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Background: Receptor-binding cancer antigen (RCAS1) is a membrane protein, regarded as a tumor-associated antigen. Cancer cells evade immune response with RCAS1 up-regulation, inducing apoptosis to tumor infiltrating lymphocytes. Thyroid cancer incidence is rising and its accurate diagnosis in early stage is targeted. The aim of this study is to access RCAS1 expression in benign and malignant thyroid pathology. Methods: This is a retrospective study of 110 patients, who had thyroidectomy in a single tertiary referral centre between January 2008 until December 2014. Immunohistochemistry study for RCAS1 expression was carried out and correlation with clinical and histopathological data is attempted. Results: RCAS1 immunostaining was found positive in 81 out of 110 cases. Notably it was deemed positive in all malignant thyroid tissue samples (p

Aims: Sedation, as it is often required in critical care, is associated with immobilization, prolonged ventilation, and increased morbidity. Most sedation protocols are based on benzodiazepines. The presented study analyzes the benefit of benzodiazepine-free sedation. Methods: In 2008, 134 patients were treated according to a protocol using benzodiazepine and propofol (Group 1). In 2009, we introduced a new sedation strategy based on sufentanil, nonsteroidal anti-inflammatory drugs, neuroleptics, and antidepressants, which was applied in 140 consecutive patients (Group 2). Depth of sedation, duration of mechanical ventilation, duration of Intensive Care Unit, and hospital stay were analyzed. Results: Group 1 had both a longer duration of deep sedation (18.7 ± 2.5 days vs. 12.6 ± 1.85 days, P = 0.031) and a longer duration of controlled ventilation (311, 35 ± 32.69 vs. 143, 96 ± 20.76 h, P < 0.0001) than Group 2. Ventilator days were more frequent in Group 1 (653, 66 ± 98.37 h vs. 478, 89 ± 68.92 h, P = 0.128). Conclusions: The benzodiazepine-free sedation protocol has been shown to significantly reduce depth of sedation and controlled ventilation. Additional evidence is needed to ascertain reduction of ventilator days which would not only be of benefit for the patient but also for the hospital Management.

Seit 30 Jahren werden an der Klinik fur Anasthesie und Intensivtherapie der Uniklinik Marburg extrakorporale Lungenersatzverfahren (ECMO) eingesetzt. Diese Institution gehort damit zu den Pionieren der ECMO-Therapie in Deutschland. Alle 2 Jahre findet in der Universitatsstadt Marburg ein internationales Symposium zum Thema akutes Lungenversagen / extrakorporale Lungenersatzverfahren statt, mit Refresherkursen fur Arzte und Pflegekrafte, Hands-on-Workshops und wissenschaftlichen Vortragen international renommierter Referenten. Die Vortrage des aktuellen Symposiums werden im Folgenden fur Sie zusammengefasst.

Background This prospective, observer-blinded, randomised, multicentre study aimed at determining the non-inferiority of 50 mg of plain 1% 2-chloroprocaine vs. 10 mg of 0.5% plain bupivacaine in terms of sensory block onset time at T10 after spinal injection. The study hypothesis was that the difference in onset times of sensory block to T10 between the two drugs is ≤ 4 min. Methods One hundred and thirty patients undergoing lower abdominal or lower limb procedures (≤ 40 min) were randomised to receive one of two treatments: 50 mg of plain 1% 2-chloroprocaine (Group C, n = 66) or 10 mg of plain 0.5% bupivacaine (Group B, n = 64). Times to sensory and motor block onsets, maximum sensory block level, readiness for surgery, regression of sensory and motor blocks, first analgesic requirements, unassisted ambulation, home discharge, and side effects after 24 h and 7 days were registered blindly. Results Chloroprocaine was comparable with plain 0.5% bupivacaine in terms of time to sensory block at T10 level. Group C showed faster onsets of motor block (5 vs. 6 min), maximum sensory block level (8.5 vs. 14 min), resolution of sensory (105 vs. 225 min) and motor (100 vs. 210 min) blocks, unassisted ambulation (142.5 vs. 290.5 min), first analgesic requirement (120 vs. 293.5 min), and home discharge (150 vs. 325 min) (all comparisons, P

BACKGROUND The ability of an evoked motor response (EMR) with nerve stimulation to detect intraneural needle placement reliably at low current intensity has recently been challenged. In this study, we hypothesized that current intensity is higher in needle-nerve contact than in intraneural needle placement. METHODS Brachial plexus nerves were exposed surgically in 6 anesthetized pigs. An insulated needle connected to a nerve stimulator was placed either with 1 mm distance to the nerve (control position), adjacent to nerve epineurium (needle-nerve contact position), or inside the nerve (intraneural position). Three pulse duration settings were applied in random fashion (0.1, 0.3, or 1.0 milliseconds) at each needle position. Starting at 0.0 mA, electrical current was increased until a minimal threshold current resulting in a specific EMR was observed. Fifty threshold current measurements were scheduled for each needle position-pulse duration setting. RESULTS Four hundred-fifty threshold currents in 50 peripheral nerves were measured. Threshold current intensities (mA) to elicit EMR showed small differences between the needle-nerve contact position [median (25th-75th percentiles); 0.1 milliseconds: 0.12 (0.08-0.18) mA; 0.3 milliseconds: 0.10 (0.06-0.12) mA; 1.0 milliseconds: 0.06 (0.04-0.10) mA] and the intraneural position (0.1 milliseconds: 0.12 [0.10-0.16] mA; 0.3 milliseconds: 0.08 [0.06-0.10] mA; 1.0 milliseconds: 0.06 [0.06-0.08] mA) that are neither statistically significant nor clinically relevant. Regardless of the pulse duration that was applied, the 98.33% confidence interval revealed a difference of at most 0.02 mA. However, threshold current intensities to elicit EMR were lower for the needle-nerve contact position than for the control position (0.1 milliseconds: 0.28 [0.26-0.32] mA; 0.3 milliseconds: 0.20 [0.16-0.22] mA; 1.0 milliseconds: 0.12 [0.10-0.14] mA). CONCLUSIONS The confidence interval for differences suggests minimal current intensity to elicit a motor response that cannot reliably discern between a needle-nerve contact from intraneural needle placement. In addition, an EMR at threshold currents

Up to the present day, pain management in the ICU (Intensive Care Units) is a unresolved clinical problem due to patient heterogeneity with complex variation in etiopathology and treatment of the underlying diseases. Therefore, therapeutic strategies in terms of standard operating procedure (SOP) are a necessary to improve the pain management for intensive care patients. Common guidelines for analgosedation are often inadequate to reflect the clinical situation. In particular, for an ICU setting without permanent presence of a physician a missing pain management SOP resulting in delayed pain therapy caused by a therapeutic uncertainty of the nurse staff. In addition to our pre-existing SOP for analgosedation we implemented a pain management SOP for our interdisciplinary, anaesthesiologic ICU. A exploratory survey among the nurse staff was conducted to assess the efficacy of the SOP. The results of the evaluation after a 6 month follow-up indicated a faster onset of pain management and good acceptance by the nursing staff.

This paper tells the story of the Creative Youth Workshops (CYWs), a social space for youths, members of the minority/Muslim and the majority/Christian society, in jointly constructing alternative possibilities of living positively together in the conflict-ridden social environment of Thrace, a North Eastern Greek province bordering Bulgaria and Turkey. The CYWs constitute a sub-project within the overall frame of a comprehensive intervention inside and outside the classroom, called ‘Education of Muslim Minority Children’. © 2017 Academy of Social Sciences.

Background: The objective of the study was to evaluate whether the use of ultrasound (US) together with nerve stimulation (USNST) provides a better needle tip position for performing peripheral regional anaesthesia than the use of US or nerve stimulation (NST) alone. Methods: Needle placements were applied at the brachial plexus and sciatic nerves in 32 anaesthetised pigs. Following needle placement near the target nerve, using either the USNST or the US or NST, a volume of 0.3 ml synthetic resin was injected mimicking a ‘test-dose’ injection. The primary outcome was the incidence of close needle-to-nerve placement assessed by injectate localisation in direct contact with the nerve epineurium. Secondary endpoints were the incidences of intraneural injection and haematoma formation in direct contact with the target nerve. Results: A total of 611 punctures were performed. The evaluation for the criterion ‘close needle placement’ revealed significant differences in favour of the USNST group (98.5%) compared with the NST (90.1%) and the US group (81.6%) (P = 0.001). Significant differences were observed regarding ‘intraneural needle placement’ between the groups as well (USNST, 0.5%; US, 4%; NST, 2.5%; P = 0.034). The incidence of haematoma formation was significantly higher in the NST group (10.8%) than in the US group (2.5%) and in the USNST group (1.5%) (P = 0.001). Conclusion: These findings suggest that the USNST approach combines the benefits of the US and the NST techniques in terms of a higher rate of close needle tip placements and a lower incidence of haematoma formation.

The "Acute Respiratory Distress Syndrome" (ARDS) is a life threatening disease and is associated with a high mortality, mainly due to multi-organ failure. Invasive mechanical ventilation can worsen multi-organ failure which must be avoided. A tidal volume of 6 ml/kg bodyweight should be the aim. Extracorporeal lung assist devices like ECMO or iLA can contribute to lung-protective mechanical ventilation.

Background: The purpose of this study was to determine systematically the highest minimal stimulation current threshold for regional anaesthesia in pigs. Methods: In an established pig model for regional anaesthesia, needle placements applying electric nerve stimulation were performed. The primary outcome was the frequency of close needle to nerve placements as assessed by resin injectates and subsequent anatomical evaluation. Following a statistical model (continual reassessment method), the applied output currents were selected to limit the necessary number of punctures, while providing guidance towards the highest output current range. Results: Altogether 186 punctures were performed in 11 pigs. Within the range of 0.3–1.4 mA, no distant needle to nerve placement was found. In the range of 1.5–4.1 mA, 43 distant needle to nerve placements occurred. The range of 1.2–1.4 mA was the highest interval that resulted in a close needle to nerve placement rate of ≥95%. Conclusions: In the range of 0.3–1.4 mA, all resin deposition was found to be adjacent to nerve epineurium. The application of minimal current intensities up to 1.4 mA does not obviously lead to a reduction of epineural injectate contacts in pigs. These findings suggest that stimulation current thresholds up to 1.4 mA result in equivalent needle tip localisation in pigs.

In regional anaesthesia, there is a risk of direct nerve injury. The purpose of this study was to determine whether the diameter of the applied needle is associated with the magnitude of nerve injury after needle nerve perforation.In five anaesthetized pigs, the brachial plexus were exposed bilaterally. Up to eight nerves underwent needle nerve perforation using a 24 G pencil-point cannula (small diameter) or a 19 G pencil-point needle (large diameter). After 48 h, the nerves were resected during anaesthesia. The specimens were processed for visual examination and the detection of inflammatory cells, myelin damage and intraneural haematoma. The grade of nerve injury was scored ranging from 0 (no injury) to 4 (severe injury).Forty-eight nerves were examined. The applied injury score was significantly lower in the small-diameter group [median (inter-quartile range) 2.0 (2.0-2.0)] compared with the large-diameter group [3.5 (3.0-4.0) P0.01]. Myelin damage and intraneural haematoma occurred predominantly in the large-diameter group. Signs of post-traumatic regional inflammation were comparable among both groups.The severity of nerve injury after needle nerve perforation was related to the diameter of the applied cannula. However, no such difference exists for regional inflammation. Functional consequences of these findings need to be determined. Currently, small-diameter cannulae may be advisable for peripheral nerve blocks to minimize the risk of nerve injury in the case of nerve perforation.

Background: The purpose of this study was to determine whether the application of high stimulation current thresholds (SCT) leads to a distant needle to nerve proximity (NNP) compared with low SCT during nerve localization for regional anaesthesia in pigs. Methods: A minimal motor response to the stimulation of femoral or brachial plexus nerves in 16 anaesthetized pigs was triggered either by a minimal SCT of a low (0.01–0.3 mA) or a high (0.8–1.0 mA) current in a random order. After eliciting a motor response with a predetermined SCT, synthetic resin was injected via the needle. After postmortem dissection of the injection site, the localization of the resin deposition was determined verifying the final position of the needle tip. Depending on the proximity of resin deposition to the nerve epineurium, the needle tip placement was considered either as a close or a distant NNP. Results: A total of 235 punctures were performed. Ninety-one punctures were carried out with low SCT and 92 with a high SCT. Fifty-two punctures served as a control (1.8–2.0 mA). All injectates following both high or low SCT were considered ‘close needle tip to nerve placement’, whereas 27 of 52 injectates of the control group appeared distant to nerve epineurium. Conclusion: Regardless of the applied SCT, i.e. high or low, all resin deposition was found adjacent to nerve epineurium. These findings suggest that high and low SCT result in equivalent needle tip localization in pigs.

Background: The goal of Basic Life Support is the oxygenation of vital organs during cardiac arrest. Therefore, chest compressions are combined with ventilation in a fixed ratio. This study investigated the influence of bag/mask venti- lation on pulmonary gas exchange in anaesthetized patients performed with a ventilation/compression ratio of 2:15 com- pared to 5:50. Methods: Forty patients scheduled for elective cardiac surgery received general anesthesia (Propofol/Sufentanil/ Rocu- ronium). Upon loss of consciousness bag/mask ventilation was started (15l/min O2 with reservoir bag) over a six minute period using either 2 ventilations every 9 seconds (simulated ventilation/compression ratio 2:15) or 5 ventilations every 30 seconds (simulated ventilation/compression ratio 5:50). Arterial blood gas sampling was performed at beginning of venti- lation and after six minutes. Data were analyzed with 2-factorial ANOVA. Results: Arterial PO2 increased in both groups during the ventilation with pure oxygen (PaO2: 2:15 group: 259 mmHg (0 min), 369 mmHg (6 min); 5:50 group: 277 mmHg (0 min), 363 mmHg (6 min); n.s.). Arterial pCO2 also increased (PaCO2: 2:15 group: 47 mmHg (0min), 48 mmHg (6min); 5:50 group: 47 mmHg (0min), 52 mmHg (6min), P=0,018). Consequently, pH decreased in both groups (pH: 2:15 group; 7,37 (0min), 7,36(6min); 5:50 group: 7,38 (0min), 7,34 (6min), P=0,02). There was no critical decrease of SpO2 at any time. Conclusions: In the anesthetized patient with spontaneous circulation bag/mask ventilation simulating ventilation/comp- ression ratios of 2:15 and 5:50 enable an adequate oxygenation and stable acid base balance.

Volatile anesthetics have been shown to activate various two-pore (2P) domain K+ (K2P) channels such as TASK-1 and TREK-1 (TWIK-related acid-sensitive K+ channel), and mice deficient in these channels are resistant to halothane-induced anesthesia. Here, we investigated whether K2P channels were also potentially important targets of intravenous anesthetics. Whole cell patch-clamp techniques were used to determine the effects of the commonly used intravenous anesthetics etomidate and propofol on the acid-sensitive K+ current in rat ventricular myocytes (which strongly express TASK-1) and selected human K2P channels expressed in Xenopus laevis oocytes. In myocytes, etomidate decreased both inward rectifier K+ (Kir) current ( IK1) and acid-sensitive outward K+ current at positive potentials, suggesting that this drug may inhibit TASK channels. Indeed, in addition to inhibiting guinea pig Kir2.1 expressed in oocytes, etomidate inhibited human TASK-1 (and TASK-3) in a concentration-dependent fashion. Propofol had no effect on human TASK-1 (or TASK-3) expressed in oocytes. Moreover, we showed that, similar to the known effect of halothane, sevoflurane and the purified R-(−)- and S-(+)-enantiomers of isoflurane, without stereoselectivity, activated human TASK-1. We conclude that intravenous and volatile anesthetics have dissimilar effects on K2P channels. Human TASK-1 (and TASK-3) are insensitive to propofol but are inhibited by supraclinical concentrations of etomidate. In contrast, stimulatory effects of sevoflurane and enantiomeric isoflurane on human TASK-1 can be observed at clinically relevant concentrations.

Background The authors tested the effects of LL-37 prophylaxis or therapy on the outcome after intraabdominal sepsis and examined whether hyperthermic preconditioning plus LL-37 therapy augments host immune response and improves survival. Methods A rat model of peritoneal contamination and infection (PCI) with human stool was used to simulate clinical conditions. In trial 1, the authors compared (1) PCI, (2) LL-37 prophylaxis (0.5 mg/kg, 12 h before PCI), and (3) LL-37 therapy (0.5 mg/kg, 1 h after PCI). In trial 2, the authors compared (1) PCI, (2) LL-37 therapy, (3) hyperthermic preconditioning (41 degrees C for 1 h, 24 h before PCI), and (4) LL-37 therapy and hyperthermic preconditioning. The primary endpoint was mortality at 120 h. In trial 2, secondary endpoints were systemic levels of tumor necrosis factor alpha, interleukin 6, macrophage inflammatory protein 2, and heat shock protein 70; leukocyte counts; and neutrophil granulocyte phagocytosis. Results In trial 1, 30% of the control group compared with 70% of the LL-37 therapy group survived, but 55% after LL-37 prophylaxis survived (P = 0.038). In trial 2, 38% of the controls, 67% of the LL-37 therapy, 59% of the hyperthermic preconditioned, and 90% of the hyperthermic preconditioned plus LL-37 therapy group survived (P = 0.01). LL-37 therapy plus hyperthermic preconditioning reduced proinflammatory cytokine concentrations after sepsis; specifically compared with controls, macrophage inflammatory protein-2 and interleukin-6 levels were 1.5 +/- 1.5 versus 11 +/- 6 pg/ml (P = 0.028) and 13 +/- 8 versus 86 +/- 31 pg/ml, (P = 0.015), respectively. Conclusions In this model of intraabdominal sepsis, LL-37 therapy improved outcome. Hyperthermic preconditioning per se was not successful, but in combination with LL-37 therapy, the survival rate after sepsis was increased and the proinflammatory cytokine response was downgraded.

The aim of this study was to compare the effect of a physical therapy regimen including active exercises with the current standard treatment on reduction of pain 6 weeks and 6 months after whiplash injury caused by motor vehicle collision. Two hundred patients were enrolled in a prospective randomized controlled trial. In the standard group, treatment consisted of immobilization with a soft collar over 7 days. In the physical therapy group, patients were scheduled for 10 physical therapy appointments including active exercises within 14 days after enrollment. Pain intensity was rated by all patients daily during the first week, the sixth week, and 6 months after recruitment, using a numeric rating scale (0-10). Data analyses were performed by comparing the mean (over 1 week) pain scores between the two different treatment groups. Ninety-seven patients were randomly assigned to the standard treatment group and 103 to the physical therapy group. During the first week, there was no significant difference in mean pain intensity between the standard treatment group (4.76+/-2.15) and the physical therapy group (4.36+/-2.14). However, after 6 weeks, mean pain intensity was significantly (p=0.002) lower in the physical therapy group (1.49+/-2.26 versus 2.7+/-2.78). Similarly, after 6 months, significantly (p

Objectives: Standard therapy in Germany for acute whiplash injury has traditionally included a soft collar (cervical orthosis), an approach that is passive compared with early exercise and mobilisation. The purpose of this study is to examine the recovery in the first six weeks of groups of acute whiplash injury patients subjected to two different treatment approaches, the traditional approach of a collar compared with active, early mobilisation. Methods: Between August 1997 and February 2000 a randomised clinical trial with a total of 200 patients was performed. A total of 97 were randomly assigned to a collar therapy group, and 103 to the exercise group, treated by a physiotherapist. Study participants recorded average pain and disability twice (baseline and six week follow up) during a one week period by diary, using numeric visual analogue (VAS) rating scales ranging from 0 to 10. Results: The initial mean VAS pain intensity and VAS disability reported by the collar therapy group and the exercise group showed no statistical difference. The mean VAS pain rating reported by the collar therapy group after six weeks was 1.60 and mean VAS disability rating was 1.56. The mean VAS pain intensity of the exercise group was 1.04 and mean VAS disability was 0.92. These differences between the groups were both significant, as was the reduction in the prevalence of symptoms in the exercise therapy group compared with the collar group at six weeks. Conclusions: Early exercise therapy is superior to the collar therapy in reducing pain intensity and disability for whiplash injury.

Die HWS-Distorsion ist von groser klinischer und soziookonomischer Bedeutung. Eine Vielzahl von Problemen im Hinblick auf Diagnostik, Klassifikation, Therapie und Begutachtung sind bis heute nicht oder nur unzureichend gelost. Ziel der vorliegenden Umfrage war es den aktuellen Stand des Vorgehens beim Vorliegen einer akuten HWS-Distorsion an chirurgischen und unfallchirurgischen Kliniken in Deutschland zu evaluieren. Es wurden 1568 Kliniken in Deutschland angeschrieben und um die Beantwortung eines standardisierten, einseitigen Fragebogens zur Diagnostik, Klassifikation und Therapie der HWS-Distorsion gebeten. Zudem wurde nach der subjektiven Einschatzung der Arzte zum Beschwerdebild gefragt. Beantwortet wurden 540 (34,44%) Fragebogen. Bezuglich der klinischen Untersuchung besteht Konsens. Konventionelle Rontgenaufnahmen der HWS in 2 Ebenen werden routinemasig in 82,6% der Kliniken indiziert. Fur die Anordnung von Funktionsaufnahmen (durchschnittlichen 39,1%) ergibt sich ein sehr inhomogenes Bild. HWS-Distorsionen werden in 68,9% der Kliniken nicht, in 13,2% nach der „Quebec Task Force“ und in 13,9% nach Erdmann klassifiziert. Die HWS-Krawatte gehort in 85,6% zum therapeutischen Vorgehen; 30% der Patienten wird lediglich eine Krawatte verordnet, 55,6% erhalten zusatzlich Physiotherapie. Bei 8,3% wird nur Krankengymnastik verordnet. Nach der subjektiven Einschatzung der Arzte sind psychologische Faktoren fur chronische Verlaufe, nicht aber fur die Akutphase von Bedeutung. Die grose Variabilitat der Masnahmen zur Diagnostik, Klassifikation und Behandlung an deutschen Kliniken spiegelt die bekannten Probleme im Umgang mit dem Beschwerdebild der HWS-Distorsion wieder. Aktuelle wissenschaftliche Erkenntnisse zur funktionellen Behandlung sind bisher nur in begrenztem Mase in den klinischen Alltag ubernommen worden.

Im Tierversuch fanden die Anasthesisten um Timon Vassiliou vom Universitatsklinikum Marburg heraus, dass der Nerv-Nadel-Kontakt (NNK) als Nebenwirkung bei peripheren Nervenblockaden in enger Beziehung zur angewandten Stromstarke steht.

BACKGROUND: Diagnostic evaluation and therapeutic management of acute neck pain after whiplash is a frequent but unsolved clinical problem. Long-lasting symptoms and disability are common. Former studies proposed beneficial effects of physiotherapy in the early management of whiplash injury. The purpose of this study was to assess the effects of early active mobilization versus standard treatment with a soft cervical collar. METHODS: Between August 1997 and February 2000 a prospective randomized clinical trial with a total of 168 patients was performed. Of these patients 81 (31 male, 50 female; average age 28,78 years) were randomly assigned to the standard therapy group, which received a soft cervical collar, and 87 (31 male, 56 female; average age 29,62 years) to the early mobilization group, treated by physiotherapy. Study participants documented pain and disability twice (baseline and six week follow-up) during a one week period by diary, using numeric rating scales ranging from 0 to 10. RESULTS: The initial mean pain intensity (4,75) reported by the standard therapy group was similar to disability (4,76). There were no significant differences to initial pain (4,50) and disability (4,39) reported by the early mobilization group. The mean pain intensity reported by the standard therapy group after 6 weeks was 2,66 and disability was 2,40. The mean pain intensity indicated by physiotherapy group was 1,44 and mean disability was 1,29. The differences between the groups were both significant. CONCLUSIONS: Early mobilization is superior to the standard therapy regarding pain intensity and disability. We conclude that mobilization should be recommended as the new adequate standard-therapy in the acute management of whiplash injury. Language: de

Einfuhrung. Ein zentrales, aber wenig berucksichtigtes Problem fur die Verwertbarkeit klinischer Studien sind systematische Fehler durch Selektionseffekte. Fragestellung. Da sich nur in wenigen unfallchirurgischen Publikationen Angaben zur Selektion von Studienpatienten finden, wurde anhand einer eigenen prospektiven, randomisierten Therapievergleichstudie zur fruhfunktionellen Therapie von HWS-Beschleunigungsverletzungen Vorkommen und Bedeutung von Selektionseffekten auf den verschiedenen Stufen der Stichprobenselektion uberpruft. Material und Methoden. Das Ausgangskollektiv und die Kollektive der studientauglichen Patienten, der initialen und der finalen Studienteilnehmer wurden hinsichtlich Alter, Geschlecht und weiterer soziodemographischer sowie unfallspezifischer Merkmale und klinischer Befunde verglichen. Ergebnisse. Im Beobachtungszeitraum vom 21.08.1997 bis 30.04.1999 wurden 732 Patienten wegen einer HWS-Beschleunigungsverletzung behandelt. 453 erfullten die Ein- und Ausschlusskriterien. 107 im Recall-Verfahren ermittelten Studienteilnehmern standen 346 Escape-Patienten gegenuber. Das Studienkollektiv (n=119) reduzierte sich durch Drop-out-Falle auf 80 Studienteilnehmer. Es wurden auf 2 Selektionsstufen signifikante Selektionseffekte festgestellt. Diese hatten einen unmittelbaren Einfluss auf die Auswahl geeigneter statistischer Testverfahren. Schlussfolgerungen. Unkontrollierte Selektionseffekte konnen die interne und externe Validitat klinischer Studien gefahrden. Nur ihre Analyse ermoglicht die korrekte Interpretation der Studiendaten und die Beurteilung der Ubertragbarkeit der Ergebnisse auf Kollektive ubergeordneter Selektionsstufen.

This prospective, observer-blinded, randomised, multicentre study aimed at determining the non-inferiority of 50 mg of plain 1% 2-chloroprocaine vs. 10 mg of 0.5% plain bupivacaine in terms of sensory block onset time at T10 after spinal injection. The study hypothesis was that the difference in onset times of sensory block to T10 between the two drugs is ≤ 4 min.One hundred and thirty patients undergoing lower abdominal or lower limb procedures (≤ 40 min) were randomised to receive one of two treatments: 50 mg of plain 1% 2-chloroprocaine (Group C, n = 66) or 10 mg of plain 0.5% bupivacaine (Group B, n = 64). Times to sensory and motor block onsets, maximum sensory block level, readiness for surgery, regression of sensory and motor blocks, first analgesic requirements, unassisted ambulation, home discharge, and side effects after 24 h and 7 days were registered blindly.Chloroprocaine was comparable with plain 0.5% bupivacaine in terms of time to sensory block at T10 level. Group C showed faster onsets of motor block (5 vs. 6 min), maximum sensory block level (8.5 vs. 14 min), resolution of sensory (105 vs. 225 min) and motor (100 vs. 210 min) blocks, unassisted ambulation (142.5 vs. 290.5 min), first analgesic requirement (120 vs. 293.5 min), and home discharge (150 vs. 325 min) (all comparisons, P0.05). No chloroprocaine patient developed transient neurological symptoms.Spinal anaesthesia with 50 mg of plain 1% 2-chloroprocaine is similar to 10 mg of plain 0.5% bupivacaine in terms of onset of sensory block at T10 but shows quicker recovery from anaesthesia than with 0.5% bupivacaine.

The objective of the study was to evaluate whether the use of ultrasound (US) together with nerve stimulation (USNST) provides a better needle tip position for performing peripheral regional anaesthesia than the use of US or nerve stimulation (NST) alone.Needle placements were applied at the brachial plexus and sciatic nerves in 32 anaesthetised pigs. Following needle placement near the target nerve, using either the USNST or the US or NST, a volume of 0.3 ml synthetic resin was injected mimicking a 'test-dose' injection. The primary outcome was the incidence of close needle-to-nerve placement assessed by injectate localisation in direct contact with the nerve epineurium. Secondary endpoints were the incidences of intraneural injection and haematoma formation in direct contact with the target nerve.A total of 611 punctures were performed. The evaluation for the criterion 'close needle placement' revealed significant differences in favour of the USNST group (98.5%) compared with the NST (90.1%) and the US group (81.6%) (P = 0.001). Significant differences were observed regarding 'intraneural needle placement' between the groups as well (USNST, 0.5%; US, 4%; NST, 2.5%; P = 0.034). The incidence of haematoma formation was significantly higher in the NST group (10.8%) than in the US group (2.5%) and in the USNST group (1.5%) (P = 0.001).These findings suggest that the USNST approach combines the benefits of the US and the NST techniques in terms of a higher rate of close needle tip placements and a lower incidence of haematoma formation.

Background/Aims: Atrial fibrillation is the most common arrhythmia in the elderly, and potassium channels with atrium-specific expression have been discussed as targets to treat atrial fibrillation. Our aim was to characterize TASK-1 channels in human heart and to functionally describe the role of the atrial whole cell current ITASK-1. Methods and Results: Using quantitative PCR, we show that TASK-1 is predominantly expressed in the atria, auricles and atrio-ventricular node of the human heart. Single channel recordings show the functional expression of TASK-1 in right human auricles. In addition, we describe for the first time the whole cell current carried by TASK-1 channels (ITASK-1) in human atrial tissue. We show that ITASK-1 contributes to the sustained outward current IKsus and that ITASK-1 is a major component of the background conductance in human atrial cardiomyocytes. Using patch clamp recordings and mathematical modeling of action potentials, we demonstrate that modulation of ITASK-1 can alter human atrial action potential duration. Conclusion: Due to the lack of ventricular expression and the ability to alter human atrial action potential duration, TASK-1 might be a drug target for the treatment of atrial fibrillation.

Magnitude-frequency (G-R) relations of shallow mainshocks have been examined in five separate segments of the Hellenic Arc-Trench (HA-T) system, in its western and eastern megasegments as well as in the HA-T system considered as an entity. Data sets of Ms ≥ 4.5 and Ms ≥ 6.0 covering the 22-year and 85-year intervals of 1964–1985 and 1901–1985, respectively, have been used. Frequencies of the 22-year interval have been normalized to the 85-year interval so that to obtain frequencies N compatible with the real frequencies, Nr, of the 85-year interval for magnitudes of Ms ≥ 6.0. Straight G-R lines determined for N of small and moderate shocks as a rule do not fit, when extrapolated, the larger magnitude frequencies N and Nr. Magnitude gaps, bulge effects, and trends toward the vertical are the geometrical expressions of the nonlinear structure of G-R in the large magnitude range. Magnitude gaps ranging from 0.5 to 0.9 in the Nr plots and in a wider magnitude spectrum in the N plots, of four out of five separate segments, indicate that the stress fails to release with ruptures of moderate size, thus implying that the characteristic earthquake model may provide an adequate explanation for the G-R nonlinearity. The Ionian Islands segment constitutes an obvious exception. No magnitude gap in Nr appears and the G-R linearity is well shaped. Characteristic events may not occur in that segment. When two or more segments are examined together as megasegments, the magnitude gap disappears because of overlapping of separate gaps. The nonlinear structure of G-R shows the general need for properly designed models of seismic hazard determination.

In the case of needle nerve contact during peripheral blocks, pencil point needles are considered less traumatic compared with bevelled needles. However, there are not enough data to prove this notion. Therefore, the aim of this study was to challenge the hypothesis that nerve perforation with short bevelled needles is associated with major nerve damage compared with pencil point needles.In five anaesthetised pigs, the brachial plexus was exposed bilaterally. Up to eight nerves underwent needle nerve perforation using a pencil point needles cannula or an short bevelled needle. After 48 h, the nerves were resected. The specimens were processed for visual examination and the detection of inflammatory cells (haematoxylin-eosin, i.e. CD68-immunohistochemistry to detect macrophages), myelin damage (Kluver-Barrera staining) and intraneural haematoma. The grade of nerve injury was characterised by an objective score ranging from 0 (no injury) to 4 (severe injury).Fifty nerves were examined. According to the injury score applied, there was no significant difference between the pencil point needles [median (inter-quartile range) 2.0 (2.0-2.0)] and the short bevelled-needle group [median 2.0 (2.0-2.0) P=0.23]. No myelin damage was observed. Signs of post-traumatic inflammation were equally distributed among both groups.In the present study, the magnitude of nerve injury after needle nerve perforation was not related to one of the applied needle types. Post-traumatic inflammation rather than structural damage of nerve tissue is the only notable sign of nerve injury after needle nerve perforation with either needle type. However, neither the pencil point- nor the short bevelled needle can be designated a less traumatic device.

The purpose of this study was to determine systematically the highest minimal stimulation current threshold for regional anaesthesia in pigs.In an established pig model for regional anaesthesia, needle placements applying electric nerve stimulation were performed. The primary outcome was the frequency of close needle to nerve placements as assessed by resin injects and subsequent anatomical evaluation. Following a statistical model (continual reassessment method), the applied output currents were selected to limit the necessary number of punctures, while providing guidance towards the highest output current range.Altogether 186 punctures were performed in 11 pigs. Within the range of 0.3-1.4 mA, no distant needle to nerve placement was found. In the range of 1.5-4.1 mA, 43 distant needle to nerve placements occurred. The range of 1.2-1.4 mA was the highest interval that resulted in a close needle to nerve placement rate ofor =95%.In the range of 0.3-1.4 mA, all resin deposition was found to be adjacent to nerve epineurium. The application of minimal current intensities up to 1.4 mA does not obviously lead to a reduction of epineural injectate contacts in pigs. These findings suggest that stimulation current thresholds up to 1.4 mA result in equivalent needle tip localisation in pigs.

Aim: To test whether clamping during liver surgery predisposes to hepatic vein thrombosis. Methods: We performed a retrospective analysis of 210 patients who underwent liver resection with simultaneous inflow and outflow occlusion. Intraoperatively, flow in the hepatic veins was assessed by Doppler ultrasonography during the reperfusion phase. Postoperatively, patency of the hepatic veins was assessed by contrast-enhanced CT angiography, when necessary after 3-6 mo follow up. Results: Twelve patients (5.7%) developed intraoperative liver remnant swelling. However, intraoperative ultrasonography did not reveal evidence of hepatic vein thrombosis. In three of these patients a kinking of the common trunk of the middle and left hepatic veins hindering outflow was recognized and was managed successfully by suturing the liver remnant to the diaphragm. Twenty three patients (10.9%) who developed signs of mild outflow obstruction postoperatively, had no evidence of thrombi in the hepatic veins or flow disturbances on ultrasonography and contrast-enhanced CT angiography, while hospitalized. Long term assessment of the patency of the hepatic veins over a 3-6 mo follow-up period did not reveal thrombi formation or clinical manifestations of outflow obstruction. Conclusion: Extrahepatic dissection and clamping of the hepatic veins does not predispose to clinically important thrombosis. © 2009 The WJG Press and Baishideng. All rights reserved.

Die Nervenstimulation zur Identifikation der peripheren Nerven anhand der Reizantwort eines Kennmuskels ist ein bekanntes und etabliertes Verfahren. Nach dem Gesetz von Coulomb ist die gewahlte Stromstarke proportional zur Entfernung der elektrostatischen Ladung des Nervens. Je naher die Nadel am Nerv liegt, desto hoher ist die Reizantwort. Bis dato wurde als Schwellenstrom ein Wert von 0,3 mA festgelegt, um sicherzustellen, dass eine intraneurale Lage der Nadel detektiert werden kann. Der geringe Strom resultiert jedoch oft in einer frustranen Suche nach der Zielstruktur und mehrfachen Punktionen, die ebenfalls zu neuralen Traumata fuhren konnen.

Whiplash injury of the cervical spine is a relevant medical and socioeconomic problem, which is still the subject of controversy. We performed a survey to evaluate the current status of diagnostics, classification, treatment, and doctors' subjective opinions at surgical and trauma departments in Germany. A total of 1568 hospitals were addressed to answer a standardized questionnaire on their proceedings and opinions concerning whiplash injury. We received 540 (34.44%) completed questionnaires. There was overall agreement concerning the need for physical examination. The radiological assessment included an a.p. and a lateral plain X-ray of the cervical spine in 82.6%. The indication for functional X-rays in flexion/extension was inconsistent. On average they were performed in 39.1% of all patients. In most cases (68.9%) whiplash injury was not classified; 13.2% of doctors used the classification according to the Quebec Task Force and 13.9% according to Erdmann. A cervical collar was prescribed in 85%. While 30% of patients received only a cervical collar, 55.6% underwent additional physiotherapy. Only 8.3% were treated by physiotherapy without immobilization. The doctors' subjective opinions indicated psychological factors to be important for long-lasting problems, but not for the acute period of complaints. There is no homogeneous concept for diagnostics, classification, and treatment of patients who suffered a whiplash injury in Germany. This situation reflects the current problems in management of this condition. Scientific evidence for functional treatment to avoid adverse influence of immobilization by cervical collars has not yet been transferred to our daily routine in Germany.

Remifentanil, mivacurium and ropivacaine are the latest innovations in clinical anaesthesia and have gained increasing importance in daily practise due to their unique pharmacodynamic and pharmacokinetic properties. However, drug acquisition costs for these agents are considerably higher in most countries than for comparable substances. This review provides a systematic, critical appraisal of pharmacoeconomic studies with remifentanil, mivacurium and ropivacaine, primarily based on prospective, randomised trials. Results from analyses using cost-minimising techniques stress the issue of the higher drug acquisition costs. However, studies using a more sophisticated method (e.g., cost-effectiveness analysis) indicate comparable costs or even financial advantage in favour of the newer investigative drugs remifentanil, mivacurium and ropivacaine.

Diagnostic evaluation and therapeutic management of acute neck pain after whiplash is a frequent but unsolved clinical problem. Long-lasting symptoms and disability are common. Former studies proposed beneficial effects of physiotherapy in the early management of whiplash injury. The purpose of this study was to assess the effects of early active mobilization versus standard treatment with a soft cervical collar.Between August 1997 and February 2000 a prospective randomized clinical trial with a total of 168 patients was performed. Of these patients 81 (31 male, 50 female; average age 28,78 years) were randomly assigned to the standard therapy group, which received a soft cervical collar, and 87 (31 male, 56 female; average age 29,62 years) to the early mobilization group, treated by physiotherapy. Study participants documented pain and disability twice (baseline and six week follow-up) during a one week period by diary, using numeric rating scales ranging from 0 to 10.The initial mean pain intensity (4,75) reported by the standard therapy group was similar to disability (4,76). There were no significant differences to initial pain (4,50) and disability (4,39) reported by the early mobilization group. The mean pain intensity reported by the standard therapy group after 6 weeks was 2,66 and disability was 2,40. The mean pain intensity indicated by physiotherapy group was 1,44 and mean disability was 1,29. The differences between the groups were both significant.Early mobilization is superior to the standard therapy regarding pain intensity and disability. We conclude that mobilization should be recommended as the new adequate standard-therapy in the acute management of whiplash injury.

The internal and external validity of studies is endangered by many factors, such as selection of subjects for inclusion. Selection bias itself is a major problem, but remains unmentioned and probably unexamined in the majority of published clinical trials in traumatology.The aim of this investigation was to detect effects of subject selection which occurred during our own prospective intervention study. The clinical trial compared subjects with whiplash injury who were either treated by early mobilization or immobilization (soft collar).Source population, eligible subjects, study participants and final study participants were compared for differences on various items like age, gender and further sociodemographic as well as crash related factors and clinical findings.Between 21.08.1997 and 30.04.1999 a total of 732 patients was examined and treated after whiplash in our trauma department. The options for inclusion were met by 453 patients. While 346 escaped from the study, 107 agreed to participate. Of these another 39 patients dropped out of the study. Selection effects were detected on two different levels, leading to distinct statistical procedures from those proposed in the study protocol.Uncontrolled selection effects could undermine the interpretability of the results of clinical trials. Awareness of selection effects is mandatory regarding the applicability of these results to subjects, other than those in the group of the final study participants.

Strangeness measurements in NA49 indicate a strangeness enhancement in Pb + Pb interactions, relative to the elementary nucleon-nucleon and nucleon-nucleus collisions. It appears that the magnitude of the enhancement is similar in Pb + Pb and S + nucleus collisions. The enhancement is present in almost every central Pb + Pb collision, the dynamical fluctuations (in strangeness) appear to be minimal. The magnitude of the enhancement increases with the strangeness content of the particle species. The inverse slope systematics indicate the presence of transverse flow in the system. The cascade/lambda ratio is increased relative to elementary collisions.

Net proton and negative hadron spectra for central Pb + Pb collisions at 158 GeV per nucleon at the CERN Super Proton Synchrotron were measured and compared to spectra from lighter systems. Net baryon distributions were derived from those of net protons. Stopping (rapidity shift with respect to the beam) and mean transverse momentum [p(T)] of net baryons increase with system size. The rapidity density of negative hadrons scales with the number of participant nucleons for nuclear collisions, whereas their [p(T)] is independent of system size. The [p(T)] dependence upon particle mass and system size is consistent with larger transverse flow velocity at midrapidity for Pb + Pb compared to S + S central collisions.

The NA49 detector is a wide acceptance spectrometer for the study of hadron production in p + p, p + A, and A + A collisions at the CERN SPS. The main components are 4 large-volume TPCs for tracking and particle identification via dE/dx. TOF scintillator arrays complement particle identification Calorimeters for transverse energy determination and triggering, a detector for centrality selection in p + A collisions, and beam definition detectors complete the set-up. A description of all detector components is given with emphasis on new technical realizations. Performance and operational experience are discussed in particular with respect to the high track density environment of central Pb + Pb collisions. (C) 1999 Elsevier Science B.V. All rights reserved.

The two-proton correlation function at midrapidity from Pb + Pb central collisions at 158 A GeV has been measured by the NA49 experiment. The results are compared to model predictions from static thermal Gaussian proton source distributions and transport models rqmd and venus. An effective proton source size is determined by minimizing chi(2)/ndf between the correlation functions of the data and those calculated for the Gaussian sources, yielding sigma(eff) = 3.85 +/- 0.15(stat.)(-0.25)(+0.60)(syst.) fm. Both the rqmd and the venus model are consistent with the data within the error in the correlation peak region. (C) 1999 Published by Elsevier Science B.V. All rights reserved.

We report measurements of Xi(-) and (Xi)over-bar(+) hyperon absolute yields as a function of rapidity in 158 GeV/c Ph + Pb collisions. At midrapidity, dN/dy = 2.29 +/- 0 12 for Xi(-), and 0.52 +/- 0.05 for (Xi)over-bar(+), leading to the ratio of (Xi)over-bar(+)/Xi(-) = 0.23 +/- 0.03. Inverse slope parameters fitted to the measured transverse mass spectra are of the order of T approximate to 300 MeV near mid-rapidity. The estimated total yield of Xi(-) particles in Pb+ Pb central interactions amounts to 7.4 +/- 1.0 per collision. Comparison to Xi(-) production in properly scaled p + p reactions at the same energy reveals a dramatic enhancement (about one order of magnitude) of Xi(-) production in Pb + Pb central collisions over elementary hadron interactions. (C) 1998 Elsevier Science B.V. All rights reserved.

The directed and elliptic flow of protons and charged pions has been observed from the semicentral collisions of a 158 GeV/nucleon Ph beam with a Pb target. The rapidity and transverse momentum dependence of the flow has been measured. The directed flow of the pions is opposite to that of the protons but both exhibit negative flow at low p(t). The elliptic flow of both is fairly independent of rapidity but rises with p(t).

The composition of forward-going projectile spectator matter in fixed-target Pb+Pb collisions at 158 A.GeV at the CERN SPS has been studied as a function of centrality. The data were measured with the NA49 veto calorimeter. We observe that forward-going spectator matter in central collisions consists of 9 neutrons, 7 protons, and half a deuteron on average. At large impact parameters most spectator nucleons are bound in fragments. The relative resolution of the average impact parameter derived from the measurement of spectator neutrons is roughly 19% in the range from zero to half maximum impact parameters.

Product of charged kaons in central S + S and O + Au collisions at 200 GeV/nucleon has been studied in the NA 35 Streamer Chamber experiment. Mean multiplicities and transverse mass distributions were obtained. They were compared with nucleon-nucleon data and with model predictions. © 1992.