[Continuous lateral rotational bed therapy in patients with traumatic lung injury: an analysis from the TraumaRegister DGU®]. / Die kontinuierliche laterale Rotationstherapie bei Patienten mit Thoraxtrauma: eine Analyse aus dem TraumaRegister DGU®.

BACKGROUND: Patients with severe thoracic trauma often receive continuous lateral rotational bed therapy (CLRT) for the treatment of lung contusions. In this study, the effects of CLRT on mortality, morbidity and length of stay (LOS) in the intensive care unit (ICU) and in the hospital were evaluated. METHODS: Retrospective data from the TraumaRegister DGU® were analysed, focusing on patients with severe thoracic trauma. Patients treated with CLRT were compared to a control group with comparable trauma severity who had received conventional therapy. RESULTS: A total of 1476 patients (239 with CLRT, 1237 without CLRT) were included in this study. Both groups were similar for demographic characteristics. The median CLRT duration was 6 (4-10) days. Patients receiving CLRT were ventilated for 17 (10-26) days compared to 14 (8-22) days (p = 0.001) in the control group. The ICU length of stay differed significantly (CLRT: 23 [14-32] days; control: 19 [13-28] days; p = 0.002). Also, organ failure occurred more frequently in patients treated with CLRT (CLRT: 76.6%, control: 67.6%; p = 0.006). No differences could be detected regarding mortality rates, multiple organ failure and hospital LOS. CONCLUSIONS: The results of this retrospective analysis fail to detect a benefit for CLRT therapy in trauma patients. Considering inherent limitations of retrospective studies, caution should be exerted when interpreting these results. Further research is warranted to confirm these findings in a prospective trial.

Quality of post-operative patient handover in the post-anaesthesia care unit: a prospective analysis.

BACKGROUND: Anaesthesiology plays a key role in promoting safe perioperative care. This includes the perioperative phase in the post-anaesthesia care unit (PACU) where problems with incomplete information transfer may have a negative impact on patient safety and can lead to patient harm. The objective of this study was to analyse information transfer during post-operative handovers in the PACU. METHODS: With a self-developed checklist including 59 items the information transfer during post-operative handovers was documented and subsequently compared with patient information in anaesthesia records during a 2-month period. RESULTS: A total number of 790 handovers with duration of 73 ± 49 s was analysed. Few items were transferred in most of the cases such as type of surgery (97% of the cases), regional anaesthesia (94% of the cases) and cardiac instability (93% of the cases). However, some items were rarely transferred, such as American Society of Anesthesiologists physical status (7% of the cases), initiation of post-operative pain management (12% of the cases), antibiotic therapy (14% of the cases) and fluid management (15% of the cases). There was a slight correlation between amount of information transferred and duration of post-operative handovers (r = 0.5). CONCLUSION: The study shows that post-operative handovers in the PACU are in most cases incomplete. It appears useful to optimise the post-operative handover process, for example by implementing a standardised handover checklist.

Mechanism- and experience-based strategies to optimize treatment response to the capsaicin 8% cutaneous patch in patients with localized neuropathic pain.

The capsaicin 8% cutaneous patch is an emergent new treatment option for patients with peripheral neuropathic pain. In randomized controlled clinical studies relevant pain relief for 12 weeks was achieved in about one third of patients following a single application. The first part of this paper is a review of the pathophysiology, pharmacology, and published clinical trials with the capsaicin 8% cutaneous patch. The second part reports on outcomes of an interdisciplinary expert workshop, where new treatment results of three major German pain centers were presented and reviewed with the objectives of obtaining responder rates for different pain syndromes, assessing maintenance of effect under real-life conditions, and giving recommendations for practical care. The 12 week responder rates with pain relief of ≥ 30% were comparable in patients with mononeuropathies (37.9%) and postherpetic neuralgia (38.8%). Similar responder rates were seen in a subgroup of patients with cervical spine radiculopathy and back pain (46.7%). In HIV-associated neuropathy the responder rates were high (47.8%) but lower in patients with other polyneuropathies (17.6%). Response rates were nearly identical after 1 week (46.6%) and 4 weeks (43.3) and dropped only slightly at 12 weeks (37.4%). In a subgroup of 54 patients who underwent a second treatment, efficacy was maintained. Response rates in patients with or without lidocaine pretreatment were comparable. Treatment with the capsaicin 8% cutaneous patch was generally safe and well tolerated. The workshop panel recommended further investigation of opportunities to improve the application procedure and to perform studies on the skin penetration and distribution of capsaicin. A modified quantitative sensory testing (QST) should be developed for clinical practice in order to better understand the correlation of sensory profiles and response to capsaicin treatment.

[Quality management in acute pain therapy: results from a survey of certified hospitals]. / Qualitätsmanagement in der Akutschmerztherapie : Ergebnisse einer Befragung TÜV-zertifizierter Kliniken.

AIM: Systems for and methods of quality management are increasingly being implemented in public health services. The aim of our study was to analyze the current state of the integrated quality management concept "quality management acute pain therapy" of the TÜV Rheinland® (TÜV) after a 5-year project period. MATERIAL AND METHODS: General characteristics of the participating hospitals, number of departments certified by the TÜV and implementation of structures and processes according to the TÜV guidelines were evaluated by a mail questionnaire. Furthermore, positive and negative aspects concerning the effects of certification were evaluated by the hospitals' representatives of certification. RESULTS: A total of 36 questionnaires were returned. Since 2006 the number of certified hospitals (2011: n = 48) and surgical departments (2011: n = 202) has increased continuously. The number of certified medical departments is low (2011: n = 39); however, in the last 3 years, it has increased by about 200-300% annually. Standard operative procedures for pain therapy and measurement of pain intensity at regular intervals were implemented in all certified clinics (100%). Although 41% take part in the benchmarking project QUIPS (Quality Improvement in Postoperative Pain Therapy), 24% do not systematically check the quality of the outcome of pain management. Acceptance of the new pain therapy concepts among nursing staff was rated positively (ratio positive:negative 16:1); however, acceptance among physicians was rated negatively (1:15). CONCLUSION: Certification by the TÜV leads to sustainable implementation of quality management principles. Future efforts should focus on better integration of physicians in acute pain therapy and the development of an integrated tool to measure patients' outcome.

[Use of the film Keep on the open road in palliative care education of undergraduate medical students : Proof-of-concept study]. / Verwendung des Kinofilms Halt auf freier Strecke in der palliativmedizinischen Pflichtlehre von Medizinstudenten. "Proof-of-concept"-Studie.

OBJECTIVE: Recently palliative care has become an integral and compulsory part of undergraduate medical training in Germany. From 2014 onwards every German medical faculty must have developed and implemented undergraduate teaching in this cross-disciplinary medical field and to conduct examinations. At Witten/Herdecke University (Germany) this new cross-sectional course in palliative care was taught for the first time in 2011. The film "Keep on the open road" was incorporated and the use of this film as part of compulsory palliative care education was evaluated from the student perspective. METHOD: In two teaching units (1.5 h each) the film was watched with the students and discussed in the context of the palliative care setting with a special focus on psychosocial aspects. A semi-quantitative evaluation was performed after the debriefing. RESULTS: A total of 23 students participated in the course, 87 % (n = 20) evaluated the use of the film as unrestricted useful and 14 indicated a benefit from the film in terms of their medical attitude. Most of the students (n = 19, 83%) did not consider bed-side teaching to be more useful than the film unit. The free text answers underlined that primarily the multidisciplinary aspects of a palliative treatment situation and the meaning of a social environment were highlighted by the film. CONCLUSIONS: According to the evaluation of the students and the judgement of the participating teachers the use of the film is a suitable method to clarify complex medical, social and psychological aspects in palliative care. Especially at faculties with much larger numbers of students the film unit is thought to be a helpful method to teach psychosocial aspects and to promote development of attitude in palliative care. In future semesters further experience with the unit and the use of films in palliative care teaching will be collected.

Development of a risk index for the prediction of chronic post-surgical pain.

The incidence of chronic post-surgical pain (CPSP) after various common operations is 10% to 50%. Identification of patients at risk of developing chronic pain, and the management and prevention of CPSP remains inadequate. The aim of this study was to develop an easily applicable risk index for the detection of high-risk patients that takes into account the multifactorial aetiology of CPSP. A comprehensive item pool was derived from a systematic literature search. Items that turned out significant in bivariate analyses were then analysed multivariately, using logistic regression analyses. The items that yielded significant predictors in the multivariate analyses were compiled into an index. The cut-off score for a high risk of developing CPSP with an optimal trade-off between sensitivity and specificity was identified. The data of 150 patients who underwent different types of surgery were included in the analyses. Six months after surgery, 43.3% of the patients reported CPSP. Five predictors multivariately contributed to the prediction of CPSP: capacity overload, preoperative pain in the operating field, other chronic preoperative pain, post-surgical acute pain and co-morbid stress symptoms. These results suggest that several easily assessable preoperative and perioperative patient characteristics can predict a patient's risk of developing CPSP. The risk index may help caregivers to tailor individual pain management and to assist high-risk patients with pain coping.

[Analgesic therapy of calciphylaxis with levomethadone : a case study]. / Analgetische therapie mit levomethadon bei kalziphylaxie : eine kasuistik.

Calciphylaxis, or calcific uremic arteriopathy, is a rare complication of end-stage renal impairment. It is characterized by calcification of arterioles and development of intensely painful subcutaneous ischemic ulcerations. While symptomatic management is the mainstay of treatment, particular emphasis is placed on adequate analgesia. Conventional analgesic concepts have mostly proved to be insufficient which increases the extreme suffering of patients. This case report describes the successful analgesic treatment of calciphylaxis with levomethadone.

[Quality assurance in acute pain therapy : Development of software for the acute pain service]. / Qualitätssicherung in der Akutschmerztherapie : Entwicklung einer Software für den Akutschmerzdienst.

A detailed documentation system is essential for an effectively working acute pain service. Patient-related documentation aids the physician with check lists and algorithms and may thus further improve clinical practice. As adequate software was missing, we developed a database that was first adapted to the in-house conditions, but can also be adjusted to other surroundings. By integrating "one-click documentation" and new codes for clinical observations, a user-friendly software was created that notably improved the quality of documentation. In the first test period more than 30,000 ward rounds were collected, and a considerably improved documentation quality could be achieved.

[Problems and deficits in the transition from inpatient and outpatient care of cancer patients. A qualitative analysis]. / Schnittstellenproblematik beim Ubergang von stationärer zu ambulanter Versorgung von Tumorpatienten. Eine qualitative Analyse.

INTRODUCTION: Problems and deficits in the transition between hospital-based and outpatient care of cancer patients were evaluated. The project was initiated by the Public Health Department of the City of Aachen and was carried out with cooperation from all hospitals in the urban areas. METHOD: From September 2002 to April 2003 a total of 145 cancer patients fulfilling the inclusion criteria from 4 regional hospitals were documented at 4 time points within a period of 6-8 weeks by questionnaires, telephone and personal interviews. Aspects of interest were disease type, symptom burden, well-being, the homecare situation and medical aids required. RESULTS: Patients and their relatives reported on inadequate pain management, insufficient preparation of transition, problems in information flow, organisational problems, lack of attention and humaneness, deficiency of care, delay of diagnosis, inadequate access to services, insufficient prescription of drugs and adjuvants, financial problems and quarrels with the health insurance company on payment of aid devices. Coping strategies were mostly non-functional and not problem-orientated. DISCUSSION: Special attention should be paid to psychosocial and interpersonal needs of patients. Volunteers may have an important role in the care of patients and relatives. The introduction of case managers might lead to an advancement of care. Sensitisation of physicians, nurses and other caregivers for deficits in transition of patients is needed and should be covered in palliative care education and training.

[Treatment discontinuation and obligation to treat: an extended model for the decision-making process]. / Behandlungsabbruch und Behandlungspflicht am Ende des Lebens: Ein erweitertes Modell zur Entscheidungsfindung.

Social developments and medical progress in the last decades have led to a significant change of values in medicine, which spans from the cornerstone of the patient's autonomy to the increasingly difficult decision-making process related to available medical treatments. This conflict exaggerates with end-of-life situations, where a purely palliative approach to the therapy is applied, or in cases of reduced ability for patient's consent. From a legal point of view, many uncertainties have been clarified in recent years. The patient's autonomy has been strengthened, however, the law requires the doctor to review and carefully balance the treatment options so that a new and modified patient-doctor relationship is often necessary in this difficult decision-making process. The doctor should no longer retreat into the classical role of a neutral advisor and leave the complete responsibility of medical decisions to the patient. Instead, in order for the patient to be able to make a balanced and individually tailored autonomous decision, the doctor needs to bring in his medical expertise along with his own personal experiences and personal opinions, as long as he clearly differentiates between personal and professional views. This way the patient will be empowered to make complex medical decisions, considering his personal situation and previous experiences as well as his own set of values. For complex situations medical practitioners can find support from reflection within the treatment team, or through an external ethical advisory panel. Algorithms can be helpful to illustrate the steps in a decision-making process and thus support medical staff in situations of difficult medical decisions.

Effects of furosemide, captopril and indometacin on the renin-angiotensin system and the renal prostaglandins in anesthetized neonatal piglets.

The effects of the diuretic furosemide (CAS 54-31-9) 1 mg/kg bw i.v., of the angiotensin converting enzyme (ACE) inhibitor captopril (CAS 62571-86-2) 1 mg/kg bw p.o. and the prostaglandin synthesis inhibitor indometacin (CAS 53-86-1) 2 mg/kg bw p.o. on kidney function, salt and water excretion, the excretion of renal prostaglandins PGE2, PGF2a, 6-keto-PGF1a, thromboxane B2 (TXB2) and the plasma renin activity (PRA) were investigated on 29 neonatal piglets. Within 1 h, fuorsemide led to pronounced diuresis and natriuresis, to a rise of the glomerular filtration rate (GFR) (which ist low in neonatal pigs) by 1.8 times, increased the excretion of renal prostaglandins (especially the vasoconstrictor, thromboxane B2 (TXB2 and PGF2a) and raised the PRA significantly. Under captopril, the PRA rose significantly, whereas there was no unequivocal change in the excretion of renal prostaglandins. There was a pronounced decline of the sodium and potassium excretion in the urine with a fall in the concentrations of electrolytes in serum and of the hematocrit. Under indometacin, the excretion of all prostaglandins in the urine declined (this decline was most pronounced for PGE2). There was also a decrease in sodium excretion, whereas there was no significant change in PRA. It can be concluded from the results that the effects of the investigated drugs on the pig neonate kidney is at least partially attributable to an influence on hormonal factors.

Urinary prostacyclin and thromboxane A2 metabolites in preterm and full-term infants in relation to plasma renin activity and blood pressure.

The metabolites of prostacyclin and thromboxane A2, 6-ketoprostaglandin F1 alpha and thromboxane B2, were measured in urine of 27 preterm and 21 full-term infants. Their values were analyzed in correlation to plasma renin activity, urinary function, and systolic blood pressure. The 6-ketoprostaglandin F1 alpha excretion was significantly higher in the preterm infants as compared to the full-term infants (p less than 0.001). This decrease of 6-ketoprostaglandin F1 alpha in the full-term infants was associated with a decrease in the plasma renin activity and an increase in systolic blood pressure. In contrast, the urinary excretion of thromboxane B2 was low, without significant difference between the two groups, and there was no correlation to the parameters mentioned above.

Studies of the immaturity of the ADH-dependent cAMP system in conscious newborn piglets--possible impairing effects of renal prostaglandins.

In 24 conscious newborn piglets the effects of 20 micrograms/kg body weight IV 1-deamino-8-D-arginine-vasopressin (DDAVP) in group 1, 5 mg/kg PO indomethacin in group 2, and the combined effects of both drugs in group 3 were studied by measuring urinary flow rate, urinary osmolality, creatinine clearance, total urinary and nephrogenous cyclic-adenosine 3':5'-monophosphate (cAMP) excretion, medullary cAMP content, and renal prostaglandin (PG)E2 and PGF2 alpha, excretion. DDAVP alone had no significant effects on ther above parameters, whereas indomethacin alone reduced only the PG excretion significantly. When both drugs were administered simultaneously, urinary concentration increased significantly (urinary flow rate decreased from 2.4 +/- 0.4 to 1.4 +/- 0.3 ml/hr (means +/- S.E.), and urinary osmolality increased from 444 +/- 29 to 552 +/- 33 mOsm/liter). Total urinary and nephrogenous cAMP excretion increased from 590 +/- 48 to 854 +/- 78 and 302 +/- 36 to 590 +/- 81 pmoles/hr/g kidney weight, respectively, whereas PGE2 and PGF2 alpha decreased from 249 +/- 33 to 19 +/- 4 and 192 +/- 32 to 43 +/- 7 pg/hr/g kidney weight, respectively. In addition, medullary cAMP content was considerably higher in group 3 (2010 +/- 200 pmoles/g medulla) than that observed in the control (1187 +/- 137), DDAVP (1218 +/- 115), and indomethacin (1230 +/- 168) groups.

Effect of antidiuretic hormone and dibutyryl cAMP upon the urinary concentrating capacity in neonatal piglets.

In 18-one-day-old anesthetized piglets, the effects of 1-deamino-8-D-arginine-vasopressin (DDAVP) with and without administration of dibutyryl adenosine 3':5'-monophosphate (DBcAMP) upon the urinary concentrating system were studied. Supramaximal doses of 20 microgram DDAVP per kg body weight did not affect fractional water and fractional urea excretion, urinary flow rate, and relative urinary osmolarity. The same dose combined with DBcAMP (0.2 mg/kg body weight per min) changed these parameters significantly. This increase in the responsiveness of the urinary concentrating system to DDAVP by DBcAMP was paralleled by a significant increase in urinary and plasma cyclic adenosine 3':5'-monophosphate concentration and a tremendous increase in the medullary cyclic adenosine 3':5'-monophosphate content (2.5 X 10(5) pmoles/g medulla) as compared to the controls (6.4 X 10(2) pmoles/g medulla) and the animals which received DDAVP without DBcAMP (8.0 X 10(2) pmoles/g medulla). To exclude the possibility that the increased medullary cyclic adenosine 3':5'-monophosphate production might be caused by degradation of the dibutyryl derivative, in vitro studies with [3H]DBcAMP were performed. Incubation of labeled DBcAMP with a renal medulla homogenate of a 1-day-old piglet for 30, 60, and 90 min did not decrease the amount of [3H]DBcAMP.

Renal prostaglandins: relationship to the development of blood pressure and concentrating capacity in pre-term and full term healthy infants.

The relationships between urinary prostaglandins (PGs)E2 and F2 alpha and the postnatal development of blood pressure and renal concentrating capacity were investigated in 14 pre-term and 32 full term healthy infants. Mean PGE2 and PGF2 alpha excretion was 18.9 and 10.1 ng/h/1.73 m2, respectively, in pre-term infant. In full term infants mean urinary PGE2 was significantly lower (13.4 ng/h/1.73 m2) and PGF2 alpha significantly higher (22.2 ng/h/1.73 m2). The decrease of the PGE2/PGF2 alpha ratio (P less than 0.001) was accompanied by an increase in blood pressure. High PGE2 levels in pre-term infants were inversely correlated with urinary cAMP excretion. A decreasing PGE2/PGF2 alpha ratio in full term infants was associated with increasing urinary osmolality. After intranasal administration of antidiuretic hormone (DDAVP) in 8 full term infants the increase in urinary osmolality and cAMP excretion was accompanied by a drop in PGE2 excretion to less than half the basal values. These findings suggests that the postnatal changes in urinary PG excretion are associated with a concomittant increase in blood pressure and in the concentrating capacity of the neonatal kidney.

Urinary cyclic AMP and renal concentrating capacity in infants.

In 15 infants between 1 and 31 weeks the effect of antidiuretic hormone (ADH) on the renal concentrating capacity and urinary cyclic AMP (cAMP) was tested. A significant decrease of urine flow and a significant increase of osmolality, urea and cAMP was observed indicating that the distal nephron of the infant kidney is responsive to exogenous ADH and that its effect is mediated by cAMP. The results of a second series with 52 normally hydrated infants demonstrate that the nonlinear age-related increase of osmolality and urea in urine is accompanied by a similar pattern of cAMP excretion, pointing out that the maturation of the concentrating capacity seems to be related to an increasing responsiveness of the cAMP system to ADH. Furthermore the results raise the possibility that increasing concentrations of urea and solutes in the medulla and papilla of the infant kidney may have--in the presence of very low ADH secretion--an additional stimulating effect on cAMP formation.

Effects of ADH on the activity and function of the renin-angiotensin-aldosterone system in infants and in children.

In babies ranging in age from 1 to 25 weeks and in children between 1 and 14 years, plasma renin activity and urinary aldosterone activity were determined in relation to urinary sodium excretion. A reciprocal correlation was found demonstrating that the hyperactivity of the renin-angiotensin-aldosterone system is stimulated in infants by a low sodium intake. A second stimulus was observed in the influence of the hypothalamo-neurohypophyseal system, when the plasma renin activity was suppressed by administration of antidiuretic hormone and sodium excretion increased due to a decreased aldosterone activity. Our study suggests that there exists a feedback between the renin-angiotensin-aldosterone system and ADH release and that this feedback plays an important role in the regulation of water and electrolyte balance in the young infant.