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Therapeutic decisions in lung cancer critically depend on the determination of histologic types and oncogene mutations. Therefore, tumor samples are subjected to standard histologic and immunohistochemical analyses and examined for relevant mutations using comprehensive molecular diagnostics. In this study, an alternative diagnostic approach for automatic and label-free detection of mutations in lung adenocarcinoma tissue using quantum cascade laser-based infrared imaging is presented. For this purpose, a five-step supervised classification algorithm was developed, which was not only able to detect tissue types and tumor lesions, but also the tumor type and mutation status of adenocarcinomas. Tumor detection was verified on a data set of 214 patient samples with a specificity of 97% and a sensitivity of 95%. Furthermore, histology typing was verified on samples from 203 of the 214 patients with a specificity of 97% and a sensitivity of 94% for adenocarcinoma. The most frequently occurring mutations in adenocarcinoma (KRAS, EGFR, and TP53) were differentiated by this technique. Detection of mutations was verified in 60 patient samples from the data set with a sensitivity and specificity of 95% for each mutation. This demonstrates that quantum cascade laser infrared imaging can be used to analyze morphologic differences as well as molecular changes. Therefore, this single, one-step measurement provides comprehensive diagnostics of lung cancer histology types and most frequent mutations.

Interactions between drugs and micronutrients have received only little or no attention in the medical and pharmaceutical world in the past. Since more and more pharmaceutics are used for the treatment of patients, this topic is increasingly relevant. As such interactions - depending on the duration of treatment and the status of micronutrients - impact the health of the patient and the action of the drugs, physicians and pharmacists should pay more attention to such interactions in the future. This review aims to sensitize physicians and pharmacists on drug micronutrient interactions with selected examples of widely pescribed drugs that can precipitate micronutrient deficiencies. In this context, the pharmacist, as a drug expert, assumes a particular role. Like no other professional in the health care sector, he is particularly predestined and called up to respond to this task. The following article intends to point out the relevance of mutual interactions between micronutrients and various examples of widely used drugs, without claiming to be exhaustive.

In light of the steadily increasing need for economical efficacy and capacity utilization it was the aim of this proof-of-concept work to implement an automated logfile-based analysis tool for MRI scanner utilization and to establish a process analysis. As a primary step, analyses of scanner and protocol utilization, parametrization of protocol processes, their durations, age dependency, and scan efficacy were to be tested. Logfiles were continuously extracted from a 1.5 T MR scanner (Philips Achieva) and automatically explored for relevant scan parameters. Parameters were extracted into a database and logically combined to protocol parameters. Visualization was achieved using PowerBI (Microsoft, USA). Data aggregation comprised a day-based and protocol-based strategy. In addition, age- and regional-based testing was performed. The frequency of protocol usage was evaluated and those protocols with frequent usage compared regarding efficacy to those rarely used. After successful technical implementation, 3659 MR exams were available for further analysis. Out of a plethora of parameters, those relevant to the understanding of the scan process were identified. The initial results mirror the daily scanner usage and allow identifying, e. g., shortened scanner usage on Fridays or longer examination times in children. A scan efficacy of 69.6 ± 17.6 % excluding preparation process was identified as a parameter with high potential to be optimized in daily routine. The logfile-based analysis of MR scanner processes was successfully introduced and holds the promise to be extended into a comprehensive analytic tool for the analysis and optimization of scanner processes. In combination with other variables from the departmental or institutional infrastructure or patient-specific information such tool may be developed into a intelligent steering tool. · The automated log file analysis of MR-scanner processes was successfully introduced. · The log file-analysis allows for a detailed analysis of scanner processes. · From a log file-analysis, there is potential benefit to users, applications specialists and developers.· Frydrychowicz A, Boppel T, Sieber V et al. Automatic, log file-based process analysis of a clinical 1.5T MR scanner: a proof-of-concept study. Fortschr Röntgenstr 2021; 193: 919 - 927.ZIEL: Vor dem Hintergrund stetig wachsender Anforderungen bzgl. Effizienzsteigerung und Scannerauslastung war es das Ziel dieser Machbarkeitsstudie, eine automatisierte Logfile-basierte Prozessanalyse an einem MRT-Scanner der klinischen Routine einzurichten, eine Prozessmetrisierung zu erreichen und Auswertungen der Auslastung, Protokollnutzung, Altersabhängigkeiten und Effizienz durchzuführen. Logfiles eines 1,5T-MR-Scanners (Philips Achieva) wurden automatisch exportiert, relevante Daten extrahiert, einer Datenbank zugeführt, zu definierten Ablaufparametern zusammengeführt und mittels PowerBI (Microsoft, USA) visualisiert. Daten wurden tages- und protokollbezogen aggregiert und bezogen auf Regionen und Alterskategorien ausgewertet. Analysen der Häufigkeiten, Identifikation der häufigsten Protokolle und deren Vergleich sowie Effizienzanalysen wurden durchgeführt. Nach erfolgreicher Implementierung standen nach Einschluss von 3659 Untersuchungen eine Vielzahl von Ablaufparametern und Bewertungsmöglichkeiten zur Verfügung. Aus diesen wurden Parameter identifiziert, die den Scannerablauf wiedergeben. Erste Ergebnisse spiegelten erfolgreich die täglichen Prozesse und Unterschiede wider, z. B. die verkürzte Messzeit an Freitagen und längere Untersuchungszeiten bei Kindern. Als optimierungswürdig wurde die um Vorbereitungsprozesse bereinigte Scaneffizienz von 69,6 ± 17,6 % ermittelt, die geringe Unterschiede zwischen häufig und selten genutzten Protokollen aufwies. Die Logfile-basierte Analyse der Scannerabläufe wurde erfolgreich vorgestellt und öffnet weitreichende Möglichkeiten zur Prozessanalyse, Prozessoptimierung und Kombination mit strukturellen Umgebungsvariablen, die zukünftig für eine intelligentere Ablauf- und Prozesssteuerung eingesetzt werden können. · Eine automatisierte Logfile-Analyse der Prozesse eines MRT-Scanners ist erfolgreich eingeführt worden.. · Die Logfile-basierte Analyse erlaubt eine detaillierte Analyse der Abläufe eines Scanners.. · Die Logfile-basierte Prozessanalyse verspricht weitreichenden Nutzen für Anwender, Applikationsspezialist und Entwickler..· Frydrychowicz A, Boppel T, Sieber V et al. Automatic, log file-based process analysis of a clinical 1.5T MR scanner: a proof-of-concept study. Fortschr Röntgenstr 2021; 193: 919 – 927.

There is a broad spectrum of pathologies that can affect the chest wall and we can divide them in 3 main groups: congenital malformations, traumatic injuries and neoplastic diseases. In this chapter we will describe the surgical techniques applied to this.

Background: Data collection has gained a great importance in numerous areas in the last years and also in the medical field. Collecting data is the key to knowledge and consequently improving data quality is fundamental, as the results of the data analysis can have a large impact on the clinical practice. Methods: Collected data can be employed to assess the performance of surgeons or institutions and to implement hospital´s performance and productivity. The chest wall database is one of the satellites composing the European Society of Thoracic Surgery (ESTS) database and includes data on risk factors, surgical techniques, processes of care and outcomes related to chest wall pathologies. The participation to the registry is free and voluntary for the ESTS members. The ESTS chest wall database includes data on risk factors, surgical techniques, processes of care and outcomes related to chest wall pathologies. The collected data are designed for quality control and performance audit. Acquired data are anonymous, independently accessed and encrypted on a Dendrite platform, which provides data security and regular backups. The registry is managed by an external company (KData Clinicak Srl), which works together with the database committee in revising and updating periodically the database. Results: The ESTS chest wall database is structured in four main sections: preoperative, intraoperative, postoperative and follow up. For each procedure registered in the database are collected a number of different variables regarding the patients’ characteristics, the surgical technique, the postoperative course until the discharge and also follow up data. Correction of pectus excavatum is the most common procedures registered in 2017 (392 patients, 67% of all data), followed by pectus bar removal (159 patients, 27% of all procedures). Conclusions: The ESTS chest wall database is an ambitious European project, which aims to standardize all chest wall procedures in all their aspects.

Supplemental Digital Content is available in the text., Objectives Depending on the specific national emergency medical systems, venous cannulations may be performed by physicians, paramedics or both alike. Difficulties in the establishment of vascular access can lead to delayed treatment and transport. Our study investigates possible inter-professional differences in the difficulties of prehospital venous cannulation. Methods Paramedics were interviewed for their personal attitudes towards and experiences in venous access. We analysed 47 candidate predictor variables in terms of cannulation failure and exceedance of a 2 min time threshold. Multivariable logistic regression models were fitted for variables of potential predictive value (P0.60) of their respective receiver operating characteristic curve. Results were compared with previously published data from emergency physicians. Results A total of 552 cannulations were included in our study. All 146 participants voted that paramedics should be eligible to perform venous catheterizations. Despite ample experience in the task, almost half of them considered prehospital venous cannulations more difficult than those performed in hospital. However, the multivariable logistic regression found only patient-related and puncture site factors to be predictive of cannulation failure (patient age, vein palpability with tourniquet, insufficient ambient lighting: model AUC: 0.72) or cannulation delay (vein palpability with tourniquet: model AUC: 0.60). Conclusion Our study shows that venous cannulation is well established among paramedics. It presents itself with similar difficulties across medical professions. Not the numerous specific circumstances of prehospital emergency care, but universal factors inherent to the task will influence the success at venous catheterization.

Purpose The purpose of this study was to compare the effectiveness of a Xenon halogen with a light-emitting diode (LED) laryngoscope light handle in a difficult airway scenario, as well as in an inhalation injury airway scenario that combines a difficult airway and a limited view. Methods We recruited forty-two anesthetists into a randomized crossover trial. Each performed tracheal intubation (TI) with a Xenon halogen and a LED light handle in the two manikin scenarios. The primary endpoint was the “time to intubate”. Other endpoints were the “time to vocal cords”, the “time to ventilate”, the rate of successful intubation, the number of intubation attempts, the Cormack-Lehane score, the number of optimization maneuvers, the number of audible dental click sounds indicating dental damage and subjective impressions. Results In the difficult airway scenario, no significant differences in the recorded intubation times were observed. In the inhalation injury airway scenario, the intubation times were significantly shorter using the LED light handle. Regarding the subjective values, the LED illuminant enabled a significant better view and illumination of the oropharyngeal space and the vocal cords, in both manikin scenarios. Conclusion The LED laryngoscope light handle did not affect the recorded intubation times in the simulated difficult airway scenario, but provided significant advantages in the inhalation injury airway scenario that combines a difficult airway with a limited view caused by a sooted pharynx. We therefore hypothesize, that the LED illuminant might be beneficial in the airway management of burn patients with severe inhalation injury.

The learning curve of the uniportal video-assisted thoracoscopic surgery (VATS) approach is linked to a larger rate of intraoperative complications, which can lead to an emergency conversion to thoracotomy. Despite technical advancements and the large number of surgical videos posted on specialized websites, live surgery events and experimental courses have significantly contributed to accelerate the learning and evolution of minimally invasive thoracic surgery. Bleeding and other complications are the most dreaded event for many VATS surgeons. This article analyzes possible major intraoperative complications during uniportal VATS and explains how to manage them effectively and safely.

Intravenous access in prehospital emergency care allows for early administration of medication and extended measures such as anaesthesia. Cannulation may, however, be difficult, and failure and resulting delay in treatment and transport may have negative effects on the patient. Therefore, our study aims to perform a concise assessment of the difficulties of prehospital venous cannulation.We analysed 23 candidate predictor variables on peripheral venous cannulations in terms of cannulation failure and exceedance of a 2 min time threshold. Multivariate logistic regression models were fitted for variables of predictive value (P0.25) and evaluated by the area under the curve (AUC0.6) of their respective receiver operating characteristic curve.A total of 762 intravenous cannulations were enroled. In all, 22% of punctures failed on the first attempt and 13% of punctures exceeded 2 min. Model selection yielded a three-factor model (vein visibility without tourniquet, vein palpability with tourniquet and insufficient ambient lighting) of fair accuracy for the prediction of puncture failure (AUC=0.76) and a structurally congruent model of four factors (failure model factors plus vein visibility with tourniquet) for the exceedance of the 2 min threshold (AUC=0.80).Our study offers a simple assessment to identify cases of difficult intravenous access in prehospital emergency care. Of the numerous factors subjectively perceived as possibly exerting influences on cannulation, only the universal - not exclusive to emergency care - factors of lighting, vein visibility and palpability proved to be valid predictors of cannulation failure and exceedance of a 2 min threshold.

Introduction: Uniportal video-assisted thoracoscopy (u-VATS) is an established technique to treat early stage lung cancer, even though in Germany most of the anatomical resections are still performed through the open approach. Aim and Objective: The aim of our study is to report our experience in starting a u-VATS program in an established lung cancer center with no previous minimally invasive practice for anatomical resections. Methods: The data of the patients who underwent u-VATS lobectomy or anatomical segmentectomy for early stage lung cancer from January 2017 to February 2019 in our department were retrospectively analyzed. Mentorships with experts were organized to train our surgeons, anesthesiologists and nurses. Finally, we invested in new dedicated VATS-instruments. Results: We performed 78 u-VATS lobectomies and 27 u-VATS segmentectomies out of a total number of 210 anatomical resections. 20 anatomical resections were done for early stage lung cancer in the first 9 months and progressively we performed more advanced cases. Lung cancer was the final diagnosis in 92% of patients. The postoperative staging was respectively 64,2% for stage I, 17,3% for stage II, 14,2% for stage III and 4,3% for stage IV (oligometastatic). On average, 18 lymph nodes per patient were resected. The overall conversion rate was 15%, mostly due to adhesions. Conclusions: The transition from open surgery to u-VATS can be done reasonably fast with good results. We started with stage I standard anatomical resection to progress with more challenging cases. The implementation of a u-VATS program requires adequate training of the entire team and the commitment to develop new skills.

The control of walking in insects is to a substantial amount a function of neuronal networks in the thoracic ganglia. While descending signals from head ganglia provide general commands such as for walking direction and velocity, it is the thoracic central nervous system that controls movements of individual joints and legs. The coordination pattern of legs is velocity dependent. However, a clear stereotypic coordination pattern appears only at high velocities. In accordance with the unit burst oscillator concept, oscillatory networks (central pattern generators (CPGs)) interlocked with movement and load sensors control the timing and amplitude of joint movements. For a leg’s movements different joint CPGs of a leg are mainly coupled by proprioceptors. Differential processing of proprioceptive signals allows a task specific modulation of leg movements, for example, for changing movement direction. A switch between walking and searching movements of a leg is under local control. When stepping into a gap missing sensory input and the activation of a local command neuron evokes stereotypic searching movements of the leg.

Objectives Former analyses reported an increased rate of poor direct laryngoscopy view in cardiac surgery patients; however, these findings frequently could be attributed to confounding patient characteristics. In most of the reported cardiac surgery cohorts, the rate of well-known risk factors for poor direct laryngoscopy view such as male sex, obesity, or older age, were increased compared with the control groups. Especially in the ongoing debate on anesthesia staff qualification for cardiac interventions outside the operating room a detailed and stratified risk analysis seems necessary. Design Retrospective, anonymous, propensity score-based, matched-pair analysis. Setting Single-center study in a university hospital. Participants No active participants. Retrospective, anonymous chart analysis. Interventions The anesthesia records of patients undergoing cardiac surgery in a period of 6 consecutive years were analyzed retrospectively. The results were compared with those of a control group of patients who underwent general surgery. Poor laryngoscopic view was defined as Cormack and Lehane classification grade 3 or 4. Measurements and Main Results The records of 21,561 general anesthesia procedures were reviewed for the study. The incidence of poor direct laryngoscopic views in patients scheduled for cardiac surgery was significantly increased compared with those of the general surgery cohort (7% v 4.2%). Using propensity score-based matched-pair analysis, equal subgroups were generated of each surgical department, with 2,946 patients showing identical demographic characteristics. After stratifying for demographic characteristics, the rate of poor direct laryngoscopy view remained statistically significantly higher in the cardiac surgery group (7.5% v 5.7%). Conclusions Even with stratification for demographic risk factors, cardiac surgery patients showed a significantly higher rate of poor direct laryngoscopic view compared with general surgery patients. These results should be taken into account for human resource management and distribution of difficult airway equipment, especially when cardiac interventional programs are implemented in remote hospital locations.

Trauma represents the leading cause of death in patients younger than 45 years old. The introduction of multidisciplinary trauma teams has resulted in an improvement in patients` outcome. The thoracic surgeon plays an invaluable role as a member of the multidisciplinary team that includes an emergency physician, surgical figure, an anaesthetist, a radiology technician plus a number of nurses. Thorough knowledge of the physiological mechanism of injury and an intensive training have contributed massively in improving the outcomes. Different surgical approaches have to be considered in order to provide the best outcome to the acute patient with chest injury.

We report on a 58-year old male suffering from an unclear necrotizing pneumonia of the right lower lobe, which was already treated unsuccessfully with antibiotics. The patient presented with productive cough, fever and haemoptysis. As differential diagnosis we considered tuberculosis, aspergilloma and lung cancer. After a thoracic surgical procedure which was performed 15 years ago in Russia for an unknown indication he underwent a re-thoracotomy to clarify the aetiology of the cavernous lesion. Hence to the entirely adherent lung to the chest wall, the lower lobe being completely fused with the diaphragm and the central location of the lesion a challenging anatomic resection of the lower lobe had to be performed. Incision of the resected lobe showed a very thick fibrotic layer and underneath an old gauze swab, which was apparently forgotten during the former operation 15 years before. The postoperative course was uneventful. The patient was discharged 12 days after the surgery. This case illustrates how preoperative diagnosis of retained foreign bodies after former surgical procedures might be difficult to achieve, and the surgical procedure can be fairly complex, as our case shows, after 15 years of chronic infection.

BackgroundSufentanil is used for general anesthesia and analgesia. The study aim was to determine the effect of pharmacologically induced changes in cardiac output on the pharmacokinetics of sufentanil in anesthetized pigs.MethodsTwenty-four pigs were randomly assigned to low, high, and control cardiac output groups. Cardiac output was decreased or increased from baseline by at least 40%, or maintained within ± 10% of baseline, respectively. Sufentanil was administered as a bolus followed by a continuous infusion for 120 min. Timed arterial samples were drawn for sufentanil concentration measurements.ResultsData from 20 animals were analyzed. The cardiac outputs (means ± SD) were 2.9 ± 0.7, 5.4 ± 0.7, and 9.6 ± 1.6 l/min in the low, control, and high cardiac output groups, respectively. The parameters of the two-compartment pharmacokinetic model for these cardiac outputs were: CL1: 0.9, 1.2, and 1.7 l/min; CL2: 0.9, 3.1, and 6.9 l/min; V1: 1.6, 2.9, and 5.2 l; and V2: 27.5, 47.0, and 79.8 l, respectively. Simulated sufentanil doses to maintain a target plasma concentration of 0.5 ng/ml for 3 h were 99.5, 128.6, and 157.6 μg for cardiac outputs of 3, 5, and 7 l/min, respectively. The context-sensitive half-times for these cardiac outputs increased from 3.1 to 19.9 and 25.9 min, respectively.ConclusionsCardiac output influences the pharmacokinetics of sufentanil. Simulations suggest that in the case of increased cardiac output, the dose should be increased to avoid inadequate drug effect at the expense of prolonged recovery, whereas for low cardiac output the dose should be reduced, and a faster recovery may be expected.

Magnesium is the fourth most abundant mineral in the body. It has been recognized as a cofactor for more than 300 enzymatic reactions, where it is crucial for adenosine triphosphate (ATP) metabolism. Magnesium is required for DNA and RNA synthesis, reproduction, and protein synthesis. Moreover, magnesium is essential for the regulation of muscular contraction, blood pressure, insulin metabolism, cardiac excitability, vasomotor tone, nerve transmission and neuromuscular conduction. Imbalances in magnesium status—primarily hypomagnesemia as it is seen more common than hypermagnesemia—might result in unwanted neuromuscular, cardiac or nervous disorders. Based on magnesium’s many functions within the human body, it plays an important role in prevention and treatment of many diseases. Low levels of magnesium have been associated with a number of chronic diseases, such as Alzheimer’s disease, insulin resistance and type-2 diabetes mellitus, hypertension, cardiovascular disease (e.g., stroke), migraine headaches, and attention deficit hyperactivity disorder (ADHD).

Aim The fear of airway problems often leads to prolonged attempts to obtain neuroaxial (spinal anesthesia or epidural anesthesia) anesthesia in obstetric anesthesia. The aim of this institutional quality management study was to revisit existing anesthesia care in the obstetric department, focusing on the frequency of delayed or failed neuroaxial anesthesia as well as the risk of airway problems in parturient and non-obstetric patients. Methods The clinical records from 8 consecutive years (2005–2013) were analyzed retrospectively. Cases of cesarean delivery with general anesthesia were analyzed and compared with an age-matched group of female patients undergoing non-obstetric abdominal or gynecological surgery with rapid sequence induction. Poor laryngeal visualization (Cormack–Lehane grade III or IV) and failed intubation were recorded. Results The records of 6393 cesarean deliveries including 851 with general anesthesia were analyzed. In 175 cases insufficient or delayed onset of regional anesthesia led to requirement for general anesthesia. The rate of poor laryngoscopic view in parturient women undergoing cesarean delivery was 14/851, and 4/814 in the reference group (P = 0.023). Failed intubation occurred in three patients undergoing cesarean delivery (0.4%) and in one non-obstetric patient (0.1%; P = 0.339). Conclusion The rate of failed intubations in patients undergoing cesarean delivery may be equivalent to non-obstetric patients. In time-challenging cesarean deliveries, delay of conversion from non-successful neuroaxial anesthesia to general anesthesia in order to avoid adverse airway events does not appear to be justified.

The role of this systematic review is to analyse and compare with a meta-analytic approach the outcomes of lobectomy versus intentional segmentectomy in the surgical treatment of stage I non-small cell lung cancer (NSCLC) as reported in the largest studies on the subject published to date. Regarding the results, most of these studies were based on the retrospective data. The size of the cohorts varied from 17 to 11,520 with a total number of 31,684 patients. The pooled hazard ratio was 1.08 (95% CI = 0.97–1.21; p = 0.16). The survival in the lobectomy group was not superior to patients treated with intentional segmentectomy in stage I NSCLC. A large numbered, prospective, randomised trials are needed to assess the feasibility of intentional segmentectomy and its oncologic value in this group of patients, in order to dissolve the questions raised by retrospective data.

Background: In recent years, many factors have revamped the interest in segmentectomies as preferred procedure for stage I non-small cell lung cancer (NSCLC). The aim of this systematic review and meta-analysis is to compare the outcomes of segmentectomy versus lobectomy regarding overall survival (OS) in the surgical treatment of stage I NSCLC, as stated in the conclusions of the largest studies conducted in this field and reported to date. Methods: The searching strategy was developed in EMBASE, MEDLINE and Cochrane CENTRAL from 1990 until December 2016. The meta-analysis was performed with the combination of the reported survival outcomes of the individual studies using a random effect model. The OS of the lobectomy group was compared with the segmentectomy group alone. The hazard ratio (HR) and standard error were extracted or calculated for each study using the Kaplan-Meier method. Results: Regarding the results, most of these studies were based on the retrospective data. The size of the cohorts varied from 17 to 11,520, with a total number of 24,542 patients. The pooled HR was 1.04 [95% confidence interval (CI), 0.92–1.18; P=0.50]. Conclusions: The survival in the segmentectomy group was not inferior to patients treated with lobectomy. In conclusion, the current meta-analysis disclosed that segmentectomies produce similar survival compared to lobectomy for patients with stage I NSCLC. To establish the role of segmentectomy in early NSCLC, more evidence is needed, in particular, a large numbered, prospective, randomised trials, which should dissolve the uncertainties and the questions raised by retrospective data.

During the last three decades, minimally invasive surgery has become common practice in all kinds of surgical disciplines and, in Thoracic Surgery, the minimally invasive approach is recommended as the treatment of choice for early-stage non-small cell lung cancer. Nevertheless, all over the world a large number of lobectomies is still performed by conventional open thoracotomy and not as video-assisted thoracic surgery (VATS), which shows the need of a proper training for this technique. Development and improvement of surgical skills are not only challenging and time-consuming components of the training curriculum for resident or fellow surgeons, but also for more experienced consultants learning new techniques. The rapid evolution of medical technologies like VATS or robotic surgery requires an evolution of the existing educational models to improve cognitive and procedural skills before reaching the operating room in order to increase patient safety. Nowadays, in the Thoracic Surgery field, there is a wide range of simulation-based training methods for surgeons starting or wanting to improve their learning curve in VATS. Aim is to overcome the learning curve required to successfully master this new technique in a brief time. In general, the basic difference between the various learning techniques is the distinction between “dry” and “wet” lab modules, which mainly reflects the use of synthetic or animal-model-based materials. Wet lab trainings can be further sub-divided into in vivo modules, where living anaesthetized animals are used, and ex vivo modules, where only animal tissues serve as basis of the simulation-based training method. In the literature, the role of wet lab in Thoracic Surgery is still debated.

Vitamin B12 is a cofactor of methionine synthase in the synthesis of methionine, the precursor of the universal methyl donor S-Adenosylmethionine (SAMe), which is involved in different epigenomic regulatory mechanisms and especially in brain development. A Vitamin B12 deficiency expresses itself by a wide variety of neurological manifestations such as paraesthesias, skin numbness, coordination disorders and reduced nerve conduction velocity. In elderly people, a latent Vitamin B12 deficiency can be associated with a progressive brain atrophy. Moderately elevated concentrations of homocysteine (>10 µmol/L) have been associated with an increased risk of dementia, notably Alzheimer’s disease, in many cross-sectional and prospective studies. Raised plasma concentrations of homocysteine is also associated with both regional and whole brain atrophy, not only in Alzheimer’s disease but also in healthy elderly people. Clinician awareness should be raised to accurately diagnose and treat early Vitamin B12 deficiency to prevent irreversible structural brain damage.

Hypoxemia caused by difficulties in airway management presents a major cause for perioperative morbidity and mortality. The ability to predict difficult laryngoscopy more accurately would enable anesthesiologists to take specific precautions to reduce airway risks and prevent patient-threatening events. Over a 6-year period of time, all anesthesia records with a documented direct laryngoscopic view were retrieved from the electronic data management system and statistically processed. The Cormack–Lehane four-point scale of grading laryngoscopy was used to assess visibility of the vocal cords. Of 102,306 cases, the overall rate of difficult laryngoscopy was 4.9 %. Male gender (6.5 %), Mallampati score III and IV (17.3 %), obesity with a BMI ≥35 kg/m2 (6.1 %), as well as physical status ASA III or IV (6.2 %), were identified as risk factors for difficult laryngoscopy. Patients undergoing surgery in the departments of oromaxillofacial (8.9 %), ear nose throat surgery (ENT) (7.4 %), and cardiac surgery (7.0 %) showed the highest rates of difficult laryngoscopy. The results indicate that the risk for difficult airway situations might substantially differ between surgical patient groups. In hospitals with departmental structures and spatially separated operating rooms, the deduction might be increased awareness and particular structural preparation for difficult airway situations in the respective subspecialties.

Objective Previous investigations reported a higher incidence of poor laryngoscopic views in pediatric patients undergoing cardiac surgery. The objective of this study was to analyze why children undergoing cardiac surgery have such an increased incidence of poor laryngoscopic views during anesthesia induction. Design This study was designed as a retrospective analysis. Setting This analysis was based on a single-center cohort of a university hospital. Participants One thousand one hundred seventy-seven general anesthesia procedures, including a direct laryngoscopic view over a period of 6 consecutive years, in pediatric patients undergoing cardiac surgery. Interventions Because of the retrospective character of this study, there were no study-related interventions. Measurements and Main Results Poor laryngoscopic views were defined as Cormack and Lehane (CML) grade III and IV. The overall incidence of poor laryngoscopic views was 3.5%. In patients younger than 1 year of age, the incidence of CML III or IV was significantly higher than in the older patients (5.6% v 1.7%). None of the patients with CML III/IV findings had Down syndrome; whereas in 9 of 41 patients with CML grade III/IV, a concomitant congenital syndrome like DiGeorge syndrome or CHARGE syndrome was found. Conclusions The general incidence of CML III/IV findings during the induction of anesthesia for pediatric cardiac surgery is more than twice as high as reported in unselected pediatric cohorts. In patients below 1 year of age and in male patients, difficult laryngoscopy is more frequent. Concomitant Down syndrome was not associated with difficult laryngoscopy.

Ziel: Magnetresonanztomografie-Untersuchungen bei Kindern in Sedierung oder Allgemeinanasthesie stellen aufgrund der Vielzahl der beteiligten Disziplinen und der daraus entstehenden Schnittstellen eine besondere organisatorische Herausforderung fur die beteiligten padiatrischen, radiologischen und anasthesiologischen Abteilungen dar. Mit der vorliegenden Arbeit sollen Erkenntnisse uber die Patientenstruktur, das anasthesiologische Vorgehen und die damit verbundenen Prozesszeiten im Zusammenhang mit MRT-Untersuchungen bei Kindern in Sedierung bzw. Allgemeinanasthesie gewonnen werden. Ziel ist es dabei, theoretische Moglichkeiten der Prozessoptimierung zu identifizieren und kritisch zu evaluieren. Material und Methoden: Es erfolgte die retrospektive Auswertung und statistische Aufarbeitung der Anasthesieprotokolle von Kindern aller Altersgruppen, die sich in einer Universitatsklinik einem MRT in Sedierung oder Allgemeinanasthesie uber eine Zeitspanne von 5 Jahren unterziehen mussten. Ergebnisse: Die mediane Zeit fur Ein- und Ausleitung bei Patienten ohne Atemwegssicherung betrug 6 min und war bei Patienten, die eine Larynxmaske (19 min) oder einen Endotrachealtubus (20 min) benotigten, signifikant langer (p Schlussfolgerung: Die anasthesiologische Versorgung von Kindern im Neugeborenen und Kleinkindalter fuhrt im Vergleich zur Versorgung von alteren Kindern zu einer Verlangerung der anasthesiologischen Prozesszeiten in der diagnostischen Radiologie. Dies ist durch die haufigere Anwendung von Methoden zur Atemwegssicherung bei jungeren Patienten bedingt. Das groste Potential zur Prozessoptimierung ist im prainterventionellen Bereich der Untersuchungen zu sehen.

BACKGROUND The purpose of this study was to investigate whether and how the extracorporal perfusion of muscle flaps with a miniaturized perfusion system could change the expression of the proapoptotic protein caspase 3 and of the ischemia-sensitive protein hypoxia-inducible factor (HIF)-1α as a first step toward the development of a clinically reliable tool for circumventing ischemia problems in free muscle flap transfer. METHODS In this study, 25 porcine rectus abdominis muscles were used and assigned to five different groups. In the baseline group (group I), the muscle flap remained in situ; in groups II and III, the muscle flap was harvested and remained ex vivo without or with subsequent single-shot heparinized flush; and in groups IV and V, the flaps were perfused with either heparinized autologous whole blood or crystalloid fluid (Jonosteril), using a miniaturized perfusion system without Exogen oxygenation. Muscle samples were taken for immunohistochemical evaluation. The proportion of positive cells for HIF-1α and caspase 3 was compared for each group (groups II through V) to the baseline group (group I). RESULTS The expression of HIF-1α and caspase 3 was increased in both groups without perfusion and was low during in vivo perfusion and extracorporal perfusion with crystalloid fluid. Heparinized autologous whole blood perfusion shows no protective effect, in contrast to the crystalloid fluid. CONCLUSIONS The data of this study indicate that the extracorporal perfusion of muscle flaps with crystalloid fluid is a possible protective strategy against ischemia. Autologous heparinized whole blood seems to have no additional protective effect in a pure perfusion setting without oxygenation.

Ileus is caused by the initiation of a complex cascade of molecular and cellular inflammatory responses within the intestinal muscularis, which might be species specific. Our objective was to investigate a possible immunological divergence in the mechanisms of postoperative- and endotoxin-induced ileus in C57BL/6 mice and Sprague-Dawley rats. Gastrointestinal transit (GIT) was measured at 24 h after the injurious stimulus. MPO-staining and F4/80 immunohistochemistry were used to quantify polymorphonuclear and monocyte infiltration of jejunal muscularis whole-mounts, and intestinal muscularis MCP-1, ICAM-1 and iNOS gene expression was assessed by RT-PCR. Intestinal muscularis subjected to in vivo surgical manipulation (SM) or LPS treatment was cultured for 24 h, and the liberation of nitric oxide and chemokines/cytokines into the culture medium was analyzed by Griess reaction and Luminex multiplex assay. Intestinal SM and lipopolysaccharide (LPS) (15 mg/kg) caused a significant delay in gastrointestinal transit, which was more severe in mice compared to rats in both injury models. Both SM- and LPS-triggered neutrophil and monocytic extravasation into the rat jejunal muscularis exceeded the cellular infiltration seen in mice. These results correlated with significantly greater increases in rat muscularis MCP-1 (syn. CCL2), ICAM-1 and iNOS message with more subsequent NO production after SM or LPS compared to mouse. The cultured muscularis obtained from SM mice released significantly more inflammatory proteins such as TNF-α, IL-1-α, IL-4 and GM-CSF compared to the manipulated rat muscularis. In contrast, LPS initiated the secretion of significantly more IL-1β by the inflamed rat muscularis compared to the mouse, but GM-CSF (syn. CSF2) liberation from mouse muscularis was markedly higher compared to LPS-treated rat muscularis. The data indicate that mechanistically the development of ileus in rat is mediated predominately through a leukocytic pathway consisting of chemotaxis, cellular extravasation and NO liberation. Whereas, the more intense mouse ileus evolves via a potent but injury-specific local cytokine response.

Laien und nicht professionelle Ersthelfer sind haufig unsicher in der Detektion eines Kreislaufstillstands. Sie konnen die klinischen Zeichen eines Kreislaufstillstands oft weder sicher noch rasch genug interpretieren. Neben einer intensivierten Ausbildung in Erster Hilfe kann die technische Detektion von Atmung und Kreislauf das Erkennen eines reanimationspflichtigen Zustands fur Laien erleichtern und moglicherweise zu einer fruheren Einleitung von Reanimationsmasnahmen fuhren. Es wurde ein miniaturisiertes, auf innovativer Technologie basierendes Sensorsystem entwickelt, das nicht invasiv in der Jugularregion einer bewusstlosen Person Puls- und Atemaktivitat erfasst und uber ein kunstliches neuronales Netzwerk analysiert. Nach 10 Sekunden wird eine Entscheidung ausgegeben, ob eine Reanimationsbehandlung empfohlen wird.

Die anasthesiologische Versorgung von Patientinnen in der Geburtshilfe bedient sich bewahrter, sicherer und leicht standardisierbarer Verfahren. Es ist eine generelle Zunahme der Inzidenz von Periduralanasthesien und Schnittentbindungen zu verzeichnen. Periduralanasthesie zur peripartalen Analgesie und Geburtserleichterung bei spontaner Entbindung sowie Spinalanasthesie zur Schnittentbindung stellen die haufigsten Verfahren dar. Die Allgemeinanasthesie zur Schnittentbindung stellt ein Reserveverfahren bei Kontraindikationen gegen ruckenmarksnahe Verfahren, bei kindlichen oder mutterlichen Notsituationen und unzureichender regionaler Schmerzausschaltung dar. Insbesondere vor ruckenmarksnahen Verfahren ist eine sorgfaltige Risikoabwagung und Gerinnungsanamnese erforderlich.

Summary Objective: Difficult laryngoscopy in pediatric patients undergoing anesthesia. Aim: This retrospective analysis was conducted to investigate incidence and predictors of difficult laryngoscopy in a large cohort of pediatric patients receiving general anesthesia with endotracheal intubation. Background: Young age and craniofacial dysmorphy are predictors for the difficult pediatric airway and difficult laryngoscopy. For difficult laryngoscopy, other general predictors are not yet described. Methods: Retrospectively, from a 5-year period, data from 11.219 general anesthesia procedures in pediatric patients with endotracheal intubation using age-adapted Macintosh blades in a single center (university hospital) were analyzed statistically. Results: The overall incidence of difficult laryngoscopy [Cormack and Lehane (CML) grade III and IV] was 1.35%. In patients younger than 1 year, the incidence of CML III or IV was significantly higher than in the older patients (4.7% vs 0.7%). ASA Physical Status III and IV, a higher Mallampati Score (III and IV) and a low BMI were all associated (P

Dual-tasking, the need to divide attention between concurrent tasks, causes a severe increase in workload in emergency situations and yet there is no standardised training simulation scenario for this key difficulty.We introduced and validated a quantifiable source of divided attention and investigated its effects on performance and workload in airway management.A randomised, crossover, interventional simulation study.Center for Training and Simulation, Department of Anaesthesiology, Erlangen University Hospital, Germany.One hundred and fifty volunteer medical students, paramedics and anaesthesiologists of all levels of training.Participants secured the airway of a manikin using a supraglottic airway, conventional endotracheal intubation and video-assisted endotracheal intubation with and without the Paced Auditory Serial Addition Test (PASAT), which served as a quantifiable source of divided attention.Primary endpoint was the time for the completion of each airway task. Secondary endpoints were the number of procedural mistakes made and the perceived workload as measured by the National Aeronautics and Space Administration's task load index (NASA-TLX). This is a six-dimensional questionnaire, which assesses the perception of demands, performance and frustration with respect to a task on a scale of 0 to 100.All 150 participants completed the tests. Volunteers perceived our test to be challenging (99%) and the experience of stress and distraction true to an emergency situation (80%), but still fair (98%) and entertaining (95%). The negative effects of divided attention were reproducible in participants of all levels of expertise. Time consumption and perceived workload increased and almost half the participants make procedural mistakes under divided attention. The supraglottic airway technique was least affected by divided attention.The scenario was effective for simulation training involving divided attention in acute care medicine. The significant effects on performance and perceived workload demonstrate the validity of the model, which was also characterised by high acceptability, technical simplicity and a novel degree of standardisation.

Die chirurgische Therapie des nicht kleinzelligen Lungenkarzinoms (NSCLC) ist streng stadienorientiert. Eine exakte, gegebenenfalls auch invasive, Diagnostik ist Voraussetzung fur die richtige Behandlung. Fur die fruhen Stadien der Erkrankung (Stadium I, II und IIIA (T3, N1)) ist die chirurgische Resektion in kurativer Intention die Behandlung der Wahl. Im Rahmen von multimodalen Konzepten konnen aber auch gut selektionierte Patienten in fortgeschrittenen Stadien von einer chirurgischen Therapie profitieren. Kontrovers diskutiert wird die Rolle der Chirurgie dagegen bei lokal fortgeschrittenem oder metastasiertem NSCLC. Die chirurgische Therapie erfordert die Lobektomie mit einer systematischen Lymphadenektomie. Als Alternative zur Thorakotomie hat sich fur das Stadium I die thorakoskopische Lobektomie (VATS-Lobektomie) etabliert. Auch im fortgeschrittenen Alter oder bei stark eingeschrankter Lungenfunktion kann eine chirurgische Resektion eine praktikable und sichere Behandlungsoption sein, die mit einer annehmbaren Lebensqualitat einhergeht. Beim kleinzelligen Lungenkarzinom (SCLC) ist die Operation nur in wenigen Fallen gerechtfertigt.

Freier Gewebetransfer zur Rumpfrekonstruktion nach „Forequarter-Amputation“ wird in der Literatur selten beschrieben. Die Verwendung eines freien Filet-Lappens aus dem amputierten Arm nach radikaler „Forequarter-Amputation“ bei grosen, invasiven und malignen Tumoren des Schultergurtels und des Thorax stellt nach wie vor eine rekonstruktive Therapieoption dar. Der Vorteil dieses Vorgehens besteht darin, dass kein weiterer Hebedefekt an anderer Korperstelle entsteht. Wir beschreiben den Fall einer Patientin mit invasiv duktalem Mammakarzinom und Fibrosarkom, welche durch auswartige konservative Masnahmen und wiederholte Bestrahlungen ein rasches Tumorwachstum mit Ulzerationen sowie starkste Schmerzen und deutliche Infektzeichen zeigte, sodass im Rahmen einer ausfuhrlichen interdisziplinaren Entscheidung und unter enger Einbeziehung der Patientin und deren Verwandte die Indikation fur eine radikale Tumorresektion im Sinne einer Hemithorakotomie gestellt wurde. Dieses ultraradikale Vorgehen ist zwar von mikrochirurgischer und von onkochirurgischer Seite technisch machbar, allerdings werfen insbesondere die postoperativen Verlaufe und die Limitationen der Wiederherstellung einer adaquaten pulmonalen Situation nach Hemithorakotomie und Sternumresektion viele unbeantwortete Fragen auf. Auf der Basis unserer interdisziplinaren Erfahrung in Grenzgebieten der ultraradikalen Tumorchirurgie wollen wir diese Fragen diskutieren, insbesondere im Hinblick auf die postoperative pulmonale Funktion, die intensivmedizinischen Moglichkeiten und naturlich die ethisch moralischen Aspekte.

Uniportal video-assisted thoracoscopic surgery (VATS) is the most advanced evolution of the minimally invasive technique, which allows often the possibility to include patients in enhanced recovery programs in order to optimize the therapeutic pathway, shorten the length of stay and reduce hospital costs. Non-intubated VATS procedures allow the performance of surgeries with minimal sedation without general anesthesia, maintaining throughout the operation spontaneous breathing. The principle is to create an iatrogenic spontaneous pneumothorax, which can provide a good lung isolation without the need of a double lumen tube. A survey between the members of the European Society of Thoracic Surgery (ESTS) showed that non-intubated VATS procedures are already performed by a large number of ESTS members for minor procedures. With the publication of new data and the spreading of uniportal VATS in many centers worldwide in the last decades, the application of the non-intubated technique in major procedure like anatomic resections is expected to grow. This technique can potentially be beneficial for high-risk patients but also could be used for the routine procedures as well, but more data are needed to establish the real benefit for these groups of patients.