Human cytomegalovirus seropositivity is associated with reduced patient survival during sepsis

BACKGROUND

Sepsis is one of the leading causes of death. Treatment attempts targeting the immune response regularly fail in clinical trials. As HCMV latency can modulate the immune response and changes the immune cell composition, we hypothesized that HCMV serostatus affects mortality in sepsis patients.

METHODS

We determined the HCMV serostatus (i.e., latency) of 410 prospectively enrolled patients of the multicenter SepsisDataNet.NRW study. Patients were recruited according to the SEPSIS-3 criteria and clinical data were recorded in an observational approach. We quantified 13 cytokines at Days 1, 4, and 8 after enrollment. Proteomics data were analyzed from the plasma samples of 171 patients.

RESULTS

The 30-day mortality was higher in HCMV-seropositive patients than in seronegative sepsis patients (38% vs. 25%, respectively; p = 0.008; HR, 1.656; 95% CI 1.135-2.417). This effect was observed independent of age (p = 0.010; HR, 1.673; 95% CI 1.131-2.477). The predictive value on the outcome of the increased concentrations of IL-6 was present only in the seropositive cohort (30-day mortality, 63% vs. 24%; HR 3.250; 95% CI 2.075-5.090; p < 0.001) with no significant differences in serum concentrations of IL-6 between the two groups. Procalcitonin and IL-10 exhibited the same behavior and were predictive of the outcome only in HCMV-seropositive patients.

CONCLUSION

We suggest that the predictive value of inflammation-associated biomarkers should be re-evaluated with regard to the HCMV serostatus. Targeting HCMV latency might open a new approach to selecting suitable patients for individualized treatment in sepsis.

[Surgery in the balance between humanity, ethics and economics]

BACKGROUND

The economic pressure in the healthcare system has noticeably increased in the past few years. The manifestation of an "economization in medicine" development raises questions about the compatibility of physicians' duties and economic incentives in the healthcare system.

OBJECTIVE

Against this background the article analyzes areas of conflict in the German healthcare system and surgery in particular. The main questions focus on: what lines of conflict can arise between ethical duties and economic requirements and what possibilities for conflict resolution can provide orientation on the macrolevel and microlevel?

MATERIAL AND METHODS

The article is based on the analysis of normative regulations, guidelines and statements from the self-administrative institutions and multidisciplinary literature from medicine, medical ethics and health economics. Core issues in the conflict area between "humanity-ethics-economics" are structured and recommendations for action are derived.

RESULTS AND DISCUSSION

Superordinate regulatory framework conditions and their subsequent incentives must not conflict with the ethical principles of medical care, especially the primary orientation to patient welfare. Institutional and individual healthcare providers have a responsibility towards patients first and only secondarily for an economically appropriate spending of public resources. The provision of medical care for people must enable an adequate livelihood. Institutional maximization of profits is to be avoided, especially concerning financial investors. In the corona pandemic, economic disincentives are becoming apparent and necessitate readjustments. Possible recommendations for action are the empowerment of the medical profession and management to engage in a qualified exchange.

Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study

BACKGROUND

In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals.

OBJECTIVE

This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals.

MATERIAL AND METHODS

This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation.

RESULTS

The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources.

CONCLUSION

In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

[Implementation of anesthesia quality indicators in Germany : A prospective, national, multicenter quality improvement study]

BACKGROUND

In 2016 the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthetists (BDA) published 10 quality indicators (QI) to compare and improve the quality of anesthesia care in Germany. So far, there is no evidence for the feasibility of implementation of these QI in hospitals.

OBJECTIVE

This study tested the hypothesis that the implementation of the 10 QI is feasible in German hospitals.

MATERIAL AND METHODS

This prospective three-phase national multicenter quality improvement study was conducted in 15 German hospitals and 1 outpatient anesthesia center from March 2017 to February 2018. The trial consisted of an initial evaluation of pre-existing structures and processes by the heads of the participating anesthesia departments, followed by a 6-month implementation phase of the QI as well as a final re-evaluation phase. The implementation procedure was supported by web-based implementation aids ( www.qi-an.org ) and internal quality management programs. The primary endpoint was the difference in the number of implemented QI per center before and after implementation. Secondary endpoints were the number of newly implemented QI per center, the overall number of successful implementations of each QI, the identification of problems during the implementation as well as the kind of impediments preventing the QI implementation.

RESULTS

The average number of implemented QI increased from 5.8 to 6.8 (mean of the differences 1.1 ± 1.3; P < 0.01). Most frequently the QI perioperative morbidity and mortality report (5 centers) and the QI temperature management (4 centers) could be implemented. After the implementation phase, the QI incidence management and patient blood management were implemented in all 16 centers. Implementation of other quality indicators failed mainly due to a lack of time and lack of structural resources.

CONCLUSION

In this study the implementation of QI was proven to be mostly feasible in the participating German hospitals. Although several QI could be implemented with minor effort, more time, financial and structural resources would be required for some QI, such as the QI postoperative visit.

[Positioning therapy and early mobilization in intensive care units : Findings from the current 2015 guidelines]

The 2007 guidelines "Positioning for prophylaxis and therapy of pulmonary disorders" were completely revised in 2015 on behalf of the German Society of Anaesthesiology and Intensive Care Medicine. With regard to practical and scientific relevance, early mobilization of patients in critical care has been included in the guidelines for the first time. Furthermore, the recommendations for prone positioning have been updated, based on current evidence in medicine and nursing. In addition, recommendations regarding unsuitable positions that may actually harm patients were made. As such, the flat supine position should only be used in cases of urgent medical or nursing needs. This underlines the importance of a moderately elevated head of bed position (20(o)-45(o)) in mechanically ventilated patients.

[Short version S2e guidelines: "Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders"]

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioned a revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientific relevance the guidelines were extended to include the issue of "early mobilization" and the following main topics are therefore included: use of positioning therapy and early mobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders : Revision 2015: S2e guideline of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI)

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Effects of hypercapnia and hypercapnic acidosis on attenuation of ventilator-associated lung injury

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are associated with impaired gas exchange, severe inflammation and alveolar damage including cell death. Patients with ALI or ARDS typically experience respiratory failure and thus require mechanical ventilation for support, which itself can aggravate lung injury. Recent developments in this field have revealed several therapeutic strategies that improve gas exchange, increase survival and minimize the deleterious effects of mechanical ventilation. Among those strategies is the reduction in tidal volume and allowing hypercapnia to develop during ventilation, or actively inducing hypercapnia. Here, we provide an overview of hypercapnia and the hypercapnic acidosis that typically follows, as well as the therapeutic effects of hypercapnia and acidosis in clinical studies and experimental models of ALI. Specifically, we review the effects of hypercapnia and acidosis on the attenuation of pulmonary inflammation, reduction of apoptosis in alveolar epithelial cells, improvement in sepsis-induced ALI and the therapeutic effects on other organ systems, as well as the potentially harmful effects of these strategies. The clinical implications of hypercapnia and hypercapnic acidosis are still not entirely clear. However, future research should focus on the intracellular signaling pathways that mediate ALI development, potentially focusing on the role of reactive biological species in ALI pathogenesis. Future research can also elucidate how such pathways may be targeted by hypercapnia and hypercapnic acidosis to attenuate lung injury.

[Airway management]

Managing the difficult airway poses an enormous challenge for anaesthesiologists, intensivists and A&E physicians, particularly because of the high probability of a potentially fatal outcome. Development and (pre-) clinical distribution of supraglottic airway devices (e.g. LMA, LT) and their enhancements, as well as the broad acceptance of awake fibre-optic intubation, led to a profound change in the strategy for managing the difficult airway. This is reflected in the revised ASA guidelines, implementing the use of the laryngeal mask airway and fibre-optic intubation. In view of the utmost importance of this topic the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) framed an independent German guideline, considering German national terms and conditions. In analogy algorithms and guidelines of the ILCOR, ERC and ATLS were revised as well as those of many other national anaesthesiological boards. Nevertheless, massive national and international deficits exist in implementing these guidelines into practice and the implicated structural requirements with respect to education, reflection, team building and equipment concerning the individual institution.

Koagulopathie

Coagulopathy after trauma is a major cause for uncontrolled hemorrhage in trauma victims. Approximately 40% of trauma related deaths are attributed to or caused by exsanguination. Therefore the prevention of coagulopathy is regarded as the leading cause of avoidable death in these patients. Massive hemorrhage after trauma is usually caused by a combination of surgical and coagulopathic bleeding. Coagulopathic bleeding is multifactorial, including dilution and consumption of both platelets and coagulation factors, as well as dysfunction of the coagulation system. Because of the high mortality associated with hypothermia, acidosis and progressive coagulopathy, this vicious circle is often referred to as the lethal triad, potentially leading to exsanguination. To overcome this coagulopahty-related bleeding an empiric therapy is often instituted by replacing blood components. However, the use of transfusion of red blood cells has been shown to be associated with post-injury infection and multiple organ failure. In the management of mass bleeding it is therefore crucial to have a clear strategy to prevent coagulopathy and to minimize the need for blood transfusion.

Influence of a 30-min break on divided attention and working memory in resident anaesthetists on daily routine

BACKGROUND

The aim of this study is to test the hypothesis that a standard 30-min break in a routine 7.5 h period of work makes a difference in cognitive function.

METHODS

In a double-blinded, cross-over trial 30 residents in anaesthesia were randomized to receive or not to receive a 30-min break between the assessment times of 07:30 and 14:00. in a normal working day. After at least 28 days the test was repeated with each resident in the opposite group. Primary outcome measure was the Test for Attentional Performance with the subtest of working memory and divided attention. Secondary outcomes are the Stanford Sleepiness Scale and the State-Trait Anxiety Inventory test.

RESULTS

The sleep, caffeine and nicotine habits in both groups were comparable. There was no difference between the two groups in the Test for Attentional Performance, Stanford Sleepiness Scale and the State-Trait Anxiety Inventory. The correlation between recovery through sleep and sleep disturbance in the night before investigation to the Stanford Sleepiness Scale (P<0.001 and P=0.003) and State-Trait Anxiety Inventory (P<0.001 and P=0.001) at the 07:30 assessment is significant. For the 14:00 assessment the only significant correlation is between the recovery through sleep with the Stanford Sleepiness Scale (P=0.04) and the State-Trait Anxiety Inventory (P=0.05).

CONCLUSION

A 30-min break during a 7.5 h daily routine did not influence cognitive function tests.

Cardiopulmonary Effects of Intravenous Prostaglandin E1 during Experimental One-Lung Ventilation

BACKGROUND

One-lung ventilation greatly improves operating conditions during thoracic surgery. Serious disadvantages of one-lung ventilation are hypoxaemia and increased pulmonary vascular resistance. Prostaglandins, like prostaglandin I2 (PGI2), are potent pulmonary vasodilators but may also influence venous admixture and systemic circulation. Since the lung is capable of extensive degradation of prostaglandin E1 (PGE1) but not of PGI2, PGE1 might affect systemic circulation to a lesser degree. Hence, we studied the effects of intravenous PGE1 on systemic and pulmonary circulation and on oxygenation during one-lung ventilation.

METHODS

Lateral thoracotomy and cross-clamping of the left main stem bronchus was performed in twelve anaesthetised and ventilated pigs. Animals were cannulated with arterial, central venous and fast response thermodilution pulmonary artery catheters for haemodynamic measurements. PGE1 was administered with infusion rates of 25, 50, and 100 ng x kg (-1) x min (-1) during one-lung ventilation.

RESULTS

All doses of PGE1 significantly decreased pulmonary vascular resistance and mean pulmonary artery pressure. However, a comparable significant reduction in systemic vascular resistance and mean arterial pressure was found. Arterial oxygen tension and venous admixture showed a slight but significant deterioration. Oxygen delivery remained unchanged or increased since the cardiac index increased.

CONCLUSION

During one-lung ventilation in the pig, infusion of PGE1 significantly decreased pulmonary vascular resistance and pulmonary artery pressure but failed to achieve selective pulmonary vasodilation.

Cardiopulmonary effects of iloprost in experimental acute lung injury

Iloprost, a prostacyclin analogue with a prolonged plasma half-life has beneficial effects in chronic pulmonary hypertension, whereas the effects in acute lung injury (ALI) are unknown. The present study was performed to evaluate the cardiopulmonary effects of iloprost in experimental ALI. ALI was induced in 18 pigs by repeated lung lavage. Animals were randomised to controls, i.v. or inhaled iloprost for 15 min. Haemodynamics, gas exchange and ventilation-perfusion distribution were measured at the end of iloprost application and after 1 and 2 h. As a short-term effect, both i.v. and inhaled iloprost significantly decreased pulmonary artery pressure without major effects on gas exchange or systemic haemodynamics. After 1 and 2 h, a reduction of pulmonary hypertension was no longer present. As a long-term effect, inhaled, but not i.v., iloprost decreased pulmonary shunt and significantly improved gas exchange after 1 and 2 h. In conclusion, the single application of iloprost revealed short-term pulmonary vasodilation without other major cardiopulmonary effects. However, inhaled iloprost improved gas exchange due to a decrease of pulmonary shunt as a long-term effect, possibly as a result of a reduction of lung oedema formation.

[Neuromonitoring with S-100 protein in the intensive care unit]

During the last years biochemical neuromonitoring with various molecules such as S-100 protein has become popular. A huge number of investigations both experimental and clinical have been undertaken to determine diagnosis and prognosis of patients with acute neurologic diseases. This article gives a review on the current knowledge, indications and limitations on the use of S-100 protein with regard to most of the acute neurological diseases an intensivist is confronted with in everyday practice.

Pulmonaler Gasaustausch: Klassische und neuere Erkenntnisse

The functional anatomy of the pulmonary gas exchanger enables an adequate oxygenation even in extreme situations, e. g. high altitude. An important mechanism is the distribution of ventilation and pulmonary perfusion. With induction of anaesthesia a relevant ventilation-perfusion mismatch results in oxygenation impairment, which can be prevented by specific anaesthetic techniques.

Factors independently associated with increased risk of pain development after ophthalmic surgery

BACKGROUND AND OBJECTIVE

Little has been documented about the development of pain after ophthalmic surgery. This study was designed to assess the incidence and severity of postoperative pain following ophthalmic surgery, and to identify key factors independently associated with development of such pain.

METHODS

In a prospective, observational cohort study, 500 patients undergoing elective ophthalmic surgery were examined by assessing numerical analogue scales and analgesic requirements.

RESULTS

Depending on anatomical location of surgery, operations could be classified into creating 'more severe' or 'less severe pain'. Patients undergoing posterior segment, corneal and muscle surgery exhibited the highest numerical analogue scale scores (risk ratio 4.5, 95% CI 3.01-6.79, P < 0.0001). Anterior segment surgery, which per se did not create much pain, resulted in significantly more pain when performed under general anaesthesia compared to regional anaesthesia (risk ratio 6.52, 95% CI 2.33-18.2, P < 0.0001). No other factors independently associated with an increased risk of developing serious postoperative pain could be identified.

CONCLUSIONS

Patients undergoing certain ophthalmic operations, especially if performed under general anaesthesia, are more likely to experience serious postoperative pain.

[Treatment of acute respiratory distress syndrome in a treatment center. Success is dependent on risk factors]

SUBJECT

Mortality rates remain high for the acute respiratory distress syndrome (ARDS) despite standardised treatment algorithms. Little is known about prognostic factors and exclusion criteria for advanced treatment including extracorporeal membrane oxygenation (ECMO).

METHODS

In an observational study design a cohort of 93 patients with severe ARDS admitted to a referral centre were analysed according to ventilatory and vital parameters.

RESULTS

Overall survival rate was 70% and in patients who received ECMO treatment it was 67%. In patients exhibiting relevant co-morbidity the odds ratio for fatal outcome increased to 4.7 (95% CI: 3.3-24.9), and patients with multiple organ failure had a 7.5-fold increase (95% CI: 2.3-25.2) for risk of death. Survivors demonstrated a more pronounced improvement in oxygenation ( p<0.05) and CO(2) removal ( p<0.05) than non-survivors.

CONCLUSIONS

Advanced treatment of ARDS including ECMO represents a therapeutic option if none of the currently considered contraindications are present. An improvement in gas exchange parameters, but not a defined value per se may be useful as a prognostic factor for favourable outcome.

Anesthetic considerations in patients with chronic pulmonary diseases

AIM

Increasing age and co-morbidities of patients admitted for surgery impose new challenges on the anesthesiologist.

METHODS

Review of current literature regarding the perioperative management of patients with chronic pulmonary disease.

RESULTS

If patients are treated adequately, surgery can be safely performed under regional and general anaesthesia. Major risk factors include type of surgery, type and duration of anesthesia, general health status and smoking history, but not certain lung function parameters. Regional anesthesia remains the first choice for intra- and postoperative care, and if general anesthesia is necessary, early extubation should be achieved. Non-invasive ventilation could be a possible alternative in weaning failure.

CONCLUSION

Assessing the functional status of patients admitted to surgery remains a difficult task, and in patients identified at risk by clinical examination additional spirometry and blood gases may be helpful. If there are signs of respiratory failure, the anaesthetist should monitor the patient closely and invasively, yet there is no reason to deny any patient a substantially beneficial operation.

[Extracorporeal membrane oxygenation by acute respiratory distress syndrome]

After various observational studies demonstrated a benefit of extracorporeal membrane oxygenation (ECMO) in the therapy of severe acute respiratory distress syndrome (ARDS), ECMO now represents an important contribution for ARDS therapy using clinical algorithms despite a lack of positive controlled studies. In specialized centers patients with severe ARDS and imminent hypoxia despite intensive conventional therapy, are treated with ECMO using blood pumps and artificial membrane lungs (oxygenators) for extracorporeal lung assist. The development of new surface modifications, optimized oxygenators and miniaturized blood pumps should increase hemocompatibility and lead to simplified treatment as well as less complications. New oxygenators with significantly decreased blood resistance allow the clinical application of pumpless arteriovenous extracorporeal lung assist (ECLA). After these new developments indications for ECMO could be extended from use not only as ultimate ratio but to less severe ARDS to enable lung protective, less invasive mechanical ventilation.

[Aerosolized and intravenous prostacyclin during one-lung ventilation. Hemodynamic and pulmonary effects]

BACKGROUND

One-lung ventilation is frequently used in thoracic surgery. However, hypoxic pulmonary vasoconstriction of the atelectatic lung may produce pulmonary hypertension. The objective of the present study was to compare the acute effects of intravenous versus aerosolized prostacyclin (PGI(2)) on pulmonary and systemic circulation.

METHODS

PGI(2) was administered in 11 anesthetized and unilaterally ventilated pigs by infusion (5, 10, and 20 ng/kg body weight/min) and by inhalation (4, 8, and 16 ng/kg body weight/min) in a cross-over design.

RESULTS

Infusion of PGI(2) reduced both pulmonary (PVR) and systemic vascular resistance (SVR). Due to a concomitant increase in cardiac index (CI) mean arterial (MAP) and pulmonary artery pressures (MPAP) did not change significantly. In contrast, aerosolized PGI(2) produced a significant decrease in PVR (-21.4 to -32.8%) and MPAP (-12.0 to -17.8%) without affecting SVR, MAP, and CI. Arterial oxygenation tension (p(a)O(2)) was not affected.

CONCLUSION

During one-lung ventilation only aerosolized prostacyclin produced a selective pulmonary vasodilation.

Modulating the pulmonary circulation: an update

Pulmonary hypertension is a common finding in pulmonary circulatory disorders of different origin. Chronic pulmonary hypertension may develop due to either cardiopulmonary or systemic diseases whereas acute and acute-on-chronic pulmonary hypertension often occur in the course of cardiothoracic surgery. Right heart failure is the major risk particularly in the course of acute pulmonary hypertension. Thus, besides basic treatment of the underlying disease the use of vasodilators is a valuable therapeutic option to decrease right ventricular afterload, but intravenous vasodilators may provoke systemic arterial hypotension and impair gas exchange due to vasodilation of pulmonary shunt areas. Therefore, inhaled vasodilators such as nitric oxide and prostacyclin have been suggested for the treatment of pulmonary hypertension especially when concomitant hypoxemia is present due to a ventilation-perfusion mismatch. However, randomised controlled trials performed to evaluate long-term effects revealed different results: thus, in chronic pulmonary hypertension inhaled vasodilators improved outcome whereas the results for the treatment of the acute respiratory distress syndrome revealed beneficial effects only when used as a rescue and/or bridging therapy in severe hypoxemia. In cardiothoracic surgery, inhaled vasodilators have been shown to improve pulmonary circulation when severe pulmonary hypertension is present. Although effective in experimental studies no clear recommendation can be made in view to the use of other vasodilators such as phosphodiesterase inhibitors or endothelin antagonists. Likewise, the combination of different vasodilators merit further investigations to prove efficacy in randomised controlled trials.

Survival of Avian Influenza Virus H7N2 in SPF Chickens and Their Environments

The survival or clearance of the avian influenza virus (AIV) of subtype H7N2 in its chicken host was evaluated using experimentally infected specific pathogen free (SPF) chickens of different age groups. Birds of different ages were successfully infected with infectious doses ranging between 10(4.7) and 10(5.7) ELD50 per bird. In infected birds, the infective virus was undetectable usually by the third week following exposure. The infectivity or inactivation time of the H7N2 AIV in various environmental conditions was studied using chicken manure, heat, ethanol, pH, and disinfectants. The H7N2 AIV was effectively inactivated by field chicken manure in less than a week at an ambient temperature of 15-20 degrees C. At a pH 2, heating at 56 degrees C, and exposure to 70% ethanol or a specific disinfectant, the AIV infectivity was destroyed in less than 30 min.

[The combination of retrobulbar block with general anaesthesia may lead to pre-emptive analgesia in patients undergoing pars plana vitrectomy]

SUBJECT

To determine whether additional regional blocking provides pre-emptive analgesia in patients undergoing elective pars plana vitrectomy.

METHODS

In a prospectively randomised, double-blinded trial we investigated the potential benefit of combining regional anaesthesia (RA) with general anaesthesia (GA). In each group 25 patients undergoing pars plana vitrectomy were either done under GA (group A), GA combined with retrobulbar block (group B) or GA combined with peribulbar block (group C). Patients were examined by assessing NAS (numeric analogue scale).

RESULTS

At all times, patients of group B experienced significantly less pain than patients in either group A or C (p < 0.001). There were no significant differences in pain scores between patients in groups A and C. Only 4 patients in group B required analgesics, whereas 17 patients in group A and 12 patients in group C.

CONCLUSION

Certain ophthalmic operations are likely to cause postoperative pain when performed under GA alone, whereas the combination of retrobulbar block with GA reduces the development of pain as pre-emptive analgesia.

Factors contributing to fatal outcome of traumatic brain injury: a pilot case control study

OBJECTIVE

Patients with traumatic brain injury (TBI) have a high mortality and morbidity. This pilot study was undertaken to identify contributors to outcome in the early management of patients with TBI and to investigate the feasibility of a larger study.

METHODS

Road trauma patients who died between January 1 and April 30, 2000 were selected from the Alfred Hospital's Intensive Care Traumatic Brain Injury database. These patients were matched with 2 survivors from the data base during the same period for age, injury severity score (ISS) and severity of brain injury using the head abbreviated injury score (head AIS). Patient injury scoring (using the revised trauma score, trauma and injury severity score and Glasgow coma score), arterial blood gas analysis, lactate concentration, inspired oxygen concentration, systolic and mean arterial blood pressure, intracranial pressure, intravenous fluid and blood transfusion volumes, body temperature, haemoglobin, white cell count, INR, APTT, temperature and plasma glucose, urea and creatinine concentrations were recorded for 48 hours from the time of injury. Time periods from the accident to key events (e.g. arrival of ambulance at accident scene, intubation, arrival at the emergency department, insertion of intracranial pressure monitor and primary surgery) were also recorded.

RESULTS

Eighteen patients (6 deceased, 12 survivors) were identified. Despite matching, deceased patients had lower initial Glasgow Coma Scores (GCS) (3.6 vs. 7.4, P = 0.01) and lower revised trauma scores (4.41 vs. 5.75; P = 0.044) compared with survivors. There were no significant differences in other parameters. However, deceased patients tended to have longer times to treatment (P = NS) and experienced trauma at night more frequently, and survivors received almost double the volume of fluid resuscitation during the first 12 hours (19.7 +/- 19.1 vs. 11.8 +/- 2.7 mL/kg/hr, P = 0.513).

CONCLUSIONS

Both initial GCS and severity of brain injury should be used to match TBI patients for injury severity in future studies. Lower initial GCS in deceased patients was likely due to greater severity of brain injury, although it is also possible that the lower GCS was due to decreased brain perfusion (perhaps reflecting inadequate resuscitation) in these patients. Volume of early fluid resuscitation, time to definitive therapy, and time of presentation to hospital may also be important determinants of patient outcome. A large case control outcome study is required to extend these observations.

[A new procedure for determining leg length and leg length inequality using ultrasound. II: Comparison of ultrasound, teleradiography and 2 clinical procedures in 50 patients]

The clinical methods still in common use for measuring leg length and leg length discrepancy (LLD) cannot always meet the demands of precision and accuracy. A method using ultrasound is presented and shown to be a standardized, non-invasive method allowing accurate determination of leg length and LLD. Once the validity had been proved experimentally, practical handling, precision and accuracy of this method were tested on 50 patients in whom teleradiography of the lower extremity was performed for different reasons. The sonographically determined measures of LLD were compared with the radiographic measurements and in addition clinical measurements were taken by direct (tape measure) and indirect methods ("lengthening" of the shorter leg by wooden blocks of known thickness). Adjustments to the ventral hip joint and to the medial knee joint served as standardized, easily reproducible sonographic reference points. The mean variance of repeated sonographic measurements as a reflection of precision amounted to 3.5 mm2 for leg length measurement, with a maximum of 13.5 mm2. In the case of LLD the mean divergence between sonographically and radiographically determined LLD was 0.9 +/- 2.7 mm, with a maximum of 6.4 mm. The clinical methods with mean divergence of -1.2 +/- 9.6 mm (direct method) and -1.0 +/- 6.1 mm (indirect method) proved to be less accurate. The method examined for measuring leg lengths and LLD by means of ultrasound is easy to manage and non-invasive. Its precision and accuracy make it superior to clinical measuring methods and could even make some radiographical examinations superfluous.

[NHL-BFM 90 therapy study in treatment of malignant non-Hodgkin's lymphomas in children and adolescents. Part 2: An intermediate term analysis of the non-B-NHL therapy group. BFM Study group]

The goals of study NHL-BFM 90 for the therapy group Non-B NHL are to prospectively evaluate the dynamic of tumor regression and the persistence of a residual mass after induction therapy for its prognostic impact. Patients (pts) of stages I and II receive induction composed of prednisone, vincristine (VCR), daunorubicin, L-asparaginase (L-ASP), cyclophosphamide (CP), cytarabine (ARA-C), 6-mercaptopurine (6-MP) and intrathecally (i.th.) methotrexate (MTX), followed by consolidation (6-MP,MTX 5 g/m2 x 4, MTX i.th.), and maintenance up to 24 months. Pts of stages III and IV receive additionally reinduction (Dexamethasone, VCR, doxorubicin, L-ASP, CP, ARA-C, 6-thioguanine, MTX i.th.) and cranial irradiation. Pts with < 70% tumor regression at day 33 of induction receive an intensified chemotherapy. Pts with > 70% tumor regression at day 33 but a persistent mass at the end of induction have a surgical resection. Pts with a completely necrotic residual mass continue with consolidation therapy. Pts with active residual lymphoma receive an intensified chemotherapy. No local radiotherapy is given. From 4/1990 to 12/1992, 80 pts were registered; 71 pts are evaluable for response. The distribution of stages is as follows: 6, 1, 47, 17 pts of stage I, II, III, IV, respectively. The probability of event free survival at 3 years is 87 +/- 4% for the whole group (median observation time 21 months). 66 pts are evaluable for the dynamic of response.(ABSTRACT TRUNCATED AT 250 WORDS)

[NHL-BFM 90 therapy study in treatment of malignant non-Hodgkin's lymphomas in children and adolescents. Part 1: Classification and allocation to strategic therapy groups. BIF study group]

One of the goals of the study NHL-BFM 90 was to investigate the distribution and prognosis of the different subtypes of Non-Hodgkin's Lymphoma (NHL) in children and adolescents according to histological, cytomorphological and immunological characteristics. From 4/1990 to 12/1992, 346 patients (pts) (84 females, 262 males) were enrolled (median age: 9.1 years; range: 0.8-17.9 years). Histology was available from 290 pts (84%), cytomorphology from 155 (44%), and immunophenotyping from 245 (70%). Cases with L1 oder L2 cytomorphology according to the French-American-British Classification were classified as lymphoblastic lymphoma and those with L3 cytomorphology as Burkitt-Type lymphoma or acute B-cell leukemia (B-ALL) if a histological classification was not available. By means of the combined analysis of all three diagnostic criterias the classification of the NHL according to the updated Kiel-classification was possible in 312 cases: 49% were classified as Burkitt-type-lymphoma (incl. B-ALL), 22% als lymphoblastic lymphoma, 10% as large cell anaplastic lymphoma (LCAL), 6% as centroblastic lymphoma, only few cases were classified as NHL of other subtypes, 3 pts (1%) suffered from low grade malignant lymphomas, and in 34 pts (10%) the NHL was not further classified. Patients were stratified according to NHL-subentities in 3 branches (Non-B-NHL, B-NHL, LCAL) of different treatment modalities. The estimated probability of a 3-year event free survival (pEFS) was 88 +/- 2% for the whole group (follow up 7 to 40 months, median 23 months) while pEFS of different subtypes was: lymphoblastic lymphoma: 91 +/- 4%; Burkitt-type-lymphoma/B-ALL: 90 +/- 2%; centroblastic lymphoma: 94 +/- 6%, LCAL: 88 +/- 6%. We conclude that the stratification of treatment modalities in study NHL-BFM 90 according to biological entities provided patients of different NHL-subtypes an equal chance to survive event free. The efficacy of the treatment strategy for rare subtypes, however, is not evaluable yet.

[A new procedure for determination of leg length and differences in leg length using sonography. I. Development and experimental studies]

The precise measurement of leg length and leg length discrepancies (LLD) plays an important role in the examination of lumbar spine and lower extremities. Those real LLD which may be posttraumatic or idiopathic, can sometimes hardly be differentiated from LLD caused by spinal scoliosis or malposition. Although there is no final agreement, to which extent a LLD becomes clinically significant, most authors state that clinical assessment of LLD by tape measure or lengthening of the short leg with blocks of known thickness is highly unreliable. Radiological methods are necessary for precise detection of LLD less than 10 mm. Since previously reported non-invasive, ultrasound-supported leg-length measurement methods proved to be complicated and unhandy, a new method was developed. To avoid radiation exposure accuracy and precision were tested on human cadavers and were compared to clinical assessments by tape measurement. A measurement device was constructed consisting of a wire rope meter and a length millimeter digital display. Measurements were taken with the examined person in supine position. The device was placed beyond their feet and the end of the rope was hinged with a metal brace to a convenient transducer in exact middle position. Thus the middle of the ultrasound monitor concords with the end of the rope. The medial knee joint and ventral hip joint were used as standardised sonographic landmarks. Ten not pre-selected mortants were measured in this manner and additionally clinical LLD was obtained with a tape measure (medial ankle to anterior superior iliac spine). Afterwards all distances were anatomically prepared and measured with a meter stick.(ABSTRACT TRUNCATED AT 250 WORDS)