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Background There has been increasing research on posttraumatic stress disorder (PTSD) following childbirth in the last two decades. The literature on predictors of who develops posttraumatic stress symptoms (PSS) suggests that both vulnerability and birth factors have an influence, but many studies measure predictors and outcomes simultaneously. Objective In this context, we aimed to examine indirect and direct effects of predictors of PSS, which were measured longitudinally. Method We assessed women within the first days (n=353), 6 weeks, and 12 months (n=183) after having given birth to a healthy infant. The first assessment included questions on demographics, pregnancy, and birth experience. The second and third assessments contained screenings for postpartum depression, PTSD, and general mental health problems, as well as assessing social support and physical well-being. We analysed our data using structural equation modelling techniques (n=277). Results Our final model showed good fit and was consistent with a diathesis-stress model of PSS. Women who had used antidepressant medication in the 10 years before childbirth had higher PSS at 6 weeks, independent of birth experiences. Subjective birth experience was the early predictor with the highest total effect on later PSS. Interestingly, a probable migration background also had a small but significant effect on PSS via more episiotomies. The null results for social support may have been caused by a ceiling effect. Conclusions Given that we measured predictors at different time points, our results lend important support to the etiological model, namely, that there is a vulnerability pathway and a stress pathway leading to PSS. PSS and other psychological measures stayed very stable between 6 weeks and 1 year postpartum, indicating that it is possible to identify women developing problems early. Highlights of the article Our results are consistent with a diathesis-stress model: vulnerability (antidepressant use in the previous 10 years) influenced posttraumatic stress symptoms at 6 weeks and 1 year, independently of stress (birth-related variables). The strongest predictor of posttraumatic stress symptoms 1 year postpartum was posttraumatic stress symptoms 6 weeks postpartum. This means that women who develop problems could be identified during routinely offered postpartum care. Women with a probable migration background experienced more PSS 1 year after the birth, which was an indirect effect through more episiotomies and more PSS after 6 weeks.

Zusammenfassung Hintergrund Die aktuelle Infektionsgefahr mit SARS-CoV-2 in Schulen wird weiterhin kontrovers diskutiert. Methodik „schugi-MV“ erfasst in strukturierten Begehungen von Schulen in Mecklenburg-Vorpommern (M-V) Daten zum Infektionsgeschehen, Hygienemanagement sowie weiteren Faktoren. Aus den Ergebnissen sollen Empfehlungen für einen sicheren Unterricht abgeleitet werden. In diesem Artikel werden Informationen zu den ersten 10, zwischen dem 18.12.2020 und 20.01.2021 besuchten Schulen vorgestellt. Ergebnisse An den besuchten Schulen lag das Verhältnis der Anzahl Indexfälle bei Erwachsenen und Kindern bei 1:1,25. Die Begehungen zeigten eine große Heterogenität der Schulen und Schulgebäude sowie der dadurch bedingten Möglichkeiten zur Umsetzung von Infektionsschutzmaßnahmen. Schlussfolgerung Basierend auf den vorliegenden, vorläufigen Ergebnissen sind Hygiene- und Infektionsschutzmaßnahmen an den Schulen in M-V nicht standardisierbar, sondern sollten Gestaltungsspielraum lassen.

Zusammenfassung Hintergrund Durch die im Zuge des Ausbruchs der „coronavirus disease 2019“ (COVID-19) im März 2020 erlassenen Kontaktverbote haben Psychotherapeuten deutlich mehr und die meisten von ihnen erstmalig Videobehandlungen (VB) angeboten. Bisher gibt es nur wenig Forschung dazu, wie Therapeuten die VB während der Pandemie erlebt haben, und es liegen keine Studien vor, die mögliche verfahrensspezifische Besonderheiten betrachten. Ziel Es soll analysiert werden, welche subjektiven Erfahrungen Therapeuten unterschiedlicher Richtlinienverfahren mit der Durchführung von VB in Zeiten der COVID-19-Pandemie gemacht haben und welche Vor- und Nachteile sie erlebten. Methoden Es handelt sich um eine „Mixed-methods“-Studie mit einer querschnittlichen Onlineerhebung. Neben quantitativen Daten wurden anhand von 7 offenen Fragen die subjektiven Erfahrungen der Therapeuten mit der Durchführung von VB erhoben und mithilfe der qualitativen Inhaltsanalyse ausgewertet. Die identifizierten Kategorien wurden einer Häufigkeitsanalyse unterzogen. Angaben von 174 ärztlichen oder psychologischen Psychotherapeuten gingen in die Auswertung ein. Ergebnisse Besonders häufig genannte Vorteile waren die örtliche und zeitliche Flexibilität, die Kontinuität des Kontaktes in Pandemiezeiten und die Vermeidung des Infektionsrisikos. Der meistbenannte Nachteil war, dass Sinneseindrücke, Mimik, Gestik, Blickkontakt und nonverbale Kommunikation fehlen. Die meisten, aber nicht alle Patienten nahmen VB gut an. Technische Probleme erschwerten die Umsetzung. Schlussfolgerungen Für viele Therapeuten blieb VB eine „Notlösung“, die nicht auf Dauer angelegt sei. Allerdings könnte VB über die Pandemiezeit hinaus helfen, Versorgungsprobleme (z. B. Unterversorgung auf dem Land) zu lösen. Die Ergebnisse der Studie leisten einen wichtigen Beitrag dazu, Chancen und Risiken der VB für die psychotherapeutische Versorgung abzuwägen sowie mögliche Gefahren und Schwierigkeiten im Auge zu behalten.

While minimally invasive liver surgery has been increasingly adopted at least for minor resections, experience with robotic liver surgery is still limited to a few highly specialized centers. Due to the fear of abdominal adhesions, a history of prior surgeries is still used as an argument for open approaches. Clinical data of all consecutive robotic resections at our center, using the da Vinci Xi surgical system, between April, 2018 and December, 2020, were collected and analyzed as part of a prospective, post-marketing observational study (DRKS00017229). Prior abdominal surgeries were specified according to the surgical approach and localization. Baseline and perioperative outcome criteria were compared between patients with prior surgeries (PS) and patients with no prior surgeries (NPS) in univariate and multivariate analyses. Out of the 126 patients undergoing robotic liver resections, 59% had a history of abdominal surgeries, which were most often colorectal resections (28%) followed by liver resections (20%). Patients with NPS were more likely to undergo robotic liver resection for hepatocellular carcinoma or benign tumors, and to have underlying liver cirrhosis when compared to patients with PS. Other baseline characteristics as well as the extent of resections were similar. Duration of surgery (258 min), conversion rates (6%), and postoperative complications rates (21% Clavien–Dindo ≥ 3) showed no differences between NPS and PS. A subgroup of patients with a history of prior liver surgery showed a longer duration of surgery in univariate analysis. However, this was not confirmed in multivariate analysis which instead revealed tumor entity and liver cirrhosis as independently correlated with duration of surgery. We propose robotic liver resection to be safe and feasible, including in patients with prior abdominal surgeries. Each patient should be evaluated for a minimally invasive procedure regardless of a history of previous operations.

ZusammenfassungFlexible Fertigungsprozesse in der Umformtechnik ermöglichen es, schnell und effizient auf veränderliche Rahmenbedingungen beispielsweise durch Kundenwünsche und rechtliche Anforderungen reagieren zu können. Besonders die inkrementellen Umformverfahren der Massivumformung zeichnen sich durch eine hohe Flexibilität aus, da die Prozesse gut anpassbar sind und die verwendeten Anlagen und Werkzeuge in einem geringeren Maße auf ein spezifisches Bauteil hin ausgelegt werden.Der hier vorgestellte Fügeprozess mittels Radial-Walzen ist geeignet, hybride Bauteile form- und kraftschlüssig miteinander zu verbinden. So lassen sich die spezifischen Vorteile verschiedener Werkstoffe kombinieren und Nutzungs- sowie Leichtbaupotenziale können gezielt genutzt werden. Die in diesem Prozess entstehende charakteristische umlaufende Kerbe in der Wellenkomponente bildet eine Schwachstelle der gefügten Bauteile, da es dort unter Last zu einer Spannungskonzentration kommt, welche die Bildung eines Risses begünstigt. Dieser Herausforderung wird mit einer Kombination der Ausnutzung der Kaltverfestigung des gewählten Werkstoffs (1.7225) und gezielt eingebrachter Druckeigenspannungen in der Kerbe begegnet. Hier liegt der Fokus auf den Druckeigenspannungen, die das Potenzial aufweisen, sich verlängernd auf die Lebensdauer auszuwirken. Sie lassen sich gezielt über eine günstige Wahl des Walzpfads zur Herstellung der Fügeverbindung beeinflussen, wie sowohl in numerischen Analysen als auch durch Eigenspannungsmessungen an Realbauteilen gezeigt wird. Es können sehr hohe Eigenspannungen in der kritischen Zone des Kerbgrunds eingebracht werden, die einen deutlichen Einfluss auf die Lebensdauer haben, wie auch die Lebensdauerberechnungen mittels des Örtlichen Konzepts deutlich zeigen.

Zusammenfassung Hintergrund Sowohl für die Erforschung von Therapeuteneffekten als auch für die Aus- und Weiterbildung ist es von hoher Bedeutung, interpersonelle Fähigkeiten von Psychotherapeuten zu messen. Eines der wenigen dafür zur Verfügung stehenden Instrumente ist die Facilitative-interpersonal-skills(FIS)-Übung. Ziele der Arbeit 1. Vorstellung der FIS-Übung, 2. Prüfung der psychometrischen und deskriptiven Eigenschaften und 3. Untersuchung der Zusammenhänge des FIS-Gesamtwerts mit Alter, Geschlecht und Ausbildungsstand der Testteilnehmer. Material und Methoden In die Querschnittsuntersuchung wurden Psychologiestudierende und Psychologen in psychotherapeutischer Ausbildung eingeschlossen. Die Teilnehmer sollten in der FIS-Übung auf herausfordernde Therapiesituationen, die in 13 Videoclips nachgestellt sind, verbal reagieren. Die audioaufgezeichneten Reaktionen wurden von je 3 geschulten Ratern eingeschätzt. Ergebnisse Der durchschnittliche FIS-Gesamtwert der 115 Studienteilnehmer (Alter: M = 31,97 Jahre, SD ± 7,94 Jahre; weiblich: n = 90, 78,3 %; in psychotherapeutischer Ausbildung: n = 72, 66,1 %) betrug 3,24 (SD ± 0,42). Die Reliabilität erwies sich als gut (Intraklassen-Korrelationskoeffizient[ICC]2FIS-Gesamtwert = 0,69; Cronbachs α = 0,958). Unter den Videoclips befanden sich 3 signifikant leichtere und 4 schwierigere. Über die Clips hinweg wurden sowohl ein Lern- als auch ein Ermüdungseffekt ersichtlich. Ausbildungskandidaten erzielten signifikant höhere Werte als Psychologiestudierende. Diskussion Die FIS-Übung erwies sich in einer größeren Stichprobe als reliabel. Es sollten mindestens 3 und maximal 9 Clips eingesetzt werden, die je nach Ausbildungsstand der Durchführenden und Clip-Schwierigkeit ausgewählt werden können. Die FIS-Übung ist zur standardisierten, empirisch fundierten Messung interpersoneller therapeutischer Fähigkeiten in Forschung und in der Aus- und Weiterbildung von großem Nutzen.

Bisherige Forschungsarbeiten berichten wenig einheitliche Befunde zum Einfluss von Therapeutenmerkmalen auf Therapieabbruche (Drop-outs). Zudem mangelt es an vergleichbaren Operationalisierungen von Therapieabbruchen. Ziel des Review war die Identifizierung von einflussreichen Therapeutenmerkmalen, die mit Therapieabbruchen zusammenhangen. Weiterhin wurden die Operationalisierungen von Therapieabbruchen in den vergangenen 20 Jahren untersucht. Die Literatursuche erfolgte via PsycARTICLES, PsycINFO, PSYNDEX und OVID MEDLINE. Extrahiert wurden die Operationalisierung des Konstrukts Therapieabbruch, Abbruchquoten, die erhobenen Therapeutenmerkmale sowie die verwendeten Erhebungsinstrumente. Das Verzerrungsrisiko der Studien wurde anhand des Tools Quality in Prognostic Studies (QUIPS) analysiert. Es konnten 23 relevante Studien mit 20.034 Patienten und 1826 Therapeuten identifiziert werden. Das Alter, das Geschlecht und die therapeutische Erfahrung hatten keinen Effekt auf den Therapieabbruch. In einigen Studien zeigte sich ein Einfluss ethnischer und kultureller Variablen. Psychologische Therapeutenvariablen wie Personlichkeitseigenschaften wurden bislang wenig untersucht. Die dahingehenden Ergebnisse konnen noch nicht abschliesend beurteilt werden. Eine einheitliche Operationalisierung fur Therapieabbruche existiert nicht. Zukunftigen Untersuchungen wird empfohlen, die Auswahl an moglichen Pradiktoren umfassender zu gestalten und sowohl Therapeuten‑, Patienten- als auch Prozessvariablen zu berucksichtigen. Zudem sollte sich nicht auf eine Operationalisierung des Konstrukts Therapieabbruch festgelegt werden, sondern stattdessen sollten mehrere Varianten gleichzeitig verwendet werden, um die Effekte der Operationalisierung auf das Ergebnis in Sensitivitatsanalysen zu untersuchen.

Background Laparoscopic techniques have become the standard approach for most liver resections. Clinical studies providing conclusive evidence which patients benefit most from minimal-invasive surgery remain limited. Methods We retrospectively analyzed data of all consecutive cases of laparoscopic liver resection between 2015 and 2018 at our center. We compared patients with and without prior abdominal surgeries with respect to postoperative complications (Clavien-Dindo score), length of operation, length of ICU stay and length of hospitalization in univariate and multivariate analyses. Results Within the study period 319 patients underwent laparoscopic liver resections, 44% of which had a history of abdominal surgeries. Pre-operative characteristics were similar to patients without prior surgeries. Both groups showed comparable rates of post-operative complications (Clavien-Dindo score ≥3a; 12% in patients without vs. 16% with prior surgeries, p = 0,322). There were no significant differences in length of surgery or length of stay in the ICU or in the hospital. Conclusion Our data suggest that history of prior abdominal surgery is not a risk factor for post-operative complications after laparoscopic liver resection. We conclude that prior abdominal surgery should not be considered a contra-indication for laparoscopic approach in liver resection.

Summary Background Patients with inflammatory diseases, such as rheumatoid arthritis, often receive glucocorticoids, but long-term use can produce adverse effects. Evidence from randomised controlled trials to guide tapering of oral glucocorticoids is scarce. We investigated a scheme for tapering oral glucocorticoids compared with continuing low-dose oral glucocorticoids in patients with rheumatoid arthritis. Methods The Steroid EliMination In Rheumatoid Arthritis (SEMIRA) trial was a double-blind, multicentre, two parallel-arm, randomised controlled trial done at 39 centres from six countries (France, Germany, Italy, Russia, Serbia, and Tunisia). Adult patients with rheumatoid arthritis receiving tocilizumab and glucocorticoids 5–15 mg per day for 24 weeks or more were eligible for inclusion if they had received prednisone 5 mg per day for 4 weeks or more and had stable low disease activaity, confirmed by a Disease Activity Score for 28 joints–erythrocyte sedimentation rate (DAS28-ESR) of 3·2 or less 4–6 weeks before and on the day of randomisation. Patients were randomly assigned 1:1 to either continue masked prednisone 5 mg per day for 24 weeks or to taper masked prednisone reaching 0 mg per day at week 16. All patients received tocilizumab (162 mg subcutaneously every week or 8 mg/kg intravenously every 4 weeks) with or without csDMARDs maintained at stable doses during the entire 24-week study. The primary outcome was the difference in mean DAS28-ESR change from baseline to week 24, with a difference of more than 0·6 defined as clinically relevant between the continued-prednisone group and the tapered-prednisone group. The trial is registered with ClinicalTrials.gov , NCT02573012 . Findings Between Oct 21, 2015, and June 9, 2017, 421 patients were screened and 259 (200 [77%] women and 59 [23%] men) were recruited onto the trial. In all 128 patients assigned to the continued-prednisone regimen, disease activity control was superior to that in all 131 patients assigned to the tapered-prednisone regimen; the estimated mean change in DAS28-ESR from baseline to week 24 was 0·54 (95% CI 0·35–0·73) with tapered prednisone and −0·08 (–0·27 to 0·12) with continued prednisone (difference 0·61 [0·35–0·88]; p Interpretation In patients who achieved low disease activity with tocilizumab and at least 24 weeks of glucocorticoid treatment, continuing glucocorticoids at 5 mg per day for 24 weeks provided safe and better disease control than tapering glucocorticoids, although two-thirds of patients were able to safely taper their glucocorticoid dose. Funding F Hoffmann-La Roche.

Minimally invasive techniques have been broadly introduced to liver surgery during the last couple of years. In this study, we aimed to report the incidence and potential risk factors for incisional hernia (IH) as well as health-related quality of life (HRQoL) after laparoscopic liver resections (LLR). All patients undergoing LLR between January 2014 and June 2017 were contacted for an outpatient hernia examination. In all eligible patients, photo documentation of the scar was performed and IH was evaluated by clinical examination and by ultrasound. Patients also completed a questionnaire to evaluate IH-specific symptoms and HRQoL. Obtained results were retrospectively analyzed with regard to patients’ characteristics, perioperative outcomes and applied minimally invasive techniques, such as multi-incision laparoscopic liver surgery or hand-assisted/single-incision laparoscopic surgery (HALS/SILS). Of 184 patients undergoing surgery, 161 (87.5%) met the inclusion criteria and 49 patients (26.6%) participated in this study. After a median time of 26 months (range 19–50 months) after surgery, we observed an overall incidence of IH of 12%. Five of 6 patients were overweight or obese (BMI ≥ 25) and 5 of 6 hernias were located at the umbilical site. Univariate analysis suggested the performance status at time of operation (ASA score ≥ 3; HR 5.616, 95% CI 1.012–31.157, p = 0.048) and the approach (HALS/SILS, HR 6.571, 95% CI 1.097–39.379, p = 0.039) as potential risk factors for IH. A higher frequency of hernia-related physical restrictions (HRR; p = 0.058) and a decreased physical functioning (p = 0.17) were noted in patients with IH; however, both being short of statistical significance. Advantages of laparoscopic surgery with regard to low rates of IH can be translated to minimally invasive liver surgery. Even though there are low rates of IH, patients with poor performance status at the time of operation should be monitored closely. While patients’ characteristics are hard to influence, it might be worth focusing on surgical factors such as the approach and the closure of the umbilical site to further minimize the rate of IH.

In Fourier transform infrared (FTIR) spectral imaging spatially distributed spectra of 2D surfaces are registered simultaneously using FTIR spectrometers equipped with array detectors. Scanning methods such as near-field FTIR spectroscopy are a promising alternative providing both, higher spatial resolution, and sensitivity. However, serial recording severely limits their imaging application due to long acquisition times involved and the resulting stability issues. In this work we demonstrate different strategies to compress the FTIR measurement already at the data acquisition stage to significantly reduce the measurement time. Corresponding reconstruction schemes and their hardware implementation will be discussed.

Purpose This is an official S3-guideline of the German Society of Gynaecology and Obstetrics (DGGG), the Austrian Society of Gynaecology and Obstetrics (ÖGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG). The guideline contains evidence-based information and recommendations on indications, complications, methods and care associated with delivery by caesarean section for all medical specialties involved as well as for pregnant women. Methods This guideline has adapted information and recommendations issued in the NICE Caesarean Birth guideline. This guideline also considers additional issues prioritised by the Cochrane Institute and the Institute for Research in Operative Medicine (IFOM). The evaluation of evidence was based on the system developed by the Scottish Intercollegiate Guidelines Network (SIGN). A multi-part nominal group process moderated by the AWMF was used to compile this S3-level guideline. Recommendations Recommendations on consultations, indications and the process of performing a caesarean section as well as the care provided to the mother and neonate were drawn up.

Kurzfristige negative Folgen psychischer Beanspruchung stellen unmittelbare Auswirkungen psychischer Belastung dar. Inwieweit sich diese im Verlaufe eines Arbeitstages entwickeln und eine vermittelnde Rolle in der Beziehung von Arbeitsintensitat als quantitative Anforderung und Erholung einnehmen, wurde bei 47 StrasenbahnfahrerInnen untersucht. Psychische Ermudung und Stress wurden alle zwei Stunden wahrend eines kompletten Arbeitstages mittels Tagebuch-Befragung erfasst. Im Ergebnis zeigte sich ein signifikanter Anstieg der Ermudung uber die Arbeitsschicht hinweg bis zum Arbeitsende. Auserdem zeigte sich ein Zusammenhang zwischen Arbeitsintensitat und Erholungsunfahigkeit. Dabei wird die Beziehung zwischen Arbeitsintensitat und Erholungsunfahigkeit ab Mitte der Arbeitsschicht komplett durch das Ermudungserleben vermittelt. Die Ergebnisse weisen auf die haufig angenommene, aber bislang kaum untersuchte vermittelnde Rolle kurzfristiger Beanspruchungsfolgen fur die Entstehung von Erholungsbeeintrachtigungen hin. Praktische Relevanz Fahrer im offentlichen Personennahverkehr stellen seit jeher eine Berufsgruppe dar, die durch hohe Arbeitsunfahigkeitsraten auffallt. Die vorliegenden Ergebnisse zeigen Ansatzpunkte fur die Arbeitsgestaltung auf. Diese umfassen die Verminderung von zu hoher Arbeitsintensitat und die Gewahrung ausreichender Erholungsmoglichkeiten. Eine solche Arbeitsgestaltung sollte den in dieser Untersuchung gefundenen Anstieg von Ermudung uber die Arbeitsschicht weitestgehend verhindern und damit Unfallrisiken sowie gesundheitliche Beeintrachtigen fur die Fahrer deutlich verringern.

Background In recent years, laparoscopic liver resection has elicited growing attention as a safe procedure for various forms of hepatic resection. In the context of an aging population, this study aims to evaluate outcomes in elderly patients (>70 y) compared with younger patients (≤70 y). Methods All consecutive patients undergoing minimally invasive liver resections between December 2013 and January 2018 at the Department of Surgery, Charite–Universitatsmedizin Berlin, were included in this analysis. Patients’ characteristics, such as body mass index, American Society of Anesthesiologists classification, as well as underlying liver disease and function, were examined and the perioperative outcomes of patients aged >70 y (group 1; G1) contrasted with patients aged ≤ 70 y (group 2; G2). Results Of 250 patients, 67 were >70 y old (G1) and 183 were ≤70 y old (G2). Patients in G1 were characterized by a higher body mass index (27.6 kg/m2 versus 24.9 kg/m2; P = 0.004) and impaired physical states (American Society of Anesthesiologists score III/IV; 60% versus 37%; P = 0.002) when compared with group 2. G1 also exhibited higher rates of primary and secondary hepatic malignancies (G1: n = 62; 92.5%; G2: n = 115, 62.8%; P = 0.031) in addition to higher rates of cirrhosis (G1: n = 30, 44.8%; G2: n = 38, 20.8%; P = Conclusions Minimally invasive liver resection is a feasible and safe procedure in elderly patients despite this age group exhibiting a higher rate of primary and secondary malignancy and cirrhosis, as well as an overall more severely compromised physical health when compared with patients under the age of 70 y. Therefore, it stands to reason that patients in poorer general health might particularly benefit from a minimally invasive approach.

Here we report a case of severe growth retardation and neurologic abnormalities in a female gray mouse lemur (Microcebus murinus), a small NHP species for which the genomic sequence recently became available. The female lemur we present here died on postnatal day 125. This lemur had impaired development of motor skills and showed severe ataxia and tremors. In addition, hearing seemed normal whereas ophthalmic examination revealed incipient bilateral cataracts, abnormal pigmentation in the lens of the left eye, and a missing optokinetic nystagmus, which indicated impaired vision. Most prominently, the lemur showed severe growth retardation. Necropsy revealed maldevelopment of the left reproductive organs and unilateral dilation of the right lateral ventricle, which was confirmed on brain MRI. Brain histology further revealed large, bilateral areas of vacuolation within the brainstem, but immunohistochemistry indicated no sign of pathologic prion protein deposition. Full genomic sequencing of the lemur revealed a probably pathologic mutation in LARGE2 of the LARGE gene family, which has been associated with congenital muscular dystrophies. However, potentially functional mutations in other genes were also present. The observed behavioral and motor signs in the presented animal might have been linked to spongiform degeneration and resulting brainstem dysfunction and progressive muscle weakness. The macroscopic developmental abnormalities and ophthalmic findings might be genetic in origin and linked to the mutation in LARGE2.

Background An early psychotherapeutic treatment of anorexia nervosa (AN) is crucial for a good prognosis. In order to improve treatment initiation, knowledge about facilitators and barriers to treatment is needed. Objective Against this background, we aimed to identify facilitators and barriers from the perspectives of patients, carers and professionals using a qualitative approach. Method To this end, semi-structured interviews were conducted in triads of female patients with AN aged 14 years and older at the beginning of their first psychotherapeutic treatment, their carers, and referring health care professionals. A modified Grounded Theory approach was used for analysis. Results In total, 22 interviews were conducted (n = 6 adults, n = 4 adolescents, 4 full triads). The duration of untreated AN ranged between 30 days and 25.85 years (M = 3.06 ± 8.01 years). A wide spectrum of facilitators and barriers within the patient, the social environment, the health care system and the society were identified. Most prominent factors were ‘recognizing and addressing’ by close others, ‘waiting times and availability’ and ‘recommendations and referrals’ by health care professionals. ‘Positive role models for treatment’ were perceived as a specific facilitative social influence. Facilitators were more frequently mentioned than barriers and most of the factors seem to hold potential for modifiability. Conclusion Overall, the findings suggest that early intervention approaches for AN should not only address patients and the health care system, but may also involve carers and successfully treated former patients. Trial registration ClinicalTrials.gov Identifier: NCT03713541.

Altered pupillary function may reflect nonconvulsive status epilepticus (NCSE). Neurological pupil index (NPi) assessed by automated pupillometry is a surrogate marker of global pupillary function. We aimed to assess NPi changes in relation to NCSE treatment response. In this prospective observational study, serial automated pupillometry was performed in 68 NCSE episodes. In accordance with local standards, patients were treated with clonazepam (1–2 mg), levetiracetam (40 mg/kg), and lacosamide (5 mg/kg) in a stepwise approach under continuous electroencephalography monitoring until NCSE was terminated. Patients with refractory NCSE received individualized regimens. NPi was assessed bilaterally before and after each treatment step. For statistical analysis, the lower NPi of both sides (minNPi) was used. Nonparametric testing for matched samples and Cohen’s d to estimate effect size were performed. Principal component analysis was applied to assess the contribution of baseline minNPi, age, sex, and NCSE duration to treatment outcome. In 97.1% of 68 episodes, NCSE could be terminated; in 16.2%, NCSE was refractory. In 85.3% of episodes, an abnormal baseline minNPi ≤ 4.0 was obtained. After NCSE termination, minNPi increased significantly (p

BACKGROUND Current literature about the effects of patients' expectations on relevant outcome measures is still conflicting and incomplete. The aim of this prospective observational study was to assess the influence of expectations and the fulfillment of expectations on postoperative pain intensity and pain relief. Furthermore, clinical characteristics influencing expectations and the fulfillment of expectations were explored. METHODS Patients undergoing elective orthopedic surgery were assessed using two standardized self-report questionnaires on the day before surgery and the third postoperative day. One hundred and seventy patients from 21 to 93 years (average age 64.6, SD 14.0 years; 55% female) were consecutively included. RESULTS While expectations of pain intensity did not correlate with pain experience after surgery, the fulfillment of expectations was associated with postoperative pain experience. Patients whose expectations were fulfilled were found to be more satisfied with the overall treatment as compared to those whose expectations were not fulfilled. Higher levels of expected pain were associated with higher fear of surgery and fear of postoperative pain. Preoperative pain intensity, length of treatment before the surgery, fear of surgery, helplessness and fear of postoperative pain were associated with higher postoperative pain intensity. Lower levels of preoperative fear of surgery and fear of postoperative pain were found to correlate with the fulfillment of pain relief. CONCLUSIONS Our study indicates that postoperative pain and satisfaction with the treatment are associated with the degree of fulfillment of expectations rather than the expected pain itself.

Background: Despite recent advances in the field of laparoscopic liver surgery, intrahepatic cholangiocarcinoma (iCC) as an entity has been nearly exempted from the new approaches because of propos...

Abdominal wall closure after pediatric liver transplantation (pLT) in infants may be hampered by graft-to-recipient size discrepancy. Herein, we describe the use of a porcine dermal collagen acellular graft (PDCG) as a biological mesh (BM) for abdominal wall closure in pLT recipients. Patients

The implications of multi-incision (MILS) and hand-assisted (HALS) laparoscopic techniques for minimally invasive liver surgery with regard to perioperative outcomes are not well defined. The purpose of this study was to compare MILS and HALS using propensity score matching. 309 patients underwent laparoscopic liver resections (LLR) between January 2013 and June 2018. Perioperative outcomes were analyzed after a 1:1 propensity score match. Subgroup analyses of matched groups, i.e., radical lymphadenectomy (LAD) as well as resections of posterosuperior segments (VII and/or VIII), were performed. MILS was used in 187 (65.2%) and HALS in 100 (34.8%) cases, with a significant decrease of HALS resections over time (p = 0.001). There were no significant differences with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) Score, previous abdominal surgery and cirrhosis between both groups. Patients scheduled for HALS were characterized by a significantly higher rate of malignant tumors (p

OBJECTIVE We aimed to provide a comprehensive overview of the role of self-esteem in the treatment of patients with anorexia nervosa (AN). Specifically, our objectives were to investigate the differences in self-esteem between individuals with AN and healthy controls, or individuals with other eating disorders, and to examine self-esteem as an outcome, predictor, moderator, and mediator in AN treatment. METHOD The databases PsycINFO, PSYNDEXplus, Ovid MEDLINE®, and ProQuest were searched for studies published from 1990 to 2018. To estimate aggregated effect sizes, we performed random-effects meta-analyses. RESULTS A screening of 1,596 abstracts and 203 full-texts identified 68 relevant publications. Results suggest a significantly lower global self-esteem in individuals with AN than in healthy controls (d = -1.90, p

Zusammenfassung Hintergrund Trotz überzeugender Ergebnisse international führender Leberzentren ist die laparoskopische Leberchirurgie in Deutschland weiterhin vergleichsweise wenig verbreitet. An der Chirurgischen Klinik der Charité – Universitätsmedizin Berlin wurde 2015 ein strukturiertes Programm zur Entwicklung der laparoskopischen Leberchirurgie etabliert, woraus sich mögliche Implikationen für die breite Etablierung an deutschen Kliniken ergeben. Methode Wir berichten hier über unsere Zentrumserfahrungen aus 250 konsekutiven, laparoskopischen Leberresektionen zwischen 12/2013 und 1/2018. Es erfolgte eine retrospektive Auswertung in Hinblick auf Indikationen, Patientencharakteristika, Komplexität der Operationen und postoperative Ergebnisse. Die Entwicklung des Programmes wurde analysiert durch Vergleich des Zeitraumes 1 (1/2014 – 12/2015) und Zeitraumes 2 (1/2016 – 12/2017). Ergebnisse Im Vergleich zum Zeitraum 1 (n = 16, 25% der Patienten) zeigte sich im Zeitraum 2 (n = 75, 50% der Patienten) ein signifikant höherer Prozentsatz von Patienten mit einem hohen ASA-Score (3/4; p = 0,001). Das hepatozelluläre Karzinom war die häufigste Indikation (n = 76, 30,4%), gefolgt von kolorektalen Lebermetastasen (n = 63, 25,2%), wobei sich über die Jahre eine Zunahme bösartiger Tumoren von 53,8% im Zeitraum 1 zu 75,7% im Zeitraum 2 (p = 0,001) zeigte. Es erfolgten 72 Major- (≥ 3 Segmente) und 178 Minorresektionen ( Schlussfolgerung Neben entsprechender Expertise in der konventionell offenen Leberchirurgie, in der minimalinvasiven Chirurgie und in der intraoperativen Sonografie ist ein strukturierter Aufbau eines Programmes notwendig, um die laparoskopische Leberchirurgie sicher an deutschen Kliniken zu implementieren. Aufgrund überzeugender Ergebnisse wird die konventionell offene Leberchirurgie in den nächsten Jahren auch in Deutschland durch laparoskopische Techniken weitestgehend abgelöst werden.

The polyacrylamide hydrogel Aquamid® has been used as a permanent filler to enhance facial soft tissue volume and correct wrinkles since 2001. Various long-term studies have proved the safety of the product. Nonetheless, if complications such as migration occur, they can be difficult to treat. Eleven patients suffering from late-onset complications after taking Aquamid® injections in the lips underwent product removal and subsequent labial reconstruction between 2009 and 2017. The reconstruction was performed using a modified bikini reduction technique combined, in eight cases, with immediate autologous fat grafting. In all the patients, general fibrosis and a diffused distribution of the product within all three layers of the lips resulted in the need for labial reconstruction. Migration, as far as in the mucosa and perioral skin, accounted for macroscopically visible yellowish accumulations. In ten out of eleven cases, an individually modified bikini reduction technique, with or without any combination of autologous fat grafting, led to an esthetically satisfying result. One patient developed a severe upper lip necrosis. Contradictory to several previous studies attesting to the lack of migration after Aquamid® application to the lips, capsule formation around the product is impaired, allowing for migration even years after the injection. Product aspiration is not possible in these cases, thus necessitating complex lip reconstruction. Bikini reduction and fat grafting are valuable tools for labial reconstruction. Product residuals within the mucosa have to be accepted. Special care has to be taken while treating smokers. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Summary Objective Recently, water jet-assisted liposuction (WAL) was successfully applied by several other authors to remove fat and induce skin contraction in nonfacial body areas. Extending the range of indications for this new method, the authors of this article report on their first experience with its use in facial contouring, fat harvesting, and hydrodissection of the facial skin flap in rhytidectomy in a case series of 25 patients. Methods Twenty-five patients (median age: 56 years) had facelift surgery under sedation, and the WAL technique was used for facial contouring, fat harvesting for facial lipotransfer, and hydrodissection of the facial skin flap. Patients were monitored for discomfort during the procedure. Complications such as bleeding, postoperative swelling, and hematoma formation were observed during a 1-week follow-up period, and intensity was rated by two independent surgeons using a special grading system. Furthermore, a patient survey (FACE-Q) was performed to analyze the patients' satisfaction and perception of the postsurgical esthetic results. Results The WAL technique can be applied under intravenous sedation without causing any discomfort in all treated patients [mean 1.16, standard deviation (SD) 0.31]. Intraoperative bleeding during WAL-assisted facial dissection was judged as not present at all times (mean 1.3, SD 0.32). Postoperative swelling (day 1: mean 1.82, SD 0.28; day 7: mean 1.18, SD 0.28) and hematoma formation following surgery (day 1: mean 1.58, SD 0.34; day 7: mean 1.18, SD 0.31) were judged as minor in all cases. Overall, no skin necrosis was detected. There was no need for revision surgery. More than half of our treated patients (n = 13) answered the FACE-Q questionnaire, verifying a high satisfaction rate with beneficial treatment results without the occurrence of any major complications. Conclusions The WAL technique seems to offer a safe and efficient treatment approach for facial contouring, facial fat harvesting, and simultaneous facial flap hydrodissection with only minor postoperative swelling and hematoma formation. Therefore, the authors believe that the WAL technique is a powerful and useful tool and should be used in modern facial plastic surgery.

Late seroma formation is a rare complication after implant-based breast enlargement surgery and even less frequent after implant removal. This case report presents a case of painful recurrent seroma formation after the removal of a ruptured Poly Implants Prothèse implant.A 52-year-old patient presented herself in our clinic with a clinical history of recurrent unilateral seroma of the right breast over a period of 8 years after the initial unilateral implant removal. Removal of the remaining implant and complete bilateral capsulectomy was performed. Intraoperative findings revealed a macroscopically thickened capsule with signs of chronic inflammation on the affected side. The clinical history and the macroscopic appearance of the capsule demanded histopathological exclusion of a possible anaplastic large cell lymphoma.Histopathological and microbiological analysis of the capsule and encapsulated material revealed no signs of malignancy or infection. Immediate soft tissue reconstruction of the breast was successfully performed using autologous fat transfer. An aesthetically satisfying result regarding symmetry and volume was achieved, and no further seroma formation was observed within a 6-month follow-up period. Level of evidence: V, Case Report.

BackgroundLipo-MERIT is an ongoing, first-in-human, open-label, dose-escalation Phase I trial investigating safety, tolerability and immunogenicity of BNT111 in patients with advanced melanoma. BNT111 is an RNA-LPX vaccine targeting the melanoma tumor-associated antigens (TAAs) New York esophageal squamous cell carcinoma 1 (NY-ESO-1), tyrosinase, melanoma-associated antigen 3 (MAGE-A3), and transmembrane phosphatase with tensin homology (TPTE). A previous exploratory interim analysis showed that BNT111, alone or combined with immune checkpoint inhibition (CPI), has a favorable adverse event (AE) profile, gives rise to antigen-specific T-cell responses and induces durable objective responses in CPI-experienced patients with unresectable melanoma.1 Here, we present preliminary data in patients with no evidence of disease (NED) at trial inclusion in the BNT111 monotherapy subgroup.MethodsPatients with stage IIIB/C and IV pre-treated cutaneous melanoma were intravenously administered with BNT111 using a prime/repeat boost protocol. Patients were treated in seven dose escalation cohorts (7.2 to 400 µg total RNA) and three expansion cohorts to further explore dose levels of 14.4, 50 and 100 μg. In this analysis, patients receiving BNT111 monotherapy were grouped as having evidence of disease (ED) or NED, and immunogenicity, efficacy and safety were evaluated. Vaccine-induced immune responses were analyzed using an interferon-γ enzyme-linked immune absorbent spot (ELISpot) assay directly ex vivo.ResultsAs of May 24, 2021, 115 patients have received BNT111 within the Lipo MERIT trial. Of 71 patients treated with BNT111 monotherapy, 38 patients had ED and 33 patients had NED after prior therapies. Baseline characteristics were similar between the two groups. ELISpot data revealed comparable BNT111-induced T-cell responses against at least one TAA in ED vs. NED patients (14/22 [64%] and 19/28 [68%] patients with available ELISpot-evaluable samples, respectively), suggesting that BNT111 has the ability to induce T-cell immunity irrespective of the presence of a detectable tumor. As previously reported for ED patients, vaccine-induced CD4+ as well as CD8+ T-cell responses were also observed in NED patients, with a substantial fraction of de novo induced responses undetectable prior to vaccination. In NED patients, clinical efficacy was promising; median disease-free survival was 34.8 months (95% confidence interval: 7.0–not reached). The safety profile was similar in ED vs. NED patients; 38/38 (100%) and 32/33 (97%) patients experienced related treatment-emergent AEs, respectively, of which the majority were mild-to-moderate flu-like symptoms.ConclusionsImmunogenicity and safety profiles of BNT111 monotherapy were comparable in ED and NED patients. Promising signs of clinical activity were observed in NED patients.AcknowledgementsThe authors would like to acknowledge Camilla West (BioNTech SE) for medical writing support.Trial RegistrationClinicaltrials.gov: NCT02410733; EudraCT No. 2013-001646-33.ReferencesSahin U, Oehm P, Derhovanessian E, et al. An RNA vaccine drives immunity in checkpoint-inhibitor-treated melanoma. Nature 2020;585(7823):107–112.Ethics ApprovalEthics & Institutional Review Board approval was obtained prior to initiation of the trial (2018-13393_21-AMG federführend).

Objective To compare the lithium dilution method for cardiac output (LiDCO) and bolus-thermo-dilution (BTD) measurements before and during infusion of dobutamine, dopamine, phenylephrine, or noradrenaline at 2 different doses in anesthetized horses and to examine the correlation between sensor voltages (saline–blood exposed) and possible measurement errors. Design Prospective experimental study. Setting University teaching hospital. Animals Nine Warmblood horses. Interventions Following 90 minutes of equilibration, 3 different doses of dobutamine (0.5–3 μg/kg/min), dopamine (1–5 μg/kg/min), phenylephrine (0.5–3 μg/kg/min), or noradrenaline (0.1–0.5 μg/kg/min) were administered for 15 minutes in anesthetized horses, and measurements using the LiDCO were performed at the lowest and highest doses. Pairs of LiDCO and BTD measurements were collected and sensor voltages exposed to blood and saline were measured before and at the end of each infusion period. Agreement between LiDCO and BTD was assessed with the Bland–Altman method. Measurement and Main Results The biases (2 standard deviations) before infusion of dobutamine, dopamine, phenylephrine, and noradrenaline were 1.1 (5.7), 1.6 (7.3), 0.2 (6.6), and 1.5 (4.1) L/min, respectively, and minimally and nonsignificantly changed following low-dose catecholamine infusions. Following infusion of higher doses, biases were significantly higher compared to baseline with 10.7 (7.8), 11.2 (11.9), 6.9 (11.7), and 3.5 (3.8) L/min, respectively. The difference between saline- and blood-exposed sensor voltage decreased during infusion of high doses of catecholamines with correlations (rs = 0.62) between cardiac output differences and sensor voltage differences (saline-blood). Conclusions This study demonstrated that catecholamines could lead to overestimation in a dose-dependent fashion in LiDCO measurements. Monitoring changes in sensor voltage differences (saline-blood) is a valuable and clinically applicable tool to predict errors in LiDCO measurements.

Background Freehand ventricular catheter placement may represent limited accuracy for the surgeon's intent to achieve primary optimal catheter position. Objective To investigate the accuracy of a ventricular catheter guide assisted by a simple mobile health application (mhealth app) in a multicenter, randomized, controlled, simple blinded study (GAVCA study). Methods In total, 139 eligible patients were enrolled in 9 centers. Catheter placement was evaluated by 3 different components: number of ventricular cannulation attempts, a grading scale, and the anatomical position of the catheter tip. The primary endpoint was the rate of primary cannulation of grade I catheter position in the ipsilateral ventricle. The secondary endpoints were rate of intraventricular position of the catheter's perforations, early ventricular catheter failure, and complications. Results The primary endpoint was reached in 70% of the guided group vs 56.5% (freehand group; odds ratio 1.79, 95% confidence interval 0.89-3.61). The primary successful puncture rate was 100% vs 91.3% (P = .012). Catheter perforations were located completely inside the ventricle in 81.4% (guided group) and 65.2% (freehand group; odds ratio 2.34, 95% confidence interval 1.07-5.1). No differences occurred in early ventricular catheter failure, complication rate, duration of surgery, or hospital stay. Conclusion The guided ventricular catheter application proved to be a safe and simple method. The primary endpoint revealed a nonsignificant improvement of optimal catheter placement among the groups. Long-term follow-up is necessary in order to evaluate differences in catheter survival among shunted patients.

Zusammenfassung Ziel: Vergleich von Epiduralanästhesie und ultraschallgesteuerter Nervenblockade bezüglich analgetischer Effektivität, klinischer Anwendbarkeit sowie Nebenwirkungen bei orthopädischen Eingriffen an der Hintergliedmaße des Hundes. Material und Methoden: In die prospektive, geblindete, randomisierte klinische Studie gingen 22 Hunde der ASA(American Society of Anesthesiologists)-Stufen I und II ein, bei denen ein orthopädischer Eingriff ab dem distalen Drittel des Femurs erfolgte. Den Hunden wurden randomisiert 0,5 mg/kg Bupivacainhydrochlorid (0,5%) und 0,1 mg/kg Morphinsulfat (1%) epidural (EPI) oder unter Ultraschallkontrolle perineural (LA) verabreicht. Intraoperativ wurden Herzfrequenz, Atemfrequenz, mittlerer arterieller Blutdruck (MAP), endexspiratorische Isoflurankonzentration und die Anzahl der zusätzlich benötigten Fentanyl-Boli (5 µg/kg i. v.) als Rescue-Analgesie protokolliert. Präoperativ sowie postoperativ zu Stunde 2, 4, 6, 12 und 24 nach Extubation wurde der Schmerzgrad mittels der Kurzform des Glasgow Composite Measure Pain Scale (GCMPS) bestimmt. Bei einem GCMPS > 6 erhielten die Hunde Methadon (0,2 mg/kg i. v.) als Rescue-Analgesie. Zur statistischen Auswertung dienten Chi-Quadrat-Test, Fisher-Test, Wilcoxon-Test sowie ein- und zweifaktorielle ANOVA mit Signifikanz bei p < 0,05. Ergebnisse: Während der Anästhesie betrug der mittlere MAP in Gruppe EPI 86,6 ± 8,7 mmHg und in Gruppe LA 111,2 ± 11,2 mmHg. Postoperativ lag der MAP in Gruppe EPI bei 95,2 ±13,1 mmHg und in Gruppe LA bei 119,3 ± 18,2 mmHg. Der MAP der Gruppe EPI war durchgehend signifikant niedriger als der der Gruppe LA (p = 0,0421). Weitere signifikante Unterschiede ergaben sich nicht. Urinretention oder motorische Beeinträchtigungen wurden nicht beobachtet. Schlussfolgerung: Die ultraschallgesteuerte Nervenblockade des N. femoralis und des N. ischiadicus garantieren eine zur Epiduralanästhesie vergleichbare perioperative Analgesie. Die Unterschiede des MAP zeigten klinisch keine Relevanz. Unter stationären Bedingungen ergab sich kein Nachteil bezüglich der Gliedmaßen- und Blasenfunktion.

Background and Aim: In recent years, minimally invasive surgical approaches have gained an increasingly important role in hepatobiliary surgery. The aim of this study was to investigate th...

Background Anorexia nervosa is a serious disorder, which often takes a chronic course. Early treatment leads to a significantly better prognosis and prevents chronicity. However, existing evidence on facilitators and barriers in anorexia nervosa treatment initiation is scarce. Aims Against this background, the FABIANA study (ClinicalTrials.gov Identifier: NCT03713541) aims to (a) identify potentially modifiable facilitators and barriers from the perspectives of adolescent and adult patients with anorexia nervosa, carers and physicians, (b) develop and test an instrument for the combined assessment of multiple key facilitators and barriers, and (c) quantify the effect of potentially modifiable versus non-modifiable key facilitators and barriers on the duration of untreated illness (DUI) in patients with anorexia nervosa. Method FABIANA is an observational, mixed-method-study divided into three consecutive substudies each corresponding to one of the study aims. All three substudies will include female patients with anorexia nervosa aged 14 years and older at the beginning of their first psychotherapeutic anorexia nervosa treatment. The qualitative substudy I and the quantitative substudy III will additionally include carers and involved physicians. The recruitment will take place at 20 cooperating study centres throughout Germany, which provide in-patient or out-patient anorexia nervosa specialist care. The DUI will be calculated based on the month of illness onset as determined in validated interviews on lifetime anorexia nervosa symptoms and the therapist-reported date of treatment initiation. Conclusions Strengths and limitations of the retrospective assessment of the DUI will be discussed. The findings of the FABIANA study will contribute to the development of evidence-based early-intervention approaches and the prevention of a chronic course of illness. Trial registration ClinicalTrials.gov Identifier: NCT03713541. Declaration of interest None.

The neurotransmitter serotonin plays a key role in the control of aggressive behaviour. While so far most studies have investigated variation in serotonin levels, a recently created tryptophan hydroxylase 2 (Tph2) knockout mouse model allows studying effects of complete brain serotonin deficiency. First studies revealed increased aggressiveness in homozygous Tph2 knockout mice in the context of a resident-intruder paradigm. Focussing on females, this study aimed to elucidate effects of serotonin deficiency on aggressive and non-aggressive social behaviours not in a test situation but a natural setting. For this purpose, female Tph2 wildtype (n = 40) and homozygous knockout mice (n = 40) were housed with a same-sex conspecific of either the same or the other genotype in large terraria. The main findings were: knockout females displayed untypically high levels of aggressive behaviour even after several days of co-housing. Notably, in response to aggressive knockout partners, they showed increased levels of defensive behaviours. While most studies on aggression in rodents have focussed on males, this study suggests a significant involvement of serotonin also in the control of female aggression. Future research will show, whether the observed behavioural effects are directly caused by the lack of serotonin or by potential compensatory mechanisms.

Cost efficiency is important for hospitals in order to provide high-quality health care for all patients. As hemihepatectomies are increasingly being performed laparoscopically, the aims of this study were to evaluate the costs of laparoscopic hemihepatectomy and to compare them to conventional open techniques. This is a retrospective analysis of clinical outcomes and financial calculations of all patients who underwent hemihepatectomy between January 2015 and December 2016 at the Department of Surgery, Campus Charite Mitte and Campus Charite Virchow-Klinikum, Berlin, Germany, being allocated to the DRG (diagnosis-related group) H01A (complex operations of the liver and pancreas with complex intensive care treatment) or H01B (operations of the liver and pancreas without complex intensive care treatment). To overcome selection bias, a 1:1 propensity score matching (PSM) analysis was performed. After PSM, a total of 64 patients were identified; 32 patients underwent laparoscopic hemihepatectomy (LH); and 32 patients received open hemihepatectomy (OH). After PSM, no significant differences were observed in clinical baseline characteristics. The duration of surgery was significantly longer for patients undergoing LH compared to OH (LH, 334 min, 186–655 min; OH, 274 min, 176–454 min; p = 0.005). Patients in the LH group had a significantly shortened median hospital stay of 5 d, when compared to OH (LH, 9.5 d, 3–35 d; OH, 14.5 d, 7–37d; p = 0.005). We observed a significant higher rate of postoperative complication in the OH group (p = 0.022). Cost analysis showed median overall costs of 17,369.85€ in the LH group and 16,103.64€ in the OH group (p = 0.390). Our data suggest that higher intraoperative costs of laparoscopic liver surgery, e.g., for surgical devices and due to longer operation times, are compensated by fewer postoperative complications and consecutive shorter length of stay when compared with OH.

Knowledge on the change process in the treatment of anorexia nervosa (AN) is an important starting point for the improvement of treatment, yet very little evidence exists. In an exploratory analysis, we aimed to investigate the interdependencies between higher-rank change process factors, BMI and AN-specific cognitions and behaviours over the course of inpatient treatment.We included 176 female adult AN inpatients from three specialized centres. The temporal interdependencies between the change factors and the outcome variables over the course of treatment (t0: beginning, t1: mid-treatment, t2: end) were investigated using a path model.The sample had a mean age of 27.1 years (SD = 8.9 years) and a mean BMI at admission of 15.0 kg/mThe results are discussed with respect to the self-determination theory and the consistency theory. Further research on the change process in AN treatment is recommended.

During the postpartum period, women are at higher risk of developing a mental disorder such as postpartum depression (PPD), a disorder that associates with mother-infant bonding and child development. Oxytocin is considered to play a key role in mother-infant bonding and social interactions and altered oxytocin plasma concentrations were found to be associated with PPD. In the present study, we evaluated oxytocin plasma levels and depressive symptoms during pregnancy and the postpartum period in healthy women. We evaluated 100 women twice during pregnancy (weeks 35 and 38) and three times in the postpartum period (within 2 days and 7 weeks and 6 months after delivery) by measuring oxytocin plasma levels with enzyme-linked immunosorbent assay (ELISA) and assessing depressive symptoms with the Montgomery-Asberg Depression Rating Scale. Oxytocin plasma levels significantly increased from the 35th week of gestation to 6 months postpartum in all women. However, levels decreased from the 38th week of gestation to 2 days after delivery in participants with postpartum depressive symptoms, whereas they continuously increased in the group without postpartum depressive symptoms; the difference between the course of oxytocin levels in the two groups was significant (Δt2-t3: t = 2.14; p = 0.036*). Previous depressive episodes and breastfeeding problems predicted postpartum depressive symptoms. Our results indicate that alterations in the oxytocin system during pregnancy might be specific for women who develop postpartum depressive symptoms. Future studies should investigate whether oxytocin plasma levels might have predictive value in women at high risk for PPD.

Objectives To investigate possible interactions visible on electroencephalogram recordings caused by concomitant administration of marbofloxacin and carprofen or cimicoxib in dogs without central nervous system disease. Methods Totally 21 client-owned dogs undergoing different surgeries were included in a randomised, blinded, clinical study. Each dog was assigned to one of two groups treated with either carprofen or cimicoxib pre- and postoperatively. After anaesthetic induction both groups received marbofloxacin intravenously while recording an electroencephalogram. Offline electroencephalogram analysis included qualitative evaluation and Fast Fourier Transformation. Postoperative analgesia was evaluated for 24 hours and after 10 days with the short-form Glasgow Composite Measure Pain Scale. Statistical analysis included Wilcoxon signed rank test, Mann–Whitney U test and Student's t-test with α set at 5%. Results Marbofloxacin injection caused no effects on quantitative and qualitative electroencephalogram parameters in both groups. No differences in postoperative pain scoring were found between treatment groups. Clinical Significance Concurrent use of marbofloxacin with either cimicoxib or carprofen did not induce neuroexcitatory activities in dogs without CNS disease directly after administration.

Introduction In a single-center, prospective, randomized clinical trial three different configured wound dressings Biobrane ® , Dressilk ® and PolyMem ® were compared with each other regarding objective and subjective healing parameters and cost efficiency. Methods 28 burn patients received surgical treatment with split-thickness skin grafting, while utilizing Biobrane ® , Dressilk ® and PolyMem ® as a single bound donor site wound dressing in all patients. Following a standardized case report form, we monitored several parameters such as pain, transparency of the dressing, active bleeding, exudation and inflammation by using the Verbal Rating Scale 1–10 through out. Results With regard to re-epithelialization, pain and acute bleeding all three dressings were equivalent. Dressilk ® and Biobrane ® presented clearly superior to PolyMem ® in both wound assessment and in the reduction of mild inflammation and exudation. High subjective satisfaction rates were reported with Dressilk ® and Biobrane ® dressings in regard to comfort and mobility. During the continuous monitoring period Biobrane ® outperformed Dressilk ® by providing higher wound transparency rates and offering a better level of wound control during the entire study period. Regarding their cost efficiency, PolyMem ® and Dressilk ® are clearly superior to Biobrane ® . Conclusion The "ideal" wound dressing maximizes patients' comfort while reducing pain and the risk of pulling off migrating epidermal cells from the wound surface. In addition reliable wound status evaluation (minimizing complications), an increase of treatment cost value efficacy, and reduced hospitalization rates should be provided. Dressilk ® and Biobrane ® were favored by patients and surgeons for providing an effective and safe healing environment, with overall low complication rates with respect to infection and exudation. Regarding cost-effectiveness PolyMem ® and Dressilk ® presented superior to Biobrane ® .

There is a growing necessity to perform long-term anesthesia in wildlife, especially antelope. The costs and logistics of transporting wildlife to veterinary practices make surgical intervention a high-stakes operation. Thus there is a need for a field-ready total intravenous anesthesia (TIVA) infusion to maintain anesthesia in antelope. This study explored the feasibility of an etorphine-ketamine-medetomidine TIVA for field anesthesia. Ten wild-caught, adult impala ( Aepyceros melampus ) were enrolled in the study. Impala were immobilized with a standardized combination of etorphine (2 mg) and medetomidine (2.2 mg), which equated to a median (interquartile range [IQR]) etorphine and medetomidine dose of 50.1 (46.2-50.3) and 55.1 (50.8-55.4) μg/kg, respectively. Recumbency was attained in a median (IQR) time of 13.9 (12.0-16.5) min. Respiratory gas tensions, spirometry, and arterial blood gas were analyzed over a 120-min infusion. Once instrumented, the TIVA was infused as follows: etorphine at a variable rate initiated at 40 μg/kg per hour (adjusted according to intermittent deep-pain testing); ketamine and medetomidine at a fixed rate of 1.5 mg/kg per hour and 5 μg/kg per hour, respectively. The etorphine had an erratic titration to clinical effect in four impala. Arterial blood pressure and respiratory and heart rates were all within normal physiological ranges. However, arterial blood gas analysis revealed severe hypoxemia, hypercapnia, and acidosis. Oxygenation and ventilation indices were calculated and highlighted possible co-etiologies to the suspected etorphine-induced respiratory depression as the cause of the blood gas derangements. Impala recovered in the boma post atipamezole (13 mg) and naltrexone (42 mg) antagonism of medetomidine and etorphine, respectively. The etorphine-ketamine-medetomidine TIVA protocol for impala may be sufficient for field procedures of up to 120-min duration. However, hypoxemia and hypercapnia are of paramount concern and thus oxygen supplementation should be considered mandatory. Other TIVA combinations may be superior and warrant further investigation.

Im Abschnitt „Medikamentose Strategie“ des veroffentlichten Beitrags kam es zu einem Umrechnungsfehler. Bitte beachten Sie den korrigierten Text: Es liegt gute Evidenz dafur vor, dass – insbesondere beim opioidgewohnten Patienten – intraoperativ die Gabe von niedrigdosiertem Ketamin (0,5 mg/kgKG in

Background Ear and earlobe deformities after surgical rhytidectomy are common and can significantly diminish the aesthetic outcome. The main causes of ear/earlobe distortion are skin overresection, an imbalance between vertical/horizontal skin-lift vectors, and tractional distortions through superficial muscularaponeurotic system (SMAS) tension. Objectives To demonstrate a new method for earlobe suturing and ear fixation that would prevent aesthetics-related complications after facelift surgery. Methods A total of 105 primary SMAS facelift surgeries were performed between 2015 and 2016 by the first author. A combination technique consisting of a posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) was executed bilaterally within each facelift procedure (n = 210). A retrospective data analysis was conducted (preoperatively and one year postoperatively) using our hospital information system and a photometric data analysis to assess auricular displacement, earlobe distortion, and hypertrophic scarring. Results Pseudoptosis of the earlobe was noted in two cases, and auricular displacement was observed in four cases. Bilateral mild hypertrophic scarring was seen in one patient. The postoperative photometric analysis showed a natural ptosis grade I/II in all the patients, with a statistically significantly reduced postoperative earlobe size (P < 0.05). The total rate of aesthetics-related complications was 4% in our cohort (earlobe distortion with pseudoptosis: 1%; auricular displacement: 2%; hypertrophic scarring: 1%). Conclusions Our modification of the facial flap anchoring at the ear base in combination with a CMSS stabilizes the natural position of the ear and prevents distortion while allowing better control over the earlobe’s aesthetic shaping. This novel method reduces the incidence of ear/earlobe deformities and hypertrophic scarring at the ear base after rhytidectomy and, therefore, promises to be a valuable advancement. Level of Evidence: 4

IntroductionIdiopathic nephrotic syndrome is the most common glomerular disease in childhood with an incidence of 1.8 cases per 100 000 children in Germany. The treatment of the first episode implies two aspects: induction of remission and sustainment of remission. The recent Kidney Disease Improving Global Outcomes, American Academy of Pediatrics and German guidelines for the initial treatment of the first episode of a nephrotic syndrome recommend a 12-week course of prednisone. Despite being effective, this treatment is associated with pronounced glucocorticoid-associated toxicity due to high-dose prednisone administration over a prolonged period of time. The aim of the INTENT study (Initial treatment of steroid-sensitive idiopathic nephrotic syndrom in children with mycophenolate mofetil versus prednisone: protocol for a randomised, controlled, multicentre trial) is to show that an alternative treatment regimen with mycophenolic acid is not inferior regarding sustainment of remission, but with lower toxicity compared with treatment with glucocorticoids only.Methods and designThe study is designed as an open, randomised, controlled, multicentre trial. 340 children with a first episode of steroid-sensitive nephrotic syndrome and who achieved remission by a standard prednisone regimen will be enrolled in the trial and randomised to one of two treatment arms. The standard care group will be treated with prednisone for a total of 12 weeks; in the experimental group the treatment is switched to mycophenolate mofetil, also for a total of 12 weeks in treatment duration. The primary endpoint is the occurrence of a treated relapse within 24 months after completion of initial treatment.Ethics and disseminationEthics approval for this trial was granted by the ethics committee of the Medical Faculty of the University of Heidelberg (AFmu-554/2014). The study results will be published in accordance with the Consolidated Standards of Reporting Trials statement and the Standard Protocol Items: Recommendations for Interventional Trials guidelines. Our findings will be submitted to major international paediatric nephrology and general paediatric conferences and submitted for publication in a peer-reviewed, open-access journal.Trial registration numberDRKS0006547; EudraCT2014-001991-76; Pre-result.Date of registration30 October 2014; 24 February 2017.