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Introduction: The purpose of this study was to arthroscopically verify MRI diagnostic accuracy for triangular fibrocartilage complex (TFCC) lesions in a regular clinical environment. Methods: A total of 859 patients' data with both preoperative MRI of the wrist and additional wrist arthroscopy were retrospectively reviewed. Two board-certified hand surgeons and one orthopaedic surgeon executed wrist arthroscopy, whereas more than 100 radiologists examined the MRI of the wrist. The accordance of TFCC lesion classification using MRI in comparison to wrist arthroscopy and diagnostic precision of the former depending on technical details were evaluated. Results: Diagnostic accuracy of MRI for TFCC lesions is poor in comparison to wrist arthroscopy as the reference standard. Technical specifications for MRI of the wrist are heterogeneous among the radiologists. These parameters have not improved accuracy of TFCC evaluation at large. Conclusion: The accuracy of MRI in a regular clinical environment still remains inferior to wrist arthroscopy for detection of TFCC lesions. Development of a standard MRI protocol may be implemented on a regular basis and application of the Palmer classification for TFCC lesion should be sought. [ABSTRACT FROM AUTHOR]

Summary: Delirium occurs commonly following major non‐cardiac and cardiac surgery and is associated with: postoperative mortality; postoperative neurocognitive dysfunction; increased length of hospital stay; and major postoperative complications and morbidity. The aim of this study was to investigate the effect of peri‐operative administration of dexmedetomidine on the incidence of postoperative delirium in non‐cardiac and cardiac surgical patients. In this randomised, double‐blind placebo‐controlled trial we included 63 patients aged ≥ 60 years undergoing major open abdominal surgery or coronary artery bypass graft surgery with cardiopulmonary bypass. The primary outcome was the incidence of postoperative delirium, as screened for with the Confusion Assessment Method. Delirium assessment was performed twice daily until postoperative day 5, at the time of discharge from hospital or until postoperative day 14. We found that dexmedetomidine was associated with a reduced incidence of postoperative delirium within the first 5 postoperative days, 43.8% vs. 17.9%, p = 0.038. Severity of delirium, screened with the Intensive Care Delirium Screening Checklist, was comparable in both groups, with a mean maximum score of 1.54 vs. 1.68, p = 0.767. No patients in the dexmedetomidine group died while five (15.6%) patients in the placebo group died, p = 0.029. For patients aged ≥ 60 years undergoing major cardiac or non‐cardiac surgery, we conclude that the peri‐operative administration of dexmedetomidine is associated with a lower incidence of postoperative delirium. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to report long-term objective and patient-reported outcome after arthroscopic debridement of central degenerative triangular fibrocartilage complex (TFCC) lesions. Methods: A total of 17 patients with central degenerative TFCC (Palmer type 2C) lesions and ulnar positive variance who were treated by arthroscopic debridement were retrospectively reviewed. Mean follow-up was 8.8 years. Assessment facilitating the Modified Mayo Wrist score (MMWS), the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH score), recording of pain level and of patient satisfaction, and radiological examination were done. Results: Patients reached a pain level of 1.7 VAS, MMW score of 92, and DASH score of 22. No significant differences could be detected between the operated and the contralateral extremity regarding range of motion and grip strength for all patients. No perioperative complications occurred. Conclusion: Arthroscopic debridement of central degenerative TFCC lesions is safe, reliable, and efficacious even for ulnar positive variance. Level of evidence: Therapeutic IV. [ABSTRACT FROM AUTHOR]

Introduction: Biomechanical evaluation of the viscoelastic properties tissue deformation, stiffness, and maximum breaking load of the human A2 pulley. We hypothesized that the A2 pulleys of index, middle, and ring fingers exhibit no difference regarding the aforementioned biomechanical parameters. Methods: Forty-one A2 pulleys of 14 upper extremities (8 body donors) were assessed. Cyclic and load-to-failure testing were performed. The biomechanical parameters tissue deformation during cyclic and load-to-failure testing, stiffness, and maximum breaking load were determined. Results: No significant differences between the fingers could be detected regarding the biomechanical parameters. A significant negative correlation could be detected between stiffness and deformation of the pulley. Significant positive correlations could be identified between stiffness and maximum breaking load and between maximum breaking load and deformation of the pulleys. Conclusions: Assessment of the viscoelastic properties of the A2 finger pulley promotes precise diagnosis of pulley lesions and will help to optimize treatment. [ABSTRACT FROM AUTHOR]

Trunk disease fungal pathogens reduce olive production globally by causing cankers, dieback, and other decline-related symptoms on olive trees. Very few fungi have been reported in association with olive dieback and decline in South Africa. Many of the fungal species reported from symptomatic olive trees in other countries have broad host ranges and are known to occur on other woody host plants in the Western Cape province, the main olive production region of South Africa. This survey investigated the diversity of fungi and symptoms associated with olive dieback and decline in South Africa. Isolations were made from internal wood symptoms of 145 European and 42 wild olive trees sampled in 10 and 9 districts, respectively. A total of 99 taxa were identified among 440 fungal isolates using combinations of morphological and molecular techniques. A new species of Pseudophaeomoniella, P. globosa, had the highest incidence, being recovered from 42.8 % of European and 54.8 % of wild olive samples. This species was recovered from 9 of the 10 districts where European olive trees were sampled and from all districts where wild olive trees were sampled. Members of the Phaeomoniellales (mainly P. globosa) were the most prevalent fungi in five of the seven symptom types considered, the only exceptions being twig dieback, where members of the Botryosphaeriaceae were more common, and soft/white rot where only Basidiomycota were recovered. Several of the species identified are known as pathogens of olives or other woody crops either in South Africa or elsewhere in the world, including species of Neofusicoccum, Phaeoacremonium, and Pleurostoma richardsiae. However, 81 of the 99 taxa identified have not previously been recorded on olive trees and have unknown interactions with this host. These taxa include one new genus and several putative new species, of which four are formally described as Celerioriella umnquma sp. nov., Pseudophaeomoniella globosa sp. nov., Vredendaliella oleae gen. & sp. nov., and Xenocylindrosporium margaritarum sp. nov. [ABSTRACT FROM AUTHOR]

Introduction: In operative treatment of Dupuytren's disease, in certain cases proximal interphalangeal joint (PIP) flexion contracture remains after fasciectomy which can be corrected by a supplementary arthrolysis, but few data comparing primary and revision surgery are available. Materials and Methods: Fifteen patients who had a fasciectomy and supplementary PIP arthrolysis at the affected finger for the first time were compared to 13 patients who had a revision fasciectomy with a supplementary PIP arthrolysis. Upon follow-up at 22 months, flexion contracture was measured and data were compared to the preoperative values. Patient satisfaction with the outcome of the operation was determined and patients completed the Disabilities of the Arm, Shoulder and Hand outcome measure questionnaire. Results: Fingers of patients with Dupuytren's disease that had a partial fasciectomy and supplementary arthrolysis of the PIP for the first time had a median residual PIP flexion contracture of 30° compared 39° of fingers that had a partial fasciectomy and supplementary arthrolysis of the PIP as a revision. The patients of both groups were equally satisfied with the outcome of the operation, while their DASH scores were nearly identical. Conclusion: After a mean follow-up of 2 years, the outcome of recurrent PIP contracture is comparable in patients with Dupuytren's disease that were treated by partial fasciectomy and supplementary arthrolysis for the first time and as a revision. [ABSTRACT FROM AUTHOR]

Nineteen Phaeoacremonium species are currently known in South Africa. These have been reported from grapevines, fruit trees, fynbos twig litter and arthropods. In other countries some of these Phaeoacremonium species are also known from hosts such as European olive, quince and willow that commonly occur in the Western Cape Province of South Africa, where most South African records of Phaeoacremonium have been made. The aim of this study was to investigate the species diversity and host-range of Phaeoacremonium in the Western Cape Province of South Africa by characterising 156 isolates collected from 29 woody hosts. Phylogenetic analyses of combined actin and beta-tubulin datasets allowed for the identification of 31 species among the 156 isolates, including 13 new species and 3 known species that had not been recorded in South Africa previously. The new Phaeoacremonium species include P. album, P. aureum, P. bibendum, P. gamsii, P. geminum, P. junior, P. longicollarum, P. meliae, P. oleae, P. paululum, P. proliferatum, P. rosicola and P. spadicum. All previous records of P. alvesii in South Africa were re-identified as P. italicum, but both species were recovered during this survey. A total of 35 described Phaeoacremonium species are now known from South Africa, more than double the number reported from any other country. This high diversity reflects the high diversity of indigenous flora of the Cape Floral Region, a biodiversity hotspot mainly situated in the Western Cape Province. Paraphyly and incongruence between individual phylogenies of the actin and beta-tubulin regions complicated species delimitation in some cases indicating that additional phylogenetic markers should be investigated for use in Phaeoacremonium phylogenies to prevent misidentifications and the introduction of vague species boundaries. [ABSTRACT FROM AUTHOR]

Studies that have investigated circadian, weekday and seasonal variation in postoperative mortality have been relatively small or have been for scheduled surgery. We retrospectively tested a large mixed surgical cohort from a German tertiary care university hospital for the presence of cyclical variation in all-cause in-hospital mortality after operations performed between 2006 and 2013. We analysed mortality rates after 247,475 operations, adjusted for age, sex, comorbidities, location, urgency and duration of the surgery, and intra-operative blood transfusions. The mortality odds ratio (95%CI) after operations started in the morning (08:00-11:00) were lowest, 0.73 (0.66-0.80), p < 0.001 and highest for operations started in the afternoon (13:00-17:00), 1.29 (1.18-1.40), p < 0.001. Mortality at the weekend was the same as during the week. There was no seasonal variation in mortality, p = 0.12. However, the interference of four-yearly and ten-monthly cycle amplitudes resulted in higher mortality odds ratio (95%CI) in winter 2008-2009, 1.41 (1.18-1.69), p < 0.001, and lower mortality in spring 2011 and 2012, 0.70 (0.56-0.85) and 0.67 (0.53-0.85), p < 0.001 and p = 0.001, respectively. The ability to predict cyclical phenomena would facilitate the design of interventional studies, aimed at reducing mortality following surgery in the afternoon and when cycles interfere constructively. [ABSTRACT FROM AUTHOR]

Background: The aim was to analyse the association between severity of complications up to 30 days after surgery and pre-operative nutritional and physical performance parameters.Methods: The participants were a subsample of the previously published PERATECS study (ClinicalTrials.gov: NCT01278537) and included 517 onco-geriatric patients aged ≥ 65 years, undergoing thoracoabdominal, gynaecological, or urological surgery. Post-operative complications were classified according to the Clavien Classification System (CCS). Independent risk factors related to the severity of complications, defined as major complications (CCS IIIa-V) and graded complications (CCS grade 0-V), were analysed using logistic and ordinal regression, respectively.Results: In total, 132 patients suffered major post-operative complications. The development of major post-operative complications was independently associated with body mass index (BMI) < 20 kg/m2 , hypoalbuminaemia (< 30 g/l), longer duration of surgery, and specific tumour sites (upper gastrointestinal, gynaecological, colorectal) (all P < 0.05). Higher-grade complications were predicted by Timed Up and Go (TUG) > 20 s, hypoalbuminaemia (< 30 g/l), higher American Society of Anesthesiologists (ASA) status III-IV, longer duration of surgery (> 165 min), and specific tumour sites (upper gastrointestinal, gynaecological) (all P < 0.05). Mini Nutritional Assessment (MNA) scores and weight loss were not independent risk factors for the severity of complications.Conclusions: Nutritional and physical performance risk factors that predicted the severity of complications differed between major and higher-grade post-operative complications, but hypoalbuminaemia independently predicted both. The results support the need for pre-operative risk screening. Due to the explorative nature of the study, further research is required in larger cohorts to corroborate these findings. [ABSTRACT FROM AUTHOR]

A regular hydration status and compensated vascular filling are targets of perioperative fluid and volume management and, in parallel, represent precautions for sufficient stroke volume and cardiac output to maintain tissue oxygenation. The physiological and pathophysiological effects of fluid and volume replacement mainly depend on the pharmacological properties of the solutions used, the magnitude of the applied volume as well as the timing of volume replacement during surgery. In the perioperative setting surgical stress induces physiological and hormonal adaptations of the body, which in conjunction with an increased permeability of the vascular endothelial layer influence fluid and volume management. The target of haemodynamic monitoring in the operation room is to collect data on haemodynamics and global oxygen transport, which enable the anaesthetist to estimate the volume status of the vascular system. Particularly in high risk patients this may improve fluid and volume therapy with respect to maintaining cardiac output. A goal-directed volume management aiming at preventing hypovolaemia may improve the outcome after surgery. The objective of this article is to review the monitoring devices that are currently used to assess haemodynamics and filling status in the perioperative setting. Methods and principles for measuring haemodynamic variables, the measured and calculated parameters as well as clinical benefits and shortcomings of each device are described. Furthermore, the results for monitoring devices from clinical studies of goal-directed fluid and volume therapy which have been published will be discussed. [ABSTRACT FROM AUTHOR]

Problem: Missed infections of the hand and wrist joints can lead to significant morbidity and require immediate surgical intervention by an experienced hand surgeon. Decisive therapeutic measures: Early initiation of correct treatment including radical surgical debridement of the infection site and adequate immobilization in conjunction with systemic antibiotic therapy under inpatient conditions are prerequisites for preserving joint function. Early functional physiotherapy of adjacent joints is a crucial cornerstone of treatment. [ABSTRACT FROM AUTHOR]

A regular hydration status and compensated vascular filling are targets of perioperative fluid and volume management and, in parallel, represent precautions for sufficient stroke volume and cardiac output to maintain tissue oxygenation. The physiological and pathophysiological effects of fluid and volume replacement mainly depend on the pharmacological properties of the solutions used, the magnitude of the applied volume as well as the timing of volume replacement during surgery. In the perioperative setting surgical stress induces physiological and hormonal adaptations of the body, which in conjunction with an increased permeability of the vascular endothelial layer influence fluid and volume management. The target of haemodynamic monitoring in the operation room is to collect data on haemodynamics and global oxygen transport, which enable the anaesthetist to estimate the volume status of the vascular system. Particularly in high risk patients this may improve fluid and volume therapy with respect to maintaining cardiac output. A goal-directed volume management aiming at preventing hypovolaemia may improve the outcome after surgery. The objective of this article is to review the monitoring devices that are currently used to assess haemodynamics and filling status in the perioperative setting. Methods and principles for measuring haemodynamic variables, the measured and calculated parameters as well as clinical benefits and shortcomings of each device are described. Furthermore, the results for monitoring devices from clinical studies of goal-directed fluid and volume therapy which have been published will be discussed. [ABSTRACT FROM AUTHOR]

Background: There is some evidence that patients’ outcomes improve if they are involved in shared decision making (SDM). A chronic pain clinic or premedication visit could be adequate settings for the implementation of SDM. So far, the patients’ preference for involvement in decision making and their desire for information have not been tested in anesthesiological settings. Methods: A group of chronic pain patients was compared with a group of patients in the premedication visit with respect to SDM, the desire for information and perceived involvement in care. The autonomy preference index (API, measuring preference for involvement and desire for information) and the perceived involvement in care scale (PICS, measuring patients’ perception of easier involvement by doctors and information exchange) were administered. Results: In total, 190 chronic pain patients and 151 patients of premedication were included in this study. Patient of the premedication visit had significantly higher SDM scores. Desire for information was high, but there were no differences between groups. Younger patients [B (estimate) =− 0.3; 95% CI (−0.4) − (−0.1)], women (B = 10.9; 95% CI 6.3–15.4) and patients with higher educational level (B = 10.1; 95% CI 5.6–14.6) had more desire for SDM. PICS scores were basically influenced by groups: chronic pain patients felt more facilitated by doctors [B =− 0.185; 95% CI (−0.4) – (−0.1)] and had more information exchange [B =− 19.5; 95% CI (−15.8) – (−2.4)] than patients in the premedication visit. Conclusion: In both anesthesiological settings, the desire for information was high, but patients in the premedication visit had higher SDM scores, especially young female patients with higher educational level. Real patient–physician interaction showed that premedication patients felt less involved by doctors and had less information exchange compared with the chronic pain patients. Therefore, premedication visits should be focussed more on adequate information exchange and involvement of the patient in the shared decision making process. [ABSTRACT FROM AUTHOR]

Purpose: The "Enhanced recovery after surgery" (ERAS) concept has been continuously developed for many surgical disciplines. Shorter length of stay (LOS) and associated cost savings have been achieved without an increase in the complication or readmission rate. Current guidelines helped to support an increasing standardisation of care. One innovation of the recently published update is the proposal to integrate prehabilitation (PREHAB) into the ERAS concept. On this basis, the authors provide an overview of the current data on ERAS concepts in gynecological oncology and review the evidence of prehabilitation concepts.Methods: Systematic literature review of all comparative studies on ERAS concepts in gynecological oncology and prehabilitation undergoing abdominal cancer surgery was performed using the standard databases. Outcomes of interest included prehabilitation program composition (exercise, nutritional, and psychological interventions), duration and outcome measures used to determine impact of prehabilitation vs. standard care.Results: Five studies reported on PREHAB programs in gynecology (three RCTs, one study protocol, one pilot study). There is no trial evaluating a pathway for patients with extensive ovarian or cervical cancer. Study protocols were heterogenous, but showed improvements in both physical and psychological parameters. ERAS protocols in ovarian cancer patients were investigated in 12 observational studies, mostly single center and only 1 RCT, in 4 studies patients with ovarian cancer or patients. Most studies showed improvement in complication rate and shorter LOS.Discussion: PREHAB programs seem feasible in abdominal cancer surgery and may improve surgical outcome. However, there is no prospective trial in gynecological oncology so far. Furthermore, there is no concept combining ERAS and PREHAB interventions. Therefore, the authors encourage the further development of both by describing in a novel treatment algorithm. [ABSTRACT FROM AUTHOR]

The importance of partial liver resection as a therapeutic option to cure hepatic tumors has increased over the last decades. This has been influenced on the one hand by advances in surgical and anesthetic management resulting in a reduced mortality after surgery and on the other hand by an increased incidence of hepatocellular carcinoma. Nowadays, partial resection of the liver is performed safely and as a routine operation in specialized centers. This article describes the pathophysiological changes secondary to liver failure and assesses the perioperative management of patients undergoing partial or extended liver resection. It looks in detail at the preoperative assessment, the intraoperative anesthetic management including fluid management and techniques to reduce blood loss as well as postoperative analgesia and intensive care therapy. [ABSTRACT FROM AUTHOR]

Background: To analyze safety issues of regional anaesthesia and analgesia in Germany only a few single center studies are available. Therefore, the German Society for Anaesthesiology and Intensive Care Medicine (Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI) and the Professional Association of German Anaesthetists (Berufsverband Deutscher Anästhesisten, BDA) initiated a network for safety in regional anaesthesia. From this the first results on infectious complications will be reported.Materials and Methods: In a Delphi process the documentation of the setup and maintenance of regional anaesthesia and analgesia was agreed with the participants in a working group from the DGAI. After approval by the officially authorized representative for patient data privacy protection a registry was programmed to collect anonymous data. Up to October 2008 data from 6 centers could be analyzed.Results: After testing for plausibility 8,781 regional anaesthesia procedures (22,112 catheter days) could be analyzed. The 5,057 neuraxial and 3,724 peripheral catheter-based procedures were in place for a median of 2.48 days (range 1.0-3.0 days) and 4 severe, 15 moderate and 128 mild infections were recorded. Diabetics were not found to show a statistically significant increase in risk (2.6% compared to 1.9% for non-diabetics: n.s.). Neuraxial procedures seem to have a higher rate of infections than peripheral procedures (2.7% vs. 1.3%, p<0.0001). Multiple punctures of the skin also seem to be associated with a higher infection rate than single skin punctures (4.1% vs. 1.6%, p<0.0001).Conclusions: Infectious complications of catheter-based regional anaesthesia are common. Strict hygienic standards must therefore be complied with. More data are necessary to calculate risk factors. The registry provided can also be used as a benchmark to reduce these rates further. [ABSTRACT FROM AUTHOR]

Introduction: Digital pyogenic flexor tenosynovitis requires fast, aggressive treatment. Although this infection occurs frequently, treatment consensus is lacking.Materials and Methods: Between 2011 and 2015, 22 patients with acute pyogenic flexor tenosynovitis were treated with a single open debridement followed by irrigation; the incision was closed and a 10-day antibiotic course was administered. The average incision-to-suture time was 25 min, and the average hospital stay was 4 days. Recovery was uncomplicated for 20 patients, while two were reoperated, one due to germ resistance and the other due to necrotizing fasciitis. At an average of 30 month postoperatively, 21 of the 22 patients were available for follow-up. The affected finger was inspected, and sensibility, range of motion, and grip force were compared with the opposite side, and the DASH score was determined. Each patient documented pain in the affected finger at rest and during activity, and rated overall satisfaction with the treatment on a visual analogue scale.Results: Almost all patients were free of pain at follow-up and very satisfied. Compared to the contralateral side, each of the affected fingers had the same range of motion and sensibility. Grip force was similar on both sides. The average DASH score was 35 points.Conclusion: A single open debridement with irrigation and primary wound closure followed by 10 days of antibiotic treatment resolved uncomplicated pyogenic flexor tenosynovitis. After 2 and a half years, the treatment yielded high patient satisfaction with neither functional nor subjective impairment of the affected finger. [ABSTRACT FROM AUTHOR]

Background. Frailty is a multidimensional geriatric syndrome characterized by a decline across multiple physiological systems [1]. It is accompanied by an increased vulnerability to stressors and is associated with adverse postoperative outcomes [2]. Frailty is linked to poor cognitive function and dementia, as well as structural changes of the brain [3,4]. However, it has not been investigated whether frail patients present with alterations in the electroencephalogram (EEG). We compared pre- and intraoperative EEG parameters in frail and non-frail patients. Methods. Patients aged ≥65 years undergoing elective surgery were included in this prospective observational study (NCT02265263; EA2/092/14). Frailty was assessed one day before surgery using a modified version of the Fried frailty phenotype comprising five criteria: slowness, weakness, exhaustion, weight loss and a level of low activity. Continuous frontal EEGs were recorded and analysed during 2 min periods before induction of anesthesia (preoperative) and during a stable intraoperative period (intraoperative). Only patients who received propofol for induction and volatile anesthetics for maintenance of anesthesia were included in the analyses. We compared the power spectrum within different frequency bands (δ: 1.5-4Hz, θ: 4-8Hz, α: 8-12Hz; β: 12-30Hz), as well as the spectral edge frequency (SEF) of frail and non-frail patients. Results. Of the 112 patients included in this study 14 (12,5%) were frail. No significant difference in power or SEF was found during the preoperative EEG measurements between the two groups. In the intraoperative EEG, frail patients presented with significantly lower a-power compared to non-frail patients (a-power: non-frail −3.67 [−7.77; −1.08] dB vs frail −8.71 [-13.75; −7.11] dB, p = 0.006). Moreover, intraoperative SEF values were significantly lower in frail patients (SEF: frail 10.71 [7.96; 11.34] Hz vs non-frail 13.70 [11.36; 15.62] Hz, p=0,001). In a multiple linear regression model adjusting for age, sex, ASA score, GDS Score, dose of anesthetics and cognitive abilities, frailty remained significantly associated with lower SEF values (p = 0,011). Conclusion. Preoperative frailty was associated with lower intraoperative a-power, as well as lower SEF values. This should be taken into consideration when interpreting intraoperative EEGs of elderly patients. References: 1. Fried, L.P., et al., Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci, 2001. 56(3): p. M146-56. 2. Makary, M.A., et al., Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg, 2010. 210(6): p. 901–8. 3. Avila-Funes, J.A., et al., Is frailty a prodromal stage of vascular dementia? Results from the Three-City Study. J Am Geriatr Soc, 2012. 60(9): p. 1708–12. 4. Kant, I.M.J., et al., The association between brain volume, cortical brain infarcts, and physical frailty. Neurobiol Aging, 2018. 70: p. 247–253. ▪ Fig. 1. Intraoperative Power Spectra and α-Power of Frail and Non-Frail Patients. ▪ Fig. 2. Intraoperative SFF of Frail and Non-Frail Patients. [ABSTRACT FROM AUTHOR]

Introduction The development and implementation of practice guidelines might be an important tool to evaluate the different practices and to consider different local strategies. Methods A postal questionnaire with 37 questions was sent to the leading physicians of 80 intensive care units in Germany, treating patients after cardiothoracic surgery. The survey covered the same core questions on current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support, and transfusions before and after the publication of an S3 guideline. Results A total of 77.5 % of the completed questionnaires were returned. Monitoring changed to increased use of central venous oxygen saturation ( S cvO2) in 55.1% (2005: 20.9%), end-tidal CO2-monitoring 36.2% (2005: 24.3%), and decreased use of the left atrial pressure with 12.3% (2005: 23.3%) and pulmonary artery catheter 47.5% (2005: 58.2%). For volume therapy, there is a decreased use of Hydroxyethyl starch ( HES) with 38.7% (2005: 63.4%) and an increased use of crystalloids 41.9% (2005: 22.4%). For inotropes, there is a trend to a decreased use of dopamine with 9.7% (2005: 29.1%, P = 0.074). The clinical relevance of the guidelines was judged 'high' by 43.5% and 'medium' by 50% of the responding physicians; however, change of treatments was reported by one quarter of respondents. Conclusion Despite ongoing variability in the use of monitoring devices, volume replacement and vasopressor/inotrope use in cardiac surgery patients, there have been some changes in the therapy of these patients after publication of the guidelines. Because the guideline has been considered as clinically relevant, further interdisciplinary development and implementation support should be considered. [ABSTRACT FROM AUTHOR]

Background: Natural orifice surgery (NOS) is now being elaborated with the aim to make abdominal surgery simpler and safer. In order to obtain women's perception of NOS and their willingness to consent to this type of approach a survey was conducted among female employees from surgical disciplines at the University Hospital Charité Berlin. Material and methods: A written description and information on minimally invasive surgery and the NOS concept were distributed among 500 female physicians and nursing staff along with a 14-item questionnaire. Of the staff members 118 participants completed the questionnaire anonymously. Data analysis was carried out using SPSS 16.0. Results: With regard to ovarectomy 55% of women surveyed indicated that they would prefer a transvaginal approach to standard laparoscopy (44%) or a transgastric approach (1%). When asked about preferred access for cholecystectomy only 31% would prefer the transvaginal method compared to 61% for the laparoscopic technique. Objections against the transvaginal access concerned the impact on a healthy sexual life and effects on fertility. Reasons for choosing NOS were no wound pain and no scar. Conclusion: This survey shows that among the surveyed female medical employees the transvaginal approach is associated with concerns and fears but these are not justifiable, as the transvaginal access has been used for more than 100 years for gynecological purposes. There is a strong need for outcome data to enlighten female patients and to help guide physicians when talking to patients regarding NOS and the transvaginal approach. [ABSTRACT FROM AUTHOR]

The importance of partial liver resection as a therapeutic option to cure hepatic tumors has increased over the last decades. This has been influenced on the one hand by advances in surgical and anesthetic management resulting in a reduced mortality after surgery and on the other hand by an increased incidence of hepatocellular carcinoma. Nowadays, partial resection of the liver is performed safely and as a routine operation in specialized centers. This article describes the pathophysiological changes secondary to liver failure and assesses the perioperative management of patients undergoing partial or extended liver resection. It looks in detail at the preoperative assessment, the intraoperative anesthetic management including fluid management and techniques to reduce blood loss as well as postoperative analgesia and intensive care therapy. [ABSTRACT FROM AUTHOR]

Background: Since October 2004 German Anaesthesiology Societies have officially recommended a decreased fasting period of 2 h for clear fluids and 6 h for solid food before elective surgery. A survey of patients and health care workers was carried out in our university clinic to assess the implementation of the new fasting recommendations.Methods: Surgical patients (n=865) as well as physicians and nurses specialized in anaesthesia and surgery (n=2,355) were invited to complete a written questionnaire. The survey inquired about prescribed and practiced duration of fasting, attitudes towards reduced preoperative fasting and knowledge of the new guidelines.Results: Data from 784 patients (91%) and 557 health care workers (24%) were analysed. Patients reported mean fasting times of 10+/-5 h for fluids and 15+/-4 h for solid food. Of the patients 52% and 16% would have preferred to drink and eat before surgery, respectively and 10% were informed about the new recommendations of shorter preoperative fluid and solid fasting. Such patients reported significantly reduced fasting times for fluids compared with those who were recommended to fast for the traditional longer periods (8+/-6 versus 12+/-4 h, p<0.001). Preoperative fasting advice remembered by the patients significantly differed from the prescribed recommendations (2 h fluid fasting, 22 versus 53%, p<0.001). Anaesthesiologists were significantly more knowledgeable of the new guidelines (90 versus 32-42%, p<0.001) and significantly more willing to recommend the new short preoperative fasting times (75 versus 15-19%, p<0.001) than other health care workers. Of all health care workers 82% and 32% reported patients' frequent desire to drink and eat before surgery, respectively, 92% considered reduced preoperative fasting to be positive, 76% feared increased risks for patients and 42% expected a decreased flexibility in their daily work.Conclusion: The current guidelines for preoperative fasting have not been widely implemented. Besides a knowledge discrepancy, remarkable concerns remain regarding higher risk for patients which may be important barriers to implementation. Nevertheless, health care workers are aware of patients' desire for shorter preoperative fasting. If the new guidelines are recommended patients will make use of them. Further training of staff and adequate implementation tools are needed. [ABSTRACT FROM AUTHOR]

To analyze safety issues of regional anaesthesia and analgesia in Germany only a few single center studies are available. Therefore, the German Society for Anaesthesiology and Intensive Care Medicine (Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin, DGAI) and the Professional Association of German Anaesthetists (Berufsverband Deutscher Anästhesisten, BDA) initiated a network for safety in regional anaesthesia. From this the first results on infectious complications will be reported. In a Delphi process the documentation of the setup and maintenance of regional anaesthesia and analgesia was agreed with the participants in a working group from the DGAI. After approval by the officially authorized representative for patient data privacy protection a registry was programmed to collect anonymous data. Up to October 2008 data from 6 centers could be analyzed. After testing for plausibility 8,781 regional anaesthesia procedures (22,112 catheter days) could be analyzed. The 5,057 neuraxial and 3,724 peripheral catheter-based procedures were in place for a median of 2.48 days (range 1.0-3.0 days) and 4 severe, 15 moderate and 128 mild infections were recorded. Diabetics were not found to show a statistically significant increase in risk (2.6% compared to 1.9% for non-diabetics: n.s.). Neuraxial procedures seem to have a higher rate of infections than peripheral procedures (2.7% vs. 1.3%, p<0.0001). Multiple punctures of the skin also seem to be associated with a higher infection rate than single skin punctures (4.1% vs. 1.6%, p<0.0001). Infectious complications of catheter-based regional anaesthesia are common. Strict hygienic standards must therefore be complied with. More data are necessary to calculate risk factors. The registry provided can also be used as a benchmark to reduce these rates further. [ABSTRACT FROM AUTHOR]

Background: Up to as many as 38,000 people die in German hospitals each year as a result of preventable medical errors. Anesthetic procedures are generally safer than internal medical procedures and the mortality associated with anesthesia is estimated to be 3.3-5 cases per million. However, this is still 10 times higher than the risk associated with civilian aviation for example. Up to 80% of mistakes are attributable to inadequate execution of non-technical skills (NTS) such as communication, teamwork and organization of the working environment. Training in non-technical skills through Anesthesia Crisis Resource Management (ACRM) is an integral part of the Berlin Simulation Training (BeST) curriculum. The aim of this study was to describe the subjective evaluation of change in routine clinical behavior as a result of simulator training using latent outcome variables such as "subjective evaluation of learning outcome", with special emphasis on communication.Material and Methods: In total 235 doctors with varying levels of professional experience received BeST training between 2001 and 2004. An anonymous postal questionnaire was sent to 228 of these participants and the response rate was 64% The questionnaire contained 13 questions covering evaluation of the workshop and learning outcome with respect to communication in the operating room (OR), teamwork in the OR and medical knowledge. Following factor analysis 3 latent outcome variables (subjective evaluation of the learning outcome, workshop-related change in perception of the value of communication and general value and relevance) were generated. Logistic regression was used to determine whether there was any relationship between the latent outcome variables and a number of independent factors.Results: It was not possible to demonstrate any relationship between the level of professional training, age or date of the workshop and the variables selected to describe subjective evaluation of behavioral change as a result of the workshop. How realistic the candidates perceived the training scenarios to be (p<0.01) and the sex of the candidates (p=0.03) were both significantly related to evaluation and female candidates were more likely to positively evaluate the simulator training. From the candidates' perspective the training significantly altered their perception of the value of NTSs, and in particular communication, during the management of critical incidents in the OR.Conclusion: Well-staged and realistic simulation is associated with better learning outcomes. It may be important to take gender aspects into account in ACRM training. [ABSTRACT FROM AUTHOR]

In patient care several clinical departments are often involved in the treatment of a single case. Due to this shared work and internal patient transfer between departments the respective departments have to share the single reimbursement sum which is granted for each hospital case in the German DRG system. The intensive care unit in particular, at least if maintained as an independent department, has a high rate of internal transfers and most of the patients will be transferred back to the original department prior to discharge from hospital. Different models have been suggested regarding the splitting of DRG reimbursement between clinical departments, however, no research has been done on the splitting of supplemental revenues. The allocation of supplemental revenues is especially complex for revenues generated over many days of hospital care or for clustered revenues. In most cases the supplemental revenues are simply allocated to the department from which the patient is ultimately discharged. This would lead to a significant economic risk for the intensive care unit, as a considerable proportion of medical services which are eligible for triggering supplemental revenues are applied there. In this study all cases treated in two intensive care units in a university hospital in 2007 were analyzed in which supplemental revenue-related medical services were performed over a longer period of time or graduated according to different amounts. In a total of 385 cases, 691 supplemental revenues were analyzed. Three different methods of supplemental revenues allocation were analyzed regarding the financial impact on the intensive care unit: allocation to the department from which the patient is discharged, allocation according to the length of stay in a particular department (in this case the intensive care unit) and allocation based on actually documented medical services eligible for supplemental revenues. The supplemental revenues take up a considerable share of the total reimbursement for intensive care. Based on the first 2 allocation methods the intensive care unit would receive 20% less supplemental revenues compared to the third allocation method, which supposedly reflects best the actual costs. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary bypass (CPB) impairs intestinal barrier function and induces systemic inflammation after cardiac surgery. The objective of this study was to evaluate the effect of profound haemodilution (haematocrit 19–21%) during normothermic CPB on gastrointestinal permeability and cytokine release in comparison with a standard haemodilution (haematocrit 24–26%). [ABSTRACT FROM PUBLISHER]

Delayed starts of operation room (OR) processes in the morning lead to suboptimal use of expensive OR personnel and resources. Therefore, the anaesthesiologist has to take care that anaesthesia preparation and induction are finished in time and the patients are ready for the surgical intervention according to the OR time schedule. However, if the anaesthesiologist starts too early, preincision waiting periods occur. The literature provides little data regarding the complex interaction of anaesthesia process times and delayed operation starts in the morning. In this prospective study 710 first operation positions in the morning were analyzed with respect to the incidence of and reasons for delayed finishing of anaesthesia induction and investigated the interaction of early and late finishing of anaesthesia induction. In 27.5% of anaesthesia inductions the preset time schedule was not reached and the average delay was 19.3+/-17.2 min. The main anaesthesia-dependent reasons for delays were complex anaesthesia inductions with difficult line placement. Also organizational difficulties such as changes in the OR case schedule and delayed patient transport were of major importance. The results of a simulation model showed that in 100% of the cases finishing anaesthesia induction in time would only be feasible if anaesthesia processes started much earlier. However, this would lead to a sharp increase in preincision waiting time with the patient being under anaesthesia but surgeons not ready to start, therefore having only a minor effect on surgical waiting time. Subsequently, on-time anaesthesia induction in all cases is not a reasonable target in OR management. [ABSTRACT FROM AUTHOR]

Background: In Germany, more than 100,000 patients are monitored and treated in 80 intensive care units (ICUs) following cardiac surgery each year. The controversies concerning the different methods of hemodynamic monitoring and the appropriate agents for volume therapy and inotropic support are well known. However, little is known about how monitoring and treatment are currently performed. Methods: A questionnaire with 39 questions was sent to the leading physicians of 80 ICUs in Germany, treating patients after cardiac surgery. The questions to be answered covered the current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support and transfusions in patients after cardiac surgery. Results: Sixty-nine per cent of the questionnaires were completed and returned. All ICUs used basic monitoring as recommended by the societies. The use of advanced hemodynamic monitoring included the pulmonary artery catheter (58.2%), transesophageal echocardiography (38.1%) and transpulmonary dilution techniques (13%). Crystalloids (21.2%) and colloids (73%) were used for volume replacement. Epinephrine (41.8%) and dobutamine (30.9%) were the first-choice inotropic drugs for the treatment of low cardiac output syndrome, followed by phosphodiesterase inhibitors (14.5%). Second-choice drugs for the treatment of low cardiac output syndrome were enoximone (29%), milrinone (25%) and dobutamine (25%). A written transfusion protocol and a transfusion threshold for red blood cells existed in 59% and 79% of ICUs, respectively. Conclusion: Hemodynamic monitoring and the variability in clinical practice with regard to volume replacement, transfusion triggers and the use of vasopressors/inotropes in cardiac surgery patients tend to follow the results of traditional experience rather than current scientific knowledge. Guidelines are therefore necessary to help to improve the standards of intensive care after cardiac surgery and thus the outcome of patients. [ABSTRACT FROM AUTHOR]

• Newborns show only minimal perioperative dynamic in EEG frequency bands. • EEGs of infants are characterized by a dominating relative δ-power with a mean of around 80%. • Infants aged 6–12 months show an increase of faster frequency bands from baseline to induction of general anaesthesia. The electroencephalographic derived indices have been developed for adult patients, however these monitors have not been validated for infants. Frontal EEGs were recorded in 115 infants aged <1 year [0–3-months (N = 27), 4–6-months (N = 30), 7–9-months (N = 29) and 10–12-months (N = 29)] who received general anaesthesia with sevoflurane. Total power (µV2) and relative β-, α-, θ-, δ-power (%) were analyzed. Additionally, in 20 EEGs event marker were added (baseline, loss of consciousness, intraoperative situation, extubation) to assess perioperative EEG dynamics. Newborns show a mean relative δ-power at 80% in intraoperative EEG compared to infants (10–12 months) showing 47.5%. Relative β-power and α-power are low in newborns (mean 3.2% and 4.6%; respectively), with a marked increase in the older infants (4–6 months) (mean 10.9% and 14.4%; respectively). EEG dynamic in newborns from baseline (relative δ-power of 88%) to the intraoperative situation (80.5%) are discrete. In contrast infants >6-months have a strong reduction of relative δ-power from baseline to the intraoperative situation, which corresponds to an increase of faster frequencies. Age dependent perioperative EEG signatures can be demonstrated in infants younger than one year. We demonstrate significant differences in EEG readouts between newborns and infants which questions our monitoring systems in paediatric anaesthesia. [ABSTRACT FROM AUTHOR]

Background/objective: Postdural puncture headache (PDPH) is a severe complication after spinal anesthesia. The aim of this study was to investigate the incidence of PDPH in two different operative cohorts and to identify risk factors for its occurrence as well as to analyze its influence on the duration of hospital stay.Material and Methods: In a retrospective study over a period of 3 years (2010-2012), 341 orthopedic surgery (ORT) and 2113 obstetric (OBS) patients were evaluated after spinal anesthesia (SPA). Data were statistically analyzed using (SPSS-23) univariate analyses with the Mann-Whitney U‑test, χ2-test and Student's t-test as well as logistic regression analysis.Results: The incidence of PDPH was 5.9% in the ORT cohort and 1.8% in the OBS cohort. Patients with PDPH in the ORT cohort were significantly younger (median 38 years vs. 47 years, p = 0.011), had a lower body weight (median 70.5 kg vs. 77 kg, p = 0.006) and a lower body mass index (median 23.5 vs. 25.2, p = 0.037). Body weight (odds ratio (97.5 % Confidence Intervall [CI]), OR 0.956: 97.5% CI 0.920-0.989, p = 0.014) as well as age (OR 0.963: 97.5% CI 0.932-0.991, p = 0.015) were identified as independent risk factors for PDPH. In OBS patients, PDPH occurred more frequently after spinal epidural anesthesia than after combined spinal epidural anesthesia (8.6% vs. 1.2%, p < 0.001) and the type of neuraxial anesthesia was identified as an independent risk factor for PDPH (OR 0.049; 97.5% CI 0.023-0.106, p < 0.001). In both groups the incidence of PDPH was associated with a longer hospital stay (ORT patients 4 days vs. 2 days, p = 0.001; OBS patients 6 days vs. 4 days, p < 0.0005).Conclusion: The incidence of PDPH was different in the two groups with a higher incidence in the ORT but considerably lower than in the literature. Age, constitution and type of neuraxial anesthesia were identified as risk factors of PDPH. Considering the functional imitations (mobilization, neonatal care) and a longer hospital stay, future studies should investigate the impact of an early treatment of PDPH. [ABSTRACT FROM AUTHOR]

Guidelines serve the decision-making process in medicine and must, therefore, be of high methodical and professional quality and must not be influenced by financial or commercial interests. Sniderman and Furberg have demanded that the process of guideline-making must be fundamentally reassessed and optimized for American circumstances. Their demands are critically assessed and commented on for the development of guidelines of the German Society for Anesthesiology and Intensive Care Medicine. [ABSTRACT FROM AUTHOR]

Background: End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play a role in the context of EOLC.Objective: Is the working environment associated with perception of NBT or clinician burnout?Material and Methods: Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis.Results: The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91 residents and 26 consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each p ≤ 0.001) and the numbers of weekend working days per month (p = 0.012). Protective factors against burnout included intensive care specialization (p = 0.001) and emotional support within the team (p ≤ 0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each p ≤ 0.001).Discussion: Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources. [ABSTRACT FROM AUTHOR]

Abstract Preserved executive functioning (EF) is crucial for daily functioning in the elderly and it appears to predict dementia development. We sought to clarify the role of atrophy-corrected cortical grey matter (GM) volume as a potential brain reserve (BR) marker for EF in the elderly. In total, 206 pre-surgical subjects (72.50 ± 4.95 years; mean MMSE score 28.50) were investigated. EF was primarily assessed using the Trail Making Test B (TMT B). Global/ lobar GM volumes were acquired with T1 MP-RAGE. Adjusting for key covariates including a brain atrophy index (i.e. brain parenchymal fraction), multiple linear regression analysis was used to study associations of GM volumes and TMT B. All GM volumes - most notably of global GM - were significantly associated with TMT B independently of GM atrophy (ß = −0.201 to −0.275, p = 0.001–0.012). Using atrophy-corrected GM volume as an estimate of maximal GM size in youth may serve as a BR predictor for cognitive decline in future studies investigating BR in the elderly. Highlights • Executive function is a marker for prediction of cognitive decline in the elderly. • Atrophy-corrected global grey matter volume predicts EF in the non-demented elderly. • Atrophy-corrected global GM volume is a potential quantitative brain reserve marker. [ABSTRACT FROM AUTHOR]

This experiment aimed to compare circulating progesterone (P4), follicular dynamics, and fertility during reuse of intravaginal P4 implants that were sanitized by autoclave or chemical disinfection in lactating Holstein cows submitted to fixed-time artificial insemination (FTAI). For this, 123 primiparous and 226 multiparous cows from 2 farms, averaging (mean ± standard deviation) 163.9 ± 141.9 d in milk, 35.7 ± 11.3 kg of milk/d, and a body condition score of 2.9 ± 0.5, were enrolled in the study. Cows were randomly assigned to 1 of 2 treatments using a completely randomized design and each cow received a reused implant (1.9 g of P4; previously used for 8 d) that was either autoclaved (AUT; n = 177) or chemically disinfected (CHEM; n = 172) on d -10. Also on d -10, cows received 2 mg of estradiol benzoate and 100 µg of GnRH. On d -3, cows received 25 mg of dinoprost (PGF2α). A second PGF2α was given on d -2, along with 1 mg of estradiol cypionate and P4 implant removal. Cows received FTAI on d 0. A subset of cows (n = 143) was evaluated by ultrasound on d -10, -8, -6, -3, -2, 0, and 5 to identify ovarian structures, and blood was sampled on d -10, -3, and -2 for P4 concentrations by RIA. Pregnancy diagnoses were performed at d 32 and 60. Statistical analyses was performed using PROC-MIXED for continuous variables and PROC-GLIMMIX of SAS 9.4 (SAS Institute Inc., Cary, NC) for binomial variables. The treatments did not differ in circulating P4 on d -10 or -3, but P4 was greater on d -2 in CHEM cows. Ovulation to the treatments on d -10 was associated with lower circulating P4 on d -10 (2.0 vs. 3.1 ng/mL) and resulted in greater P4 on d -3 (4.0 vs. 2.4 ng/mL) and more cows with a corpus luteum on d -3 (100 vs. 40%) than nonovulating cows. Cows that ovulated to d -10 treatments were more likely to have a synchronized new follicular wave (97.9 vs. 63.2%) and had an earlier wave emergence (1.9 vs. 2.6 d), resulting in less cows ovulating a persistent follicle (0.0 vs. 35.7%). Type of P4 implant, corpus luteum presence on d -10, and ovulation to d -10 treatments did not affect fertility (pregnancy per AI; P/AI). However, P/AI on farm A was greater than on farm B at 32 (40.8 vs. 27.8%) and 60 d (35.8 vs. 24.3%), independent of treatment. In conclusion, P4 implants with different P4 release patterns did not produce detectable differences in follicular dynamics, synchronization rate, or P/AI. Nevertheless, presence of corpus luteum or ovulation at the beginning of the FTAI protocol affected reproductive variables, such as timing and synchronization of follicular wave emergence, and size of the ovulatory follicle. Beyond that, more overall synchronized cows became pregnant to the FTAI protocol. [ABSTRACT FROM AUTHOR]

Objective Anaesthesia-induced dynamics in EEG are dependent on age and level of anaesthesia, but distinct characterisation in children is incomplete. Here we analyse EEG dynamics in children related to age and level of anaesthesia. Methods Frontal EEG recordings were obtained from 93 children (0–19 years) during routine clinical anaesthesia. EEG segments were selected at four different levels of anaesthesia: emergence, light anaesthesia, deep anaesthesia, and very deep anaesthesia. Results Total power differed significantly over age at deep (R 2 = 0.314; p < 0.0001) and very deep anaesthesia (R 2 = 0.403; p < 0.0001). Relative beta band power at light anaesthesia increased linearly with age (R 2 = 0.239; p < 0.0001). Level of anaesthesia caused significant differences for relative delta band power (increasing with anaesthetic depth), for relative beta band power and for spectral edge frequency (decreasing with anaesthetic depth) for all children (p < 0.0001). Conclusions EEG parameter in children were primary dependent on anaesthetic depth, where beta band power, delta band power and spectral edge frequency showed a linear relation. Age-dependency during anaesthesia procedure were only seen for single EEG parameters. Significance Different levels of anaesthesia can be identified by relative beta band power, relative delta band power and spectral edge frequency irrespective of the children’s age. [ABSTRACT FROM AUTHOR]

Aim Acute kidney injury ( AKI) is diagnosed by a 50% increase in creatinine. For patients without a baseline creatinine measurement, guidelines suggest estimating baseline creatinine by back-calculation. The aim of this study was to evaluate different glomerular filtration rate ( GFR) equations and different GFR assumptions for back-calculating baseline creatinine as well as the effect on the diagnosis of AKI. Methods The Modification of Diet in Renal Disease, the Chronic Kidney Disease Epidemiology ( CKD- EPI) and the Mayo quadratic ( MQ) equation were evaluated to estimate baseline creatinine, each under the assumption of either a fixed GFR of 75 mL min−1 1.73 m−2 or an age-adjusted GFR. Estimated baseline creatinine, diagnoses and severity stages of AKI based on estimated baseline creatinine were compared to measured baseline creatinine and corresponding diagnoses and severity stages of AKI. Results The data of 34 690 surgical patients were analysed. Estimating baseline creatinine overestimated baseline creatinine. Diagnosing AKI based on estimated baseline creatinine had only substantial agreement with AKI diagnoses based on measured baseline creatinine [Cohen's κ ranging from 0.66 (95% CI 0.65-0.68) to 0.77 (95% CI 0.76-0.79)] and overestimated AKI prevalence with fair sensitivity [ranging from 74.3% (95% CI 72.3-76.2) to 90.1% (95% CI 88.6-92.1)]. Staging AKI severity based on estimated baseline creatinine had moderate agreement with AKI severity based on measured baseline creatinine [Cohen's κ ranging from 0.43 (95% CI 0.42-0.44) to 0.53 (95% CI 0.51-0.55)]. Conclusion Diagnosing AKI and staging AKI severity on the basis of estimated baseline creatinine in surgical patients is not feasible. Patients at risk for post-operative AKI should have a pre-operative creatinine measurement to adequately assess post-operative AKI. [ABSTRACT FROM AUTHOR]

Dynamic alterations in flavin adenine dinucleotide (FAD) fluorescence permit insight into energy metabolism-dependent changes of intramitochondrial redox potential. Monitoring FAD fluorescence in living tissue is impeded by photobleaching, restricting the length of microfluorimetric recordings. In addition, photodecomposition of these essential electron carriers negatively interferes with energy metabolism and viability of the biological specimen. Taking advantage of pulsed LED illumination, here we determined the optimal excitation settings giving the largest fluorescence yield with the lowest photobleaching and interference with metabolism in hippocampal brain slices. The effects of FAD bleaching on energy metabolism and viability were studied by monitoring tissue pO2, field potentials and changes in extracellular potassium concentration ([K+]o). Photobleaching with continuous illumination consisted of an initial exponential decrease followed by a nearly linear decay. The exponential decay was significantly decelerated with pulsed illumination. Pulse length of 5 ms was sufficient to reach a fluorescence output comparable to continuous illumination, whereas further increasing duration increased photobleaching. Similarly, photobleaching increased with shortening of the interpulse interval. Photobleaching was partially reversible indicating the existence of a transient nonfluorescent flavin derivative. Pulsed illumination decreased FAD photodecomposition, improved slice viability and reproducibility of stimulus-induced FAD, field potential, [K+]o and pO2 changes as compared to continuous illumination. [ABSTRACT FROM AUTHOR]

Background: Post-operative delirium and post-operative cognitive dysfunction (POCD) are both common but it has not been clarified how closely they are associated. We aimed to assess the possible relationship in a secondary analysis of data from the 'Surgery Depth of anaesthesia and Cognitive outcome'- study.Methods: We included patients aged ≥ 60 years undergoing non-cardiac surgery planned for longer than 60 min. Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders IV criteria in the post-anaesthesia care unit (PACU) as well as within the first week after surgery. Cognitive function was assessed with a neuropsychological test battery. Multivariable analysis of POCD was performed with consideration of predisposing and precipitating factors.Results: Of 1277 randomized patients, 850 (66.6%) had complete data. Delirium was found in 270 patients (32.9% of 850). We detected POCD in 162 (20.9% of 776) at 1 week and in 52 (9.4% of 553) at 3 months. In multivariable analysis (n = 808), delirium had no overall effect on POCD (P = 0.30). Patients with no delirium in PACU but with postoperative delirium within 7 days had an increased risk of POCD at 3 months (OR = 2.56 (95%-confidence interval: 1.07-6.16), P = 0.035). No significant association was found for the other subgroups.Conclusions: There is no clear evidence that postoperative delirium is independently associated with POCD up to 3 months. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Fasting Guidelines Need to Consider that Cases May Start Earlier than Scheduled," by Franklin Dexter and Ruth E. Wachtel in the previous issue .

Background: Hemophagocytic lymphohistiocytosis (HLH) has well been studied as a genetic disorder in children (primary HLH). Mutations in the regulatory complex of the cellular immune synapse lead to a loss of function of cytotoxic T‑cells and natural killer cells with excessive inflammation based on a cytokine storm. During the last decade, an increasing number of adult HLH patients without a family history of HLH (secondary or acquired HLH) have been reported. Various triggers - infections, malignancies or autoimmune diseases - result in an acquired loss of function of these cells and a sepsis-like disease. Missed or late diagnosis is believed to be a major cause of the high mortality.Objectives: To describe the current knowledge on HLH and to raise awareness.Materials and Methods: Analysis of case reports, current studies, and expert recommendations.Results: Increased vigilance in identifying the adult form of HLH resulted in an increasing number of case reports over the past few years. HLH patients typically present with a clinical phenotype resembling severe sepsis or septic shock with fever, cytopenia, and organomegaly, which do not or insufficiently respond to anti-infective treatment. Early recognition of HLH distinction from sepsis, and prompt initiation of treatment - which is fundamentally different from sepsis - are crucial for improved outcome. A promising diagnostic parameter is ferritin, which has gained sufficient specificity, but only in the context of the triad of fever, cytopenia, and organomegaly. Treatment of adult HLH patients requires immunosuppression, with strict therapeutic guidance derived from the triggering disease.Conclusions: Because of the similar clinical presentation to that of sepsis, HLH is often not recognized, resulting in a fatal outcome. In "sepsis" patients on the ICU with deterioration despite a standard of care, HLH needs to be considered by testing for ferritin when considering differential diagnoses. The complexity of the illness requires interdisciplinary patient care with specific integration of the hematologist in the diagnostic workup and therapeutic management, because of the frequent use of chemotherapy-based immunosuppression. [ABSTRACT FROM AUTHOR]

Background: Hemophagocytic lymphohistiocytosis (HLH) has well been studied as a genetic disorder in children (primary HLH). Mutations in the regulatory complex of the cellular immune synapse lead to a loss of function of cytotoxic T-cells and natural killer cells with excessive inflammation based on a cytokine storm. During the last decade, an increasing number of adult HLH patients without a family history of HLH (secondary or acquired HLH) have been reported. Various triggers - infections, malignancies or autoimmune diseases - result in an acquired loss of function of these cells and a sepsis-like disease. Missed or late diagnosis is believed to be a major cause of the high mortality. Objectives: To describe the current knowledge on HLH and to raise awareness. Materials and methods: Analysis of case reports, current studies, and expert recommendations. Results: Increased vigilance in identifying the adult form of HLH resulted in an increasing number of case reports over the past few years. HLH patients typically present with a clinical phenotype resembling severe sepsis or septic shock with fever, cytopenia, and organomegaly, which do not or insufficiently respond to anti-infective treatment. Early recognition of HLH distinction from sepsis, and prompt initiation of treatment - which is fundamentally different from sepsis - are crucial for improved outcome. A promising diagnostic parameter is ferritin, which has gained sufficient specificity, but only in the context of the triad of fever, cytopenia, and organomegaly. Treatment of adult HLH patients requires immunosuppression, with strict therapeutic guidance derived from the triggering disease. Conclusions: Because of the similar clinical presentation to that of sepsis, HLH is often not recognized, resulting in a fatal outcome. In 'sepsis' patients on the ICU with deterioration despite a standard of care, HLH needs to be considered by testing for ferritin when considering differential diagnoses. The complexity of the illness requires interdisciplinary patient care with specific integration of the hematologist in the diagnostic workup and therapeutic management, because of the frequent use of chemotherapy-based immunosuppression. [ABSTRACT FROM AUTHOR]

Introduction. EEG based monitoring systems are routinely used for guidance of depth of anesthesia. They have been developed for adult patients however, these monitors have not been validated for children nor for infants [1–5]. Given the toxicity of anesthetics and the lack of possibilities to surveil the level of anesthesia in infants demands for further progress in EEG based monitoring of the developing brain. Method. In a retrospective study frontal peri- and intraoperative EEGs (Narcotrend Monitor) were recorded in 115 infants aged. To analyze EEG dynamics over intraoperative time-points additionally in 20 EEG recordings event markers were added (Baseline EEG, loss of consciousness (LOC), intraoperative maintenance of anesthesia (OP), Extubation). Data are presented as mean with standard deviation. Results. Newborns show a mean relative δ-power at 80% in intraoperative EEG compared to infants (10-12 months) showing 47,5%. EEG dynamics in newborns from baseline (relative δ-power of 88%) to the intraoperative situation (80.5%) are discreet. The total power is constant from baseline to OP and shows a reduction at the time of extubation. In contrast infants >6-months have a strong reduction of relative δ-power from baseline to the intraoperative situation, which corresponds to an increase of faster frequencies. Discussion. Age-dependent EEG changes can be demonstrated in infants younger than one year under general anesthesia with sevoflurane which questions our today's monitoring systems in pediatric anesthesia. To improve EEG guided anesthesia in the future more studies are needed to advance the accuracy of EEG Monitors for pediatric anesthesia. References 1. Cornelissen, L., et al., Age-dependent electroencephalogram (EEG) patterns during sevoflurane general anesthesia in infants. Elife, 2015. 4: p. e06513. 2. Akeju, O., et al., Age-dependency of sevoflurane-induced electroencephalogram dynamics in children. Br J Anaesth, 2015. 115 Suppl 1(Suppl 1): p. i66-i76. 3. Cornelissen, L., et al., Electroencephalographic markers of brain development during sevoflurane anaesthesia in children up to 3 years old. Br J Anaesth, 2018. 120(6): p. 1274-1286. 4. de Heer, I.J., S.J.M. Bouman, and F. Weber, Electroencephalographic (EEG) density spectral array monitoring in children during sevoflurane anaesthesia: a prospective observational study. Anaesthesia, 2019. 74(1): p. 45-50. 5. Purdon, P.L., et al., Electroencephalogram signatures of loss and recovery of consciousness from propofol. Proc Natl Acad Sci U S A, 2013. 110(12): p. E1142-51. ▪ Fig. 1. ▪ Fig. 2. [ABSTRACT FROM AUTHOR]

Background Myocardial apoptosis has been discussed to play a pivotal role in the development and progression of congestive heart failure (CHF). However, recently there is doubt on the evidence of myocardial apoptosis in heart failure as information on ultrastructural changes by electron microscopy is still scarce. This project therefore aimed to detect direct morphological evidence of myocardial apoptosis in an experimental heart failure model. Method Following IRB approval, an aortocaval fistula (ACF) was induced in male Wistar rats using a 16G needle. 28 ± 2 days following ACF rats were examined by hemodynamic measurements, Western blot, immunofluorescence confocal and electron microscopic analysis. Results Within 28 ± 2 days of ACF heart (3.8 ± 0.1 vs. 6.6 ± 0.3 mg/g) and lung (3.7 ± 0.2 vs. 6.9 ± 0.5 mg/g) weight indices significantly increased in the ACF group accompanied by a restriction in systolic (LVEF: 72 ± 2 vs. 39 ± 3%) and diastolic (dP/dt min. : − 10,435 ± 942 vs. − 5982 ± 745 mmHg/s) function (p < 0.01). Activated caspase-3 was significantly increased in failing hearts concomitant with mitochondrial leakage of cytochrome c into the cytosol. Finally, electron microscopy of the left ventricle (LV) of ACF rats revealed pronounced ultrastructural changes in > 70% of examined cardiomyocytes, such as nuclear chromatin condensation, myofibril loss and disarray, contour irregularities and amorphous dense bodies, mitochondriosis and damaged cell–cell-contacts between cardiomyocytes. Conclusions Volume overload induced heart failure is associated with activation of the mitochondrial apoptotic pathway. In addition, electron microscopy of the LV revealed direct ultrastructural evidence of extended myocardial apoptosis in ACF rats. [ABSTRACT FROM AUTHOR]