[What is evidence-based in the treatment of sepsis?]

BACKGROUND

The term sepsis was redefined in 2016 as a life-threatening organ dysfunction caused by an inadequate host response to an infection. The German S3 guidelines for the treatment of sepsis were published in 2018.

OBJECTIVE

What is evidence-based in the treatment of patients with sepsis?

MATERIAL AND METHODS

Discussion of the S3 guidelines and inclusion of study results after 2018.

RESULTS

The cornerstones for the treatment of sepsis continue to consist of early hemodynamic stabilization, anti-infection treatment and organ support procedures. Supportive and extracorporeal treatments are controversially discussed and continue to be intensively investigated.

CONCLUSION

Despite an improved understanding of the pathophysiology, there is still no effective causal sepsis treatment, i.e. directed against the pathological host reaction. The treatment of patients with sepsis is therefore still based on the basic principles of correction of volume deficits, anti-infective agents, source control and organ support, including the symptomatic treatment of vasoplegia with catecholamines.

Application of the World Café method to discuss the efficiency of African swine fever control strategies in European wild boar (Sus scrofa) populations

In the current epidemic of African swine fever (ASF) in Europe, the maintenance and spread of the disease among wild boar populations remains the most important epidemiological challenge. Affected and at-risk countries have addressed this situation using a diversity of wild boar management methods with varying levels of success. The methods applied range from conventional animal disease intervention measures (zoning, stakeholder awareness campaigns, increased surveillance and biosecurity measures) to measures aimed at reducing wild boar population movements (fencing and baiting/feeding) or population numbers (intensive hunting). To assess the perceived efficiency and acceptance of such measures in the context of a focal introduction of ASF, the authors organised a participatory workshop inviting experts from the fields of wildlife management, wild boar ecology, sociology, epidemiology and animal disease management to discuss the advantages and disadvantages of various control approaches. The discussions between professionals from different countries took place using the World Café method. This paper documents the World Café method as a tool for increasing the level of participation in multi-stakeholder group discussions, and describes the outputs of the workshop pertaining to the control measures. In summary, the World Café method was perceived as an efficient tool for quickly grasping comprehensive perspectives from the professionals involved in managing ASF and wild boar populations, while promoting engagement in multi-disciplinary discussions. The exercise achieved a good overview of the perceived efficiency and applicability of the different control methods and generated useful recommendations for ASF control in wild boar populations in Europe.

[Extracorporeal techniques for blood purification in sepsis: an update]

BACKGROUND

Despite ongoing development, mortality in sepsis remains considerable. Various techniques for extracorporeal cytokine removal have been described, but evidence remains conflicting.

OBJECTIVES

The aim of this article is to summarize currently used extracorporeal blood purification techniques and their evidence.

METHODS

Non-systematic literature review RESULTS: There are currently various blood purification techniques used with different levels of evidence regarding cytokine removal, vasopressor sparing effects and reduction of mortality, including high-volume dialysis with and without high cut-off filters, special adsorption filters (including CytoSorb®, CytoSorbents Europe, Berlin, Germany, and polymyxin‑B filters). There is development regarding therapeutic plasma exchange. For some blood purification techniques such as combined plasma filtration and adsorption, multicentric randomized studies found a negative effect on survival.

CONCLUSIONS

Despite a theoretical rationale, the use of blood purification methods cannot be recommended for sepsis patients due to the lack of evidence of their efficacy. Heterogeneous inflammatory responses in sepsis render conduction of larger trials difficult. Thus, future studies should cautiously identify appropriate sepsis subtypes to be included. Available techniques should be chosen as individualized complementary treatments and not as competing systems.

Time and spatial variability in the concentrations of selected metals in water and bottom sediments of Pławniowice and Dzierżno Małe reservoirs (Poland)

The migration of metals and metalloids between bottom sediments and water and the other way round is a complex process. Understanding those mechanisms is essential for recognizing transformations taking place in water reservoir ecosystems. The objective behind the following study was to define time and spatial correlations in the changes in total concentrations of selected elements (Cr, Zn, Co, Mn, Cu, Ni, Pb, As, Ba, Sb, Sr and V) in waters and bottom sediments from two water reservoirs located in Upper Silesia (Poland), i.e., Pławniowice and Dzierżno Małe. The research was carried out to demonstrate whether the bottom sediments deposited in the discussed reservoirs could pose an environmental threat due to the possible release of toxic metals and metalloids into the pelagic zone. The obtained results constitute material helping to describe the bioavailability of particular elements. They also expose the existing environmental threats for such water reservoirs and their users.

[Educational and Professional Qualifications of Adults With Myotonic Dystrophies - A Misleading Perception by the Myopathic Face?]

BACKGROUND

Myotonic dystrophies types 1 and 2 (DM1 / DM2) are the most frequent inherited progressive, segmental progeroid, multisystemic neuromuscular diseases in adulthood. The executive impairment is one of the key disease features. The myopathic face triggers the general perception of DM1 patients being associated with a low educational level.

METHODS

We used a standardized questionnaire to evaluate educational levels in adults with genetically confirmed DM1 and DM2 in comparison to data of the general population. Investigated topics included the level of education, e. g. the highest university degree aquired.

RESULTS

Out of a total cohort of 546 DM patients, 125 DM1 and 156 DM2 patients (51 %) participated in this study. There was no statistically significant difference between the two collectives as far as high school levels are concerned. 50.4 % of DM1 and 48.3 % of DM2 patients obtained the higher education entrance qualification compared to 29.6 % of the normal German population. However, there were significant differences between the two collectives in "spelling problems" (DM1 cohort: p = 0.039), "difficulty in mental arithmetic" (p = 0.043), and classification of patients "with learning difficulties" (p = 0.012).

DISCUSSION

Misled by a myopathic face, many physicians associate myotonic dystrophy with cognitive deficiency. Based on our study, the minimal deviation between DM1 and DM2 and the normal German population indicates that the multisystemic disease does not significantly influence the maximum attainable level of education in adults with DM1.

CONCLUSION

In summary, physicians should be aware that the general educational levels are rather normal in patients with myotonic dystrophy type 1 and rethink their perception of DM1 patients.

Comparison of an automated respiratory systolic variation test with dynamic preload indicators to predict fluid responsiveness after major surgery

BACKGROUND

Predicting the response of cardiac output to volume administration remains an ongoing clinical challenge. The objective of our study was to compare the ability to predict volume responsiveness of various functional measures of cardiac preload. These included pulse pressure variation (PPV), stroke volume variation (SVV), and the recently launched automated respiratory systolic variation test (RSVT) in patients after major surgery.

METHODS

In this prospective study, 24 mechanically ventilated patients after major surgery were enrolled. Three consecutive volume loading steps consisting of 300 ml 6% hydroxyethylstarch 130/0.4 were performed and cardiac index (CI) was assessed by transpulmonary thermodilution. Volume responsiveness was considered as positive if CI increased by >10%.

RESULTS

In total 72 volume loading steps were analysed, of which 41 showed a positive volume response. Receiver operating characteristic (ROC) curve analysis revealed an area under the curve (AUC) of 0.70 for PPV, 0.72 for SVV and 0.77 for RSVT. Areas under the curves of all variables did not differ significantly from each other (P>0.05). Suggested cut-off values were 9.9% for SVV, 10.1% for PPV, and 19.7° for RSVT as calculated by the Youden Index.

CONCLUSION

In predicting fluid responsiveness the new automated RSVT appears to be as accurate as established dynamic indicators of preload PPV and SVV in patients after major surgery. The automated RSVT is clinically easy to use and may be useful in guiding fluid therapy in ventilated patients.

[Employee satisfaction in hospitals - validation of the Picker employee questionnaire: the German version of the "survey of employee perceptions of health care delivery" (Picker Institute Boston)]

AIM

The aim of this study was the validation of a questionnaire specially developed for the German health-care market to measure workplace-related satisfaction of all employees in direct or indirect contact to patients. Beside this, its suitability for use in human resource and quality management was tested.

METHOD

Based on data from a postal survey of 38 054 employees from 37 hospitals a psychometric evaluation was done via exploratory factor analysis and reliability as well as regression analysis. For testing the capability to differentiate, subgroup analyses were conducted.

RESULTS

14 factors (Cronbach's alpha between 0.6 and 0.9) were extracted, explaining 44% of the variance. The factors leadership and organisational culture, conditions of employment, work load and relationship to direct line manager had the strongest influence on overall employee satisfaction. Age, gender, employment status, and senior position influence job satisfaction or relevant satisfaction-related factors.

CONCLUSIONS

Psychometric properties, the ability to differentiate between employee groups and practicability render the questionnaire well suited for use in human resource and quality management of hospitals.

Gravity Probe B: final results of a space experiment to test general relativity

Gravity Probe B, launched 20 April 2004, is a space experiment testing two fundamental predictions of Einstein's theory of general relativity (GR), the geodetic and frame-dragging effects, by means of cryogenic gyroscopes in Earth orbit. Data collection started 28 August 2004 and ended 14 August 2005. Analysis of the data from all four gyroscopes results in a geodetic drift rate of -6601.8±18.3  mas/yr and a frame-dragging drift rate of -37.2±7.2  mas/yr, to be compared with the GR predictions of -6606.1  mas/yr and -39.2  mas/yr, respectively ("mas" is milliarcsecond; 1  mas=4.848×10(-9)  rad).

Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization

BACKGROUND

Based on findings of stress-induced neural disturbances in animals and smaller hippocampal volumes in humans with posttraumatic stress disorder), we hypothesized that patients with borderline personality disorders (BPD), who often are victims of early traumatization, have smaller volumes of the hippocampus and the amygdala. We assumed that volumes of these brain regions are negatively correlated with traumatic experiences and with neuropsychological deficits.

METHODS

We studied 21 female patients with BPD and a similar group of healthy controls. We performed clinical assessments, a modified version of the Childhood Trauma Questionnaire, and magnetic resonance imaging volumetric measurements of the hippocampus, amygdala, temporal lobes, and prosencephalon. Neuropsychological testing included scales on which disturbances in BPD were previously reported.

RESULTS

The patients with BPD had nearly 16% smaller volumes of the hippocampus (P<.001) and 8% smaller volumes of the amygdala (P<.05) than the healthy controls. The results for both hemispheres were nearly identical and were controlled for the volume of the prosencephalon and for head tilts. The volumes of the hippocampus were negatively correlated with the extent and the duration of self-reported early traumatization only when BPD and control subjects were considered together. Levels of neuropsychological functioning were associated with the severity of depression but not with the volumes of the hippocampus.

CONCLUSION

In female patients with BPD, we found reduction of the volumes of the hippocampus (and perhaps of the amygdala), but the association of volume reduction and traumatic experiences remains unclear. Arch Gen Psychiatry. 2000;57:1115-1122.

One pediatric burn unit's experience with sleepwear related injuries. 1977

Review of the records of 678 children with acute injuries referred during an eight year period to this burn unit indicated that flame burns from a single ignition source (50%) outranked scalds (27%) or house fires (12%) as causes of injury. There was no temporal trend in the rank pattern. The majority of these single-source flame injuries were severe and involved ignition of the child's clothing. From 1969 through 1973, sleepwear was the clothing involved in 32% of the instances. Since that time and coincident with promulgation of strict federal and state standards for flammability of children's night clothing, a dramatic decline in the number of children referred with injuries of this type has taken place. It is probable that the single factor most important to the decline, in our experience with these injuries, is lower fabric flammability but, because our data may not be representative, corroboration is needed before one can exclude factors such as altered garment design, fire safety related practices at home, or changing patterns of hospital referral.

[Recovery time after (S)-ketamine or ketamine racemate. Recovery time after short anesthesia in volunteers]

The anaesthetic potency of the (S)-ketamine isomer is approximately double that of racemic ketamine. The aim of this study was to compare the recovery of cerebral function after a bolus of 1.3 mg/kg racemic ketamine or 0.65 mg/kg (S)-ketamine followed by continuous application of 4 or 2 mg/kg x h over 15 minutes.

METHODS

With their informed consent and approval of the local ethics committee 12 healthy volunteers were enrolled in a double-blind, cross-over study. All drugs were dissolved in identical volumes. On three dates with an interval of one week at least ketamine/NaCl, (S)-ketamine/physostigmine or (S)-ketamine/NaCl was administered (table 1). The sequence was randomized. In addition, the unspecific antagonistic potential of the centrally acting, cholinergic agonist physostigmine (0.012 mg/kg) after (S)-ketamine was tested against saline-placebo. Neuropsychological tests (tests 3-5 of the syndrome-short-test [Erzigkeit, see references]) were used to quantify cerebral function before and at 45, 75, 105, 135, 165 and 195 min after anaesthesia. All data are mean values and standard deviation. Comparisons over time and between drugs were carried out using two-dimensional analysis of variance (ANOVA). Wilcoxon-tests were used post-hoc. p < 0.05 was considered significant.

RESULTS

After (S)-ketamine the subjects were able to carry out the tasks more rapidly than after racemic ketamine (p < 0.05). Mean time to reach preoperative test performance +10% was 117.5 min for (S)-ketamine/physostigmine, 121.3 min for (S)-ketamine/NaCl and 141.6 min for racemic ketamine (p < 0.05 between (S)-ketamine and racemic ketamine). No differences were found between physostigmine and placebo. The incidence of side effects (mainly nausea, vomiting) was not different.

DISCUSSION

(S)-ketamine offers a shorter recovery time after short anaesthesia compared to racemic ketamine. The investigated dose of physostigmine was probably too low to produce antagonism of (S)-ketamine. An increased dosage of physostigmine has yet to be studied, but is likely to cause a higher rate of side effects such as nausea, vomiting, bradycardia and possibly even tonic-clonic seizures.

[A new method of ex vivo whole blood perfusion of isolated mammalian organs, exemplified by the kidney of swine]

A new method for the ex vivo perfusion of organs from large mammals is described. Gas exchange and dialysis are carried out simultaneously with a low-flux polysulfon dialysis module. The dialysate (e.g. Tyrode solution) is aerated with a mixture of oxygen and carbon dioxide to ensure gas exchange with the blood. Dialysis is carried out in a closed thermostatically controlled system. Monitoring of ultrafiltration is maintained by continuously weighing the blood reservoir and adjusting an afferent and efferent blood pump. Initial results obtained with isolated pig kidneys demonstrate the suitability of the new method for use as a model for the replacement of animal experiments. Theoretically, clinical application in the area of in vivo regional organ perfusion may also be possible.

Interaction of 11 beta-hydroxysteroid-oxido reductase in different organs of various mammalian species

Distribution of 11 beta-HSOR activity in different organs has been measured using tissue slices, homogenates, and microsomes. The biological material was incubated in vitro with cortisol/ cortisone (human preparations) or corticosterone/11-dehydrocorticosterone, respectively (animal preparations). Metabolites formed were quantified using RP-HPLC and on-line detection of labeled compounds. The typical pattern of CS-metabolism as obtained with rat tissue slices revealed that testis, rectum and kidney are predominant oxidizers of active gluco-CS, while liver and lung mainly function as reducers. Human placenta preparations display an exclusive oxidase activity. To trace different types of 11 beta-HSOR homogenates and microsomes of various organs were incubated with different cosubstrates (NAD+/NADH or NADP+/ NADPH, respectively). In accordance with previous reports, this study found that isoenzymes with different cosubstrate preferences exist in individual organs. 11 beta-HS oxidase activity displays a NAD+ preference in the human placenta. There was no apparent difference in cosubstrate preference between human and guinea pig placenta homogenates. In mice there is also a detectable reductive activity, whereas the Sprague-Dawley rat and golden hamster do not show any detectable activities.

[Ketamine racemate versus S-(+)-ketamine with or without antagonism with physostigmine. A quantitative EEG study on volunteers]

The potency of S-(+)-ketamine is approximately double that of the racemic ketamine. This study was carried out to investigate the recovery of cerebral electrical function after a bolus of 1.3 mg/kg ketamine or 0.65 mg/kg S-(+)-ketamine and subsequent continuous application of 4 mg/kg h ketamine per h or 2 mg/kg S-(+)-ketamine, per h for 15 min. Furthermore, the centrally acting, cholinergic agonist physostigmine has been reported to antagonize ketamine and to shorten the recovery period. Therefore, after S-(+)-ketamine 0.012 mg/kg physostigmine was tested against saline placebo. METHODS. With their own informed consent and the approval of the ethics committee 12 healthy volunteers were enrolled in a double-blind cross-over study. All drugs were dissolved in identical volumes. On three dates with intervals of at least 1 week between, ketamine/NaCl, S-(+)-ketamine/physostigmine or S-(+)-ketamine/NaCl was administered (Table 1). The sequence was randomized. The EEG was recorded from 20 sites according to the 10/20 system and after Fast-Fourier transformation computed into amplitudes within the delta, theta, alpha, and beta bands and within the total spectrum. The median, the spectral edge frequency and the dominant frequency (dF) were also determined. Mean values of all electrodes before and at 10, 15, 30, 45 and 195 min after the bolus injection were compared using two-dimensional analysis of variance (ANOVA, significance level P < 0.05). RESULTS. The characteristic increase in theta-amplitude and decrease of alpha-amplitude were observed after ketamine and S-(+)-ketamine. Median and dF dropped from the alpha to the theta frequency range. Ketamine led to a greater increase in total, delta, theta and beta amplitude during anaesthesia. 3 hours after ketamine/S-(+)-ketamine anaesthesia a significant decrease in the median and dominant frequency and in total, delta, theta, alpha and beta amplitudes confirmed residual impairment of cerebral function after all study drugs. No differences were found between physostigmine and placebo. DISCUSSION. The EEG changes during ketamine/S-(+)-ketamine administration suggest a slightly deeper anaesthetic level after ketamine. The course of recovery was not different after ketamine and after S-(+)-ketamine. The spectral edge frequency did not differ between measurement points, and is therefore not suitable for assessment of the depth of anaesthesia reached with ketamine/S-(+)-ketamine. The dose of physostigmine tested was probably too low to produce antagonism of S-(+)-ketamine. An increased dosage of physostigmine has yet to be studied, but is likely to cause a higher rate of side effects, such as nausea, vomiting and bradycardia, and possibly even tonic-clonic seizures.

Life cycle savings and consumption constraints: theory, empirical evidence, and fiscal implications

"Recent tests of both the pure and the extended life cycle hypothesis have generated inconclusive results on the life cycle behavior of the elderly. We extend the life cycle model by introducing a constraint on the physical consumption opportunities of the elderly which, if binding, imposes a consumption trajectory declining in age. This explains much of the received evidence on the elderly's consumption and savings behavior, in particular declining consumption, and increasing savings and wealth with increasing age. Our analysis of [Federal Republic of Germany] data gives additional support to our theory. We finally draw the implications of the theory on the incidence of consumption and income (wealth) taxes, and on the recent (inconclusive) tests of intergenerational altruism."

Emission of volatile sulfur compounds from spruce trees

Spruce (Picea Abies L.) trees from the same clone were supplied with different, but low, amounts of plant available sulfate in the soil (9.7-18.1 milligrams per 100 grams of soil). Branches attached to the trees were enclosed in a dynamic gas exchange cuvette and analyzed for the emission of volatile sulfur compounds. Independent of the sulfate supply in the soil, H(2)S was the predominant reduced sulfur compound continuously emitted from the branches with high rates during the day and low rates in the night. In the light, as well as in the dark, the rates of H(2)S emission increased exponentially with increasing water vapor flux from the needles. Approximately 1 nanomole of H(2)S was found to be emitted per mole of water. When stomata were closed completely, only minute emission of H(2)S was observed. Apparently, H(2)S emission from the needles is highly dependent on stromatal aperture, and permeation through the cuticle is negligible. In several experiments, small amounts of dimethylsulfide and carbonylsulfide were also detected in a portion of the samples. However, SO(2) was the only sulfur compound consistently emitted from branches of spruce trees in addition to H(2)S. Emission of SO(2) mainly proceeded via an outburst starting before the beginning of the light period. The total amount of SO(2) emitted from the needles during this outburst was correlated with the plant available sulfate in the soil. The diurnal changes in sulfur metabolism that may result in an outburst of SO(2) are discussed.

A note on the microeconomics of migration

"The purpose of this note is to demonstrate in a simple model that an individual's migration from a small town to a large city may be rationalized purely by a consumption motive, rather than the motive of obtaining a higher income. More specifically, it is shown that in a large city an individual may derive a higher utility from spending a given amount of income than in a small town." A formal model is first developed that includes the principal forces at work and is then illustrated using a graphic example. The theoretical and empirical issues raised are considered in the concluding section.

Ultrastructural morphometric investigations on human platelets after long-term ingestion of oral contraceptives

Platelets from healthy females, who were taking oral contraceptives over a long period of time, were investigated by ultrastructural morphometry. The size, shape, relative volumes, numerical and surface densities of the platelets and their organelles were measured. In 'long-term pill users' the platelets showed a significant increase in the area of section profile. Further changes as, for example, increased volume of platelet granules, reduced number of mitochondria, decreased volume and surface of the open canalicular system, and increased surface of the dense tubular system are to be noted.

Ultrastructural morphometric investigations on normal human liver biopsies

Normal liver biopsies of 14 volunteers were investigated ultrastructural morphometrically. Besides the determination of morphometric baseline data for comparative purposes particular emphasis was placed on the question, if morphometric evaluations of human livers yield reliable results in spite of the higher range of distribution than in experimental liver material. The results showed that the surface of the smooth endoplasmic reticulum of human liver is significantly greater than the surface of rough endoplasmic reticulum. Otherwise the morphometric data of the human liver tissue did not differ essentially to the values of the laboratory rat. The variance analytical consideration of the mean evaluated from the data of the 14 liver biopsies indicated that the standard error of nearly all proved parameters was less than 10% of the mean. The results suggest that ultrastructural morphometric evaluation of human liver biopsy samples yield reliable results provided the samples investigated are sufficiently extensive.

Ultrastructural morphometric investigations on normal human platelets

Platelets from normal human volunteers were investigated by ultrastructural morphometry. Preparation of blood samples was done in two different ways in order to evaluate the possible influence of the preparative method on the size and shape of platelets and their organelles. No significant differences could be dmonstrated for any of the measured parameters. Relative volumes of specific granules, mitochondria and the open canalicular system were calculated according to the method of Weibel. Surface and numerical densities of some compartments were determined. Direct measurements of the long and short axes of the platelets were conducted to ascertain further information about their size and shape. Absolute data are in good agreement with the few reports in the literature.

[Ultrastructural-morphometric investigations on liver biopsies--the influence of oral contraceptives on the human liver (author's transl)]

Liver biopsies from 12 healthy women were investigated morphometrically--according to the methods of Weibel (1969). All women had taken an oral contraceptive agent during 2 til 76 months. The evaluated stereological datas were compared with base-line dates for normal human liver biopsies, which were elaborated in a previous investigation (Roessner et al., 1977). Statistical analysis was performed on an IBM 360/50 computer system, including F- and student's t-test. In the liver biopsy-specimen from the women, which were on oral contraceptives, the volume-density of lysosomes per ml hepatocytes shows a pronounced, significant (p less than 0.001) increase. A moderate increase of cytoplasm is combined with decrease of nuclei-volume. The surface-densities of the rough and smooth endoplasmatic reticulum do not differ significantly from the datas calculated from normal human liver biopsies. All other datas too demonstrate that there are no striking changes in the ultrastructure of human liver, caused by oral contraceptives. Functional alterations however can not be excluded.

One pediatric burn unit's experience with sleepwear-related injuries

Review of the records of 678 children with acute injuries referred during an eight-year period to this burn unit indicated that flame burns from a single ignition source (50%) outranked scalds (27%) or house fires (12%) as causes of injury. There was no temporal trend in the rank pattern. The majority of these single-source flame injuries were severe and involved ignition of the child's clothing. From 1969 through 1973, sleepwear was the clothing involved in 32% of the instances. Since that time and coincident with promulgation of strict federal and state standards for flammability of children's night clothing, a dramatic decline in the number of children, referred with injuries of this type has taken place. It is probable that the single factor most important to the decline, in our experience with these injuries, is lower fabric flammability but, because our data may not be representative, corroboration is needed before one can exclude factors such as altered garment design, fire safety-related practices at home, or changing patterns of hospital referral.