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Analgesia, sedation and delirium management are important parts of intensive care treatment as they are relevant for patients' clinical and functional long-term outcome. Previous surveys showed that despite this fact implementation rates are still low. The primary aim of the prospective, observational multicenter study was to investigate the implementation rate of delirium monitoring among intensivists. Secondly, current practice concerning analgesia and sedation monitoring as well as treatment strategies for patients with delirium were assesed. In addition, this study compares perceived and actual practice regarding delirium, sedation and analgesia management. Data were obtained with a two-part, anonymous survey, containing general data from intensive care units in a first part and data referring to individual patients in a second part. Questionnaires from 101 hospitals (part 1) and 868 patients (part 2) were included in data analysis. Fifty-six percent of the intensive care units reported to monitor for delirium in clinical routine. Fourty-four percent reported the use of a validated delirium score. In this respect, the survey suggests an increasing use of delirium assessment tools compared to previous surveys. Nevertheless, part two of the survey revealed that in actual practice 73% of included patients were not monitored with a validated score. Furthermore, we observed a trend towards moderate or deep sedation which is contradicting to guideline-recommendations. Every fifth patient was suffering from pain. The implementation rate of adequate pain-assessment tools for mechanically ventilated and sedated patients was low (30%). In conclusion, further efforts are necessary to implement guideline recommendations into clinical practice. The study was registered (ClinicalTrials.gov identifier: NCT01278524) and approved by the ethical committee.

The German explosive safety quantitative risk analysis software (ESQRA-GE) has originally been developed to assess ammunition storage scenarios using a transparent step-by-step risk analysis procedure. Starting with the definition of a scenario including different types of ammunition, storage facilities, barriers, buildings, vehicles and locations of persons, physical hazards due to an unexpected detonation of ammunition are calculated. Apart from blast, fragment and debris throw are considered. Based on the physical hazards, damage of persons, vehicles and buildings is evaluated. Including event frequency of an unexpected detonation of ammunition and the exposure of persons to the hazard source, the individual risk of persons is computed. The increasing number of international operations of the German armed forces leads to new threat scenarios. Especially the field of explosive ordnance disposal (EOD) and the threat generated by improvised explosive devices (IEDs) can be treated using the methodology of the ESQRA-GE. The focus of the paper is the characterization of new types of hazard sources like pipe bombs and different types of ammunition, e.g. originating from the former USSR, by using fragment matrices generated via experimental, analytical-empirical and numerical approaches. While in an ammunition storage scenario position and orientation of e.g. shells are geometrically restricted, IEDs as well as abandoned explosive ordnance may be arbitrarily positioned and even buried in the ground. To assess safety measures, possible fragment shadows behind barricades are calculated. EOD scenarios can be analyzed using damage zones based on a combination of damage analysis of fragment throw and probits describing blast injuries. In summary, the risk analysis software ESQRA-GE responds to requirements posed by the international character of the missions conducted, See also ADM002313. Department of Defense Explosives Safety Board Seminar (34th) held in Portland, Oregon on 13-15 July 2010, The original document contains color images.

A growing number of international missions of the German armed forces leads to an increasing need for ammunition storage in field depots. Therefore improved planning and risk assessment tools are needed. Type and intensity of an international mission determine the number of deployed troops and the terrain available for field camps. This defines also type and amount of required ammunition as well as storage conditions. From limitations of space and available personnel the need of optimized planning arises, including the comparison of different solutions for field depots. During the deployment changes of the mission may occur. The presented 3D planning tool for ammunition field depots allows easy and fast adaptation of the existing storage layout to changed situations. The tool is based on military regulations. It makes intense use of databases, computational geometry and relational algebra. Some risks caused by the stored ammunition and given limitations cannot be avoided. We show how the German explosive safety quantitative risk analysis software (ESQRA-GE) is applied to representative planning scenarios. The ESQRA-GE follows an established risk assessment methodology. Based on the modelling of physical hazards and damage, individual and collective risks are computed. Past experience has shown that, in addition to interior threats caused by stored ammunition, shelling poses a major threat. The level of passive protection against rockets provided by representative structures of the field depot for the ammunition is evaluated employing the code "risk analysis software for forward operating bases - rocket, artillery, mortar (RAFOB-RAM)". The presented 3D tools allow the planning of ammunition field depots following the current technical guidelines of the NATO and the German Armed Forces. They provide functionalities to assess the risk due to stored ammunition and threats resulting from rocket shelling., Document includes briefing charts (23 slides, title same as report). See also ADM002313. Department of Defense Explosives Safety Board Seminar (34th) held in Portland, Oregon on 13-15 July 2010. The original document contains color images.

The Notch signaling pathway regulates many aspects of embryonic development, as well as differentiation processes and tissue homeostasis in multiple adult organ systems. Disregulation of Notch signaling is associated with several human disorders, including cancer. In the last decade, it became evident that Notch signaling plays important roles within the hematopoietic and immune systems. Notch plays an essential role in the development of embryonic hematopoietic stem cells and influences multiple lineage decisions of developing lymphoid and myeloid cells. Moreover, recent evidence suggests that Notch is an important modulator of T cell-mediated immune responses. In this review, we discuss Notch signaling in hematopoiesis, lymphocyte development, and function as well as in T cell acute lymphoblastic leukemia.

The crucial role of individual Notch receptors and the mechanism by which they maintain intestinal crypt progenitor cells were assessed by using a series of inducible gut-specific Notch mutant mice. We found that Notch1 and Notch2 receptors function redundantly in the gut, as only simultaneous loss of both receptors results in complete conversion of proliferating crypt progenitors into post-mitotic goblet cells. This conversion correlates with the loss of Hes1 expression and derepression of the cyclin-dependent kinase (CDK) inhibitors p27Kip1 and p57Kip2. We also found that the promoter of both CDK inhibitor genes is occupied by the Notch effector Hes1 in wild-type crypt progenitor cells. Thus, our results indicate that Notch-mediated Hes1 expression contributes to the maintenance of the proliferative crypt compartment of the small intestine by transcriptionally repressing two CDK inhibitors., The crucial role of individual Notch receptors and the mechanism by which they maintain intestinal crypt progenitor cells were assessed by using a series of inducible gut-specific Notch mutant mice. We found that Notch1 and Notch2 receptors function redundantly in the gut, as only simultaneous loss of both receptors results in complete conversion of proliferating crypt progenitors into post-mitotic goblet cells. This conversion correlates with the loss of Hes1 expression and derepression of the cyclin-dependent kinase (CDK) inhibitors p27Kip1 and p57Kip2. We also found that the promoter of both CDK inhibitor genes is occupied by the Notch effector Hes1 in wild-type crypt progenitor cells. Thus, our results indicate that Notch-mediated Hes1 expression contributes to the maintenance of the proliferative crypt compartment of the small intestine by transcriptionally repressing two CDK inhibitors.

The mammalian intestine has one of the highest turnover rates in the body. The intestinal epithelium is completely renewed in less than a week. It is divided into spatially distinct compartments in the form of finger-like projections and invaginations that are dedicated to specific functions. Intestinal cells are constantly produced from a stem cell reservoir that gives rise to proliferating transient amplifying cells, which subsequently differentiate and migrate to the correct compartment before dying after having fulfilled their physiological function. In recent years, a substantial body of evidence has accumulated to support the concept that signaling pathways known to be crucial for embryonic development of multiple organisms play a critical role in tightly regulating and controlling the self-renewing process of the intestine. Moreover, the same pathways appear to be deregulated in several hereditary and sporadic colorectal cancer syndromes due to activating and/or inactivating mutations of key components of such pathways. In this review we discuss recent findings demonstrating that differentiation and homeostasis of the intestine are controlled by developmental pathways such as Wnt, Notch, TGF-beta and Hedgehog, and illustrate how their deregulation contributes to intestinal neoplasia., The mammalian intestine has one of the highest turnover rates in the body. The intestinal epithelium is completely renewed in less than a week. It is divided into spatially distinct compartments in the form of finger-like projections and invaginations that are dedicated to specific functions. Intestinal cells are constantly produced from a stem cell reservoir that gives rise to proliferating transient amplifying cells, which subsequently differentiate and migrate to the correct compartment before dying after having fulfilled their physiological function. In recent years, a substantial body of evidence has accumulated to support the concept that signaling pathways known to be crucial for embryonic development of multiple organisms play a critical role in tightly regulating and controlling the self-renewing process of the intestine. Moreover, the same pathways appear to be deregulated in several hereditary and sporadic colorectal cancer syndromes due to activating and/or inactivating mutations of key components of such pathways. In this review we discuss recent findings demonstrating that differentiation and homeostasis of the intestine are controlled by developmental pathways such as Wnt, Notch, TGF-beta and Hedgehog, and illustrate how their deregulation contributes to intestinal neoplasia.

The self-renewing epithelium of the small intestine is ordered into stem/progenitor crypt compartments and differentiated villus compartments. Recent evidence indicates that the Wnt cascade is the dominant force in controlling cell fate along the crypt-villus axis. Here we show a rapid, massive conversion of proliferative crypt cells into post-mitotic goblet cells after conditional removal of the common Notch pathway transcription factor CSL/RBP-J. We obtained a similar phenotype by blocking the Notch cascade with a gamma-secretase inhibitor. The inhibitor also induced goblet cell differentiation in adenomas in mice carrying a mutation of the Apc tumour suppressor gene. Thus, maintenance of undifferentiated, proliferative cells in crypts and adenomas requires the concerted activation of the Notch and Wnt cascades. Our data indicate that gamma-secretase inhibitors, developed for Alzheimer's disease, might be of therapeutic benefit in colorectal neoplastic disease., The self-renewing epithelium of the small intestine is ordered into stem/progenitor crypt compartments and differentiated villus compartments. Recent evidence indicates that the Wnt cascade is the dominant force in controlling cell fate along the crypt-villus axis. Here we show a rapid, massive conversion of proliferative crypt cells into post-mitotic goblet cells after conditional removal of the common Notch pathway transcription factor CSL/RBP-J. We obtained a similar phenotype by blocking the Notch cascade with a gamma-secretase inhibitor. The inhibitor also induced goblet cell differentiation in adenomas in mice carrying a mutation of the Apc tumour suppressor gene. Thus, maintenance of undifferentiated, proliferative cells in crypts and adenomas requires the concerted activation of the Notch and Wnt cascades. Our data indicate that gamma-secretase inhibitors, developed for Alzheimer's disease, might be of therapeutic benefit in colorectal neoplastic disease.

Beta-catenin-mediated Wnt signaling has been suggested to be critically involved in hematopoietic stem cell maintenance and development of T and B cells in the immune system. Unexpectedly, here we report that inducible Cre-loxP-mediated inactivation of the beta-catenin gene in bone marrow progenitors does not impair their ability to self-renew and reconstitute all hematopoietic lineages (myeloid, erythroid, and lymphoid), even in competitive mixed chimeras. In addition, both thymocyte survival and antigen-induced proliferation of peripheral T cells is beta-catenin independent. In contrast to earlier reports, these data exclude an essential role for beta-catenin during hematopoiesis and lymphopoiesis.