of the protocols. This may

while children will have between six to ten colds per year [3].

be due to the fact that all the steps were necessary for the cor-

The results obtained from this study show that three hundred

rect management of common cold symptoms. Another reason

and eighty-seven or 65 percent of the cases encountered, com-

may be because the steps were depicted by a flowchart, which

mon cold symptoms are more prevalent in children (n = 387).

walked the pharmacist through a series of questions and an-

This increase in frequency may be due to the fact that children

swers leading to selection, initiation and management of the

have not yet developed any immunity against viruses. Also

condition.

nurseries, kindergartens and schools represent enclosed spaces favoring contagion. Moreover, children are less aware of the im-

A reason for non-compliance to the protocols could have been

portance of hygiene. Out of the remaining 35 percent of cases,

that pharmacists might presume that customers did not like

colds are more prevalent in females (n = 145). This may be asso-

being asked many questions and hence certain questions could

ciated with the larger amount of time women spent around

be omitted for the sake of not annoying customers. Another rea-

children [4].

son might be due to a busy pharmacy schedule, where pharmacists would consider some steps in the protocol as a waste of

Scientific Affairs

time. In fact, some pharmacist admitted that their excessive

JEMSA – Journal of EMSA on Medical and Scientific Affairs 2006

References

workload led to a degree of carelessness in the management of certain cases. However, pharmacists are duty bound at least to

1. Michel FB. Multisymptom management in the common cold. International Pharmaceutical Journal 1996; 10: 4–9

attempt the best management for a patron of the pharmacy and

2. American Pharmaceutical Association: Drug treatment pro-

if the patient does not comply, the pharmacist would not be re-

tocols. Canada: The institute; 1999: vii, xii-xiii, 382–393,

sponsible for lack of professionalism.

396–400 3. Mason P. OTC treatment of coughs and colds. Pharmaceut-

According to most pharmacists, the use of protocols abroad is

ical Journal 2002; 269: 612–614

certainly raising the profession’s image in the community. The

4. Shargel L, Mutnick AH, Souney PF et al. Comprehensive

introduction of protocols provides an opportunity for pharmacists to demonstrate their knowledge towards certain aspects of

Pharmacy Review. United States of America: Williams & Wilkins; 1997: 526–527

health-care. They also demonstrate the quantity and quality of

5. Cantrill JA, Weiss MC, Kishida M, Nicolson M. Pharmacists’

advice provided in each case [5].

perceptions and experiences of pharmacy protocols: a step in the right direction? International Journal of Pharmacy

It is important that if protocols are to be developed locally, they should be flexible and also reflect the customer’s perception. Customer’s awareness and education about the needs of more professional OTC dispensing is an important stepping-stone towards the success of drug treatment protocols.

Practice 1997; 5: 26–32

Faller, A. / Schuenke, M.

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