[Processed EEG for personalized dosing of anesthetics during general anesthesia]. / Das prozessierte EEG zur personalisierten Dosierung von Anästhetika während Allgemeinanästhesie.

Electroencephalogram (EEG)-guided anesthesia is indispensable in modern operating rooms and has become established as the standard form of monitoring. Many anesthesiologists rely on processed EEG indices in the hope of averting anesthesia-related complications, such as intraoperative awareness, postoperative delirium and other cognitive complications in their patients. This educational review aims to provide information on the five most prevalent monitors used to guide depth of sedation during general anesthesia. This article elucidates the principles underpinning the application of these monitors where known, which are generally based on power in various EEG frequency bands and on the burst suppression pattern. Convinced that EEG-guided anesthesia has the potential of benefitting many surgical patients, it is felt that many basic principles and shortcomings of processed EEG indices need to be better understood in the clinical practice. After discussing the different monitors and clinically relevant data from the literature, the article gives a short practical guidance on how to critically interpret processed EEG information and troubleshooting of confounded indices in the context of clinical situations.

Electronuclear Transition into a Spatially Modulated Magnetic State in YbRh_{2}Si_{2}.

The nature of the antiferromagnetic order in the heavy fermion metal YbRh_{2}Si_{2}, its quantum criticality, and superconductivity, which appears at low mK temperatures, remain open questions. We report measurements of the heat capacity over the wide temperature range 180 µK-80 mK, using current sensing noise thermometry. In zero magnetic field we observe a remarkably sharp heat capacity anomaly at 1.5 mK, which we identify as an electronuclear transition into a state with spatially modulated electronic magnetic order of maximum amplitude 0.1 µ_{B}. We also report results of measurements in magnetic fields in the range 0 to 70 mT, applied perpendicular to the c axis, which show eventual suppression of this order. These results demonstrate a coexistence of a large moment antiferromagnet with putative superconductivity.

Fetal 4D flow MRI of the great thoracic vessels at 3 Tesla using Doppler-ultrasound gating: a feasibility study.

OBJECTIVES: To evaluate the feasibility of Doppler-ultrasound (DUS)-gated 4D flow MRI of the fetal great thoracic vessels at 3T in a clinical setting. METHODS: Sixteen consecutive fetuses (range 30+4-38+5 weeks) with (n = 11) and without (n = 5) cardiovascular anomalies underwent 4D flow MRI of the great thoracic vessels at 3T. Direct fetal cardiac gating was obtained using a MR-compatible DUS device. 4D flow MRI-based visualisation and quantification of four target regions (ascending aorta (AAo), descending aorta (DAo), main pulmonary artery (MPA), and ductus arteriosus (DA)) were performed using dedicated software. RESULTS: Fetal 4D flow MRI of the great thoracic vessels was successful in 12/16 fetuses (75%) by adopting clinical 4D flow MR protocols in combination with direct fetal cardiac DUS-gating. Four datasets were excluded due to artefacts by fetal movement or maternal breathing. 4D flow MRI-derived time-velocity curves revealed typical arterial blood flow patterns in the aorta. 4D flow quantification was achieved for the pre-defined target regions. Average velocity and flow volume were 21.1 ± 5.2 cm/s and 6.0 ± 3.1 mL/s in the AAo, 24.3 ± 6.7 cm/s and 8.4 ± 3.7 mL/s in the DAo, 21.9 ± 6.4 cm/s and 7.8 ± 4.2 mL/s in the MPA, and 23.4 ± 4.7 cm/s and 5.9 ± 3.6 mL/s in the DA, respectively. CONCLUSIONS: Combination of DUS-gating of the fetal heart and 4D flow MRI allows comprehensive visualisation and quantification of haemodynamics in the fetal great thoracic vessels. DUS-gated fetal 4D flow MRI may provide a new diagnostic approach for prenatal assessment of blood flow haemodynamics. KEY POINTS: • Fetal cardiac Doppler-ultrasound (DUS) gating and 4D flow MRI can be successfully combined. • DUS-gated fetal 4D flow MRI allowed visualisation and evaluation of streamline directionality, illustration of blood flow variations, and pulsatile arterial waveforms in the target vessels. • 4D flow MRI-based visualisation and quantification of the fetal great thoracic vessels were successful and flow metrics agreed with echocardiographic reference values.

[The quantitative EEG in electroencephalogram-based brain monitoring during general anesthesia]. / Das quantifizierte EEG im elektroenzephalogrammbasierten Monitoring während Allgemeinanästhesie.

The electroencephalogram (EEG) is increasingly being used in the clinical routine of anesthesia in German-speaking countries. In over 90% of patients the frontal EEG changes somewhat predictably in response to administration of the normally used anesthetic agents (propofol and volatile gasses). An adequate depth of anesthesia and appropriate concentrations of anesthetics in the brain generate mostly frontal oscillations between 8 and 12 Hz as well as slow delta waves between 0.5 and 4 Hz. The frontal EEG channel is well-suited for avoidance of insufficient depth of anesthesia and excessive administration of anesthetics. This article explains the clinical interpretation of the most important EEG patterns and the biophysical background. Also discussed are important limitations and pitfalls for the clinical routine, which the anesthetist should know in order to utilize the EEG as an admittedly incomplete but clinically extremely important parameter for the level of consciousness.

Non-contrast pulmonary perfusion MRI in patients with cystic fibrosis.

PURPOSE: This study aimed to assess the feasibility of Self-gated Non-Contrast-Enhanced Functional Lung (SENCEFUL) MRI for detection of pulmonary perfusion deficits in patients with cystic fibrosis. METHODS: Twenty patients with cystic fibrosis and 20 matched healthy controls underwent SENCEFUL-MRI at 1.5 T with reconstruction of perfusion and perfusion phase maps (i.e. comparable to pulse wave delays). Four blinded readers rated both types of maps separately followed by simultaneous assessment thereof. Perfusion phase data was plotted in histograms and a Peak-to-Offset ratio was calculated for comparison to subjective scoring and correlation (Spearman) to lung function parameters. Sensitivity, specificity and positive and negative predictive values were calculated for subjective scoring and Peak-to-Offset ratios. Intraclass correlation (ICC) was used to assess the interrater agreement. RESULTS: Readers attributed pathological ratings 2.2-3.5 times more frequently to the CF-group. The sensitivity with regard to a correct assignment to CF was similar between ratings (perfusion only vs. perfusions phase only vs. simultaneous assessment: 0.54-0.56), while specificity increased from 0.75 to 0.85 for simultaneous assessment. ICC was 0.77-0.84 for subjective scoring. ROC-analysis of Peak-to-Offset ratios on a mean per-subject basis revealed a sensitivity of 0.75 and specificity of 0.85 (PPV 0.83, NPV 0.77). Functional pulmonary parameters indicative of bronchial obstruction and Peak-to-Offset ratios showed positive correlation (FEV1: 0.77; FEF75: 0.76). CONCLUSIONS: SENCEFUL-MRI bears the potential for monitoring CF including disease-associated patterns of altered pulmonary perfusion. The proposed Peak-to-Offset ratio derived from pulmonary perfusion phase measurements could represent an objective future marker for perfusion impairment.

[Automatic load-distributing band CPR (AutoPulse™) in prone position, feasible?] / Mechanische CPR (AutoPulse™) in Bauchlage, machbar?

BACKGROUND: Due to SARS-CoV­2 respiratory failure, prone positioning of patients with respiratory and hemodynamic instability has become a frequent intervention in intensive care units (ICUs), and even in patients undergoing transfer in an ambulance or helicopter. It has become increasingly important how to perform safe and effective CPR in prone position, achieving both an optimal outcome for the patient and optimal protection of staff from infection. MATERIALS AND METHODS: We conducted feasibility tests to assess the effects of CPR with an automatic load-distributing band (AutoPulse™) in prone position and discussed different aspects of mechanical chest compression (mCPR) in prone position. RESULTS: In supine position, AutoPulse™ generated a constant pressure depth of 3cm at a frequency of 84/min. In prone position, AutoPulse™ generated a constant pressure depth of 2.6cm at a frequency of 84/min. CONCLUSION: We found mCPR to be feasible in manikins in both prone and supine positions.

Limited and localized magmatism in the Central Atlantic Magmatic Province.

The Central Atlantic Magmatic Province (CAMP) is the most aerially extensive magmatic event in Earth's history, but many questions remain about its origin, volume, and distribution. Despite many observations of CAMP magmatism near Earth's surface, few constraints exist on CAMP intrusions at depth. Here we present detailed constraints on crustal and upper mantle structure from wide-angle seismic data across the Triassic South Georgia Rift that formed shortly before CAMP. Lower crustal magmatism is concentrated where synrift sedimentary fill is thickest and the crust is thinnest, suggesting that lithospheric thinning influenced the locus and volume of magmatism. The limited distribution of lower crustal intrusions implies modest total CAMP volumes of 85,000 to 169,000 km3 beneath the South Georgia Rift, consistent with moderately elevated mantle potential temperatures (<1500 °C). These results suggest that CAMP magmatism in the South Georgia Rift is caused by syn-rift decompression melting of a warm, enriched mantle.

Transanal total mesorectal excision for rectal cancer has been suspended in Norway.

BACKGROUND: Transanal total mesorectal excision (TaTME) for rectal cancer has emerged as an alternative to the traditional abdominal approach. However, concerns have been raised about local recurrence. The aim of this study was to evaluate local recurrence after TaTME. Secondary aims included postoperative mortality, anastomotic leak and stoma rates. METHODS: Data on all patients who underwent TaTME were recorded and compared with those from national cohorts in the Norwegian Colorectal Cancer Registry (NCCR) and the Norwegian Registry for Gastrointestinal Surgery (NoRGast). Kaplan-Meier estimates were used to compare local recurrence. RESULTS: In Norway, 157 patients underwent TaTME for rectal cancer between October 2014 and October 2018. Three of seven hospitals abandoned TaTME after a total of five procedures. The local recurrence rate was 12 of 157 (7·6 per cent); eight local recurrences were multifocal or extensive. The estimated local recurrence rate at 2·4 years was 11·6 (95 per cent c.i. 6·6 to 19·9) per cent after TaTME compared with 2·4 (1·4 to 4·3) per cent in the NCCR (P < 0·001). The adjusted hazard ratio was 6·71 (95 per cent c.i. 2·94 to 15·32). Anastomotic leaks resulting in reoperation occurred in 8·4 per cent of patients in the TaTME cohort compared with 4·5 per cent in NoRGast (P = 0·047). Fifty-six patients (35·7 per cent) had a stoma at latest follow-up; 39 (24·8 per cent) were permanent. CONCLUSION: Anastomotic leak rates after TaTME were higher than national rates; local recurrence rates and growth patterns were unfavourable.

ANTECEDENTES: La resección total del mesorrecto transanal (transanal total mesorectal excision, TaTME) para el cáncer de recto se ha propuesto como una alternativa al abordaje abdominal tradicional. Sin embargo, la recidiva local (local recurrence, LR) después de este procedimiento es motivo de preocupación. El objetivo de este estudio fue evaluar la LR en pacientes operados mediante TaTME. Los objetivos secundarios incluyeron la mortalidad postoperatoria, las fugas anastomóticas y el porcentaje de estomas. MÉTODOS: Se registraron los datos de todos los pacientes operados mediante TaTME y se compararon con las cohortes nacionales del Registro Noruego de Cáncer Colorrectal (Norwegian Colorectal Cancer Registry, NCCR) y del Registro Noruego de Cirugía Gastrointestinal (Norwegian Registry for Gastrointestinal Surgery, NoRGast) utilizando estimaciones de Kaplan-Meier y la prueba de log-rank para comparar curvas de LR. RESULTADOS: En Noruega, 157 pacientes se sometieron a TaTME por cáncer de recto entre octubre de 2014 y octubre de 2018. Tres de siete hospitales abandonaron el TaTME después de un total de cinco procedimientos. La LR observada fue 12/157 (7,6%), siendo ocho de ellas multifocales o extensas. La tasa estimada de LR a 2,4 años fue de 11,6 % (i.c. del 95% 6,6 a 19,9) versus 2,4 % (1,4 a 4,3) en el NCCR (log rank P < 0,001). El cociente de riesgos instantáneos (hazard ratio, HR) ajustado fue 6,7 (i.c. del 95% 2,9 a 15,3). Las fugas anastomóticas que precisaron una reintervención después de TaTME ocurrieron en un 8,4% versus 4,5% en el registro NoRGast (P = 0,047). Cincuenta y seis pacientes (35,7%) tenían un estoma en el último seguimiento; 39 (24,8%) eran permanentes. CONCLUSIÓN: Las tasas de fuga anastomótica tras una TaTME fueron más altas que los datos nacionales con tasas de LR y patrones de crecimiento desfavorables.

Estimates of calf starter energy affected by consumption of nutrients. 2. Effect of changing digestion on energy content in calf starters.

Apparent total-tract digestibility data from 3 published studies with calves from 0 to 4 mo of age were used to evaluate National Research Council (NRC; 2001) estimates of digestible energy (DE) and metabolizable energy (ME) in calf starters (CS). Calves (n = 83) or pens of calves (n = 24) were used in model development. In each study, 48 Holstein bull calves (2-3 d of age at initiation of each study) were fed varying amounts of milk replacer with CS and water for ad libitum consumption. Calf starters varied in nutrient composition and physical form (pelleted, textured, or mixed with 5% grass hay and fed as a total mixed ration). Apparent total-tract digestibility was measured at various ages. Feed and feces were collected from 20 calves per trial during 5-d collection periods during the first 56 d of each trial. In 2 studies, calves were grouped in pens (4 calves/pen) for a second 56-d measurement period. Fecal collections were repeated occasionally during the second period. Total-tract digestibilities (n = 207) of neutral detergent fiber, nonfiber carbohydrates (NFC), crude protein (CP), and fat were used to calculate ME in CS using equations from the 2001 Dairy NRC. Contributions of digestible CP and fat from milk replacer before weaning were estimated using nonlinear regression and removed from estimates of fat and CP digestibility in CS. Digestion of most nutrients in CS and calculated DE and ME in CS were low early in life and increased with increasing cumulative NFC intake. The natural logarithm of cumulative NFC intake, measured from d 0 to the end of each digestibility period, accounted for more variation in CS nutrient digestibilities, DE and ME estimates compared with daily NFC intake or intake of other nutrients, intake of milk replacer, or age of calf. Calculated ME values in CS were similar to those predicted by NRC after calves consumed approximately 15 kg of cumulative NFC or 28 kg of cumulative dry matter intake (assuming 53% NFC in CS). Current estimates of energy in CS fed to 4 mo of age may overestimate contribution of dry feed to overall energy metabolism in young calves.

Estimates of calf starter energy affected by consumption of nutrients. 1. Evaluation of models to predict changing digestion on energy content in calf starters.

Apparent total-tract digestibility data from 3 published studies with calves from 0 to 4 mo of age were used to evaluate National Research Council (2001) estimates of metabolizable energy (ME) in calf starters (CS). Calves (n = 83) or pens of calves (n = 24) were used in model development. In each study, 48 Holstein bull calves (2 to 3 d of age at initiation of each study) were fed varying amounts of milk replacer with CS and water for ad libitum consumption. Calf starters varied in nutrient content and form (pelleted, texturized, or mixed with 5% grass hay and fed as a total mixed ration). Apparent total-tract digestibility was measured at various ages from 3 to 16 wk. Feed and feces were collected from 20 calves per trial during 5-d collection periods during the first 56 d of each trial. In 2 studies, calves were grouped in pens (4 calves/pen) for a second 56-d measurement period. Fecal collections were repeated occasionally during the second period. Total-tract digestibilities (n = 207) of neutral detergent fiber, nonfiber carbohydrates, crude protein, and fat were used to calculate digestible energy (DE) and ME in CS using equations from the 2001 Dairy National Research Council. Three modeling approaches were constructed to evaluate changing digestion of nutrients, DE, and ME in CS, including linear mixed models, broken-line regression, and exponential models. Linear mixed models provided best model fit statistics for digestion of crude protein, ether extract, neutral detergent fiber, and ME. Exponential models were optimal for digestion of dry matter and nonfiber carbohydrates. Linear mixed models were selected for evaluation of effects of intake on changing nutrient digestion from CS and amount of DE and ME available at various ages.

Relationships between starch concentration of dry feed, diet digestibility, and growth of dairy calves up to 16 weeks of age.

Our objective was to examine the potential relationship between starch concentration of dry feed and growth performance of young dairy calves via mixed-effects model analyses. A database was developed from 6 published studies conducted at the Nurture Research Center, Provimi (Brookville, OH), from 2008 to 2017 that included 18 dietary treatments and 372 calves at 0 to 8 wk of age in 5 nursery trials and 26 dietary treatments and 660 calves at 8 to 16 wk of age in 8 grower trials. The dry feeds ranged from 10.1 to 53.3% starch, 12.1 to 45.3% neutral detergent fiber, and 2.7 to 3.0 Mcal/kg of metabolizable energy [dry matter (DM) basis]. In all nursery trials, with increasing starch concentration in starter, average daily gain (ADG), hip width change, and starter intake linearly increased. In all grower trials, as starch concentration of dry feed increased, ADG, hip width change, and ADG/DM intake linearly increased; DM intake and DM intake/body weight were unaffected. In addition, the calves at 6 to 16 wk of age had greater digestibility of DM and crude protein with increasing starch concentration of dry feed. As indicated by meta-regression analysis, growth responses to starch concentration were influenced by metabolizable energy concentration in dry feed fed to the calves up to 16 wk of age. Changing starch from 23 to 43% on a DM basis (a typical range in the US industry) was predicted to increase ADG and hip width change by 5.8 and 5.0%, respectively, for calves at 0 to 8 wk of age and by 9.6 and 11.2%, respectively, for calves at 8 to 16 wk of age. Positive linear relationships between starch concentration of dry feed with DM digestibility, ADG, and hip width change reflect the importance of starch in the diets of young dairy calves.

[Resuscitative endovascular balloon occlusion of the aorta : Option for incompressible trunk bleeding?] / "Resuscitative endovascular balloon occlusion of the aorta" : Option für nichtkomprimierbare Körperstammblutungen?

Hemorrhage is the single largest cause of avoidable death in trauma patients, whereby in civil emergency medicine in Europe most life-threatening hemorrhages occur in the abdomen and the pelvis. This is one reason why endovascular balloon occlusion of the aorta (EBOA), a procedure especially established in vascular surgery, is increasingly propagated for rapid bleeding control in these patients. This review article provides a comprehensive overview of the technique, indications, contraindications and complications of resuscitative endovascular balloon occlusion of the aorta (REBOA). Additionally, outcomes reported in in the currently available literature are summarized and discussed. From this practical and user-oriented consequences for future successful introduction of REBOA in the field of emergency medicine are deduced.

Application Efficacy of Vectobac WDG Against Larval Aedes aegypti Using Thermal Fog Technology.

The effectiveness of thermal fog application of Bacillus thuringiensis israelensis (Vectobac® WDG) against larval Aedes aegypti was evaluated in open and forest canopied environments in northeastern Florida, using a handheld IGEBA® TF34 thermal fogger (with water conversion kit). The product was applied at the maximum label rate of 1 kg/ha to linear transects, in each environment, containing empty 0.5-liter cups. After application, late-2nd to early-3rd instars of Ae. aegypti were added to each cup. Complete larval mortality occurred 48 h after treatment, 8 m away from the spray line in the open field while 63.4% larval mortality was achieved at this same distance in the forest canopy at 72 h posttreatment. Operational efficacy was then evaluated in an urban tropical environment in Key West, FL. In this study, empty plastic cups were placed in cryptic areas of a commercial lobster and crab trap yard. The 0.1-ha area was treated with Vectobac WDG at the maximum label rate using the same equipment. Aedes aegypti larval mortality from treated cups was >99% at 24 h posttreatment, whereas complete mortality was achieved at 48 h after application.

Effects of combined helium pre/post-conditioning on the brain and heart in a rat resuscitation model.

BACKGROUND: The noble gas helium induces cardio- and neuroprotection by pre- and post-conditioning. We investigated the effects of helium pre- and post-conditioning on the brain and heart in a rat resuscitation model. METHODS: After approval by the Animal Care Committee, 96 Wistar rats underwent cardiac arrest for 6 min induced by ventricular fibrillation. Animals received 70% helium and 30% oxygen for 5 min before cardiac arrest and for 30 min after restoration of spontaneous circulation (ROSC). Control animals received 70% nitrogen and 30% oxygen. Hearts and brains were excised after 2, 4 h or 7 days. Neurological degeneration was evaluated using TUNEL and Nissl staining in the hippocampal CA-1 sector. Cognitive function after 7 days was detected with the tape removal test. Molecular targets were measured by infrared western blot. Data are shown as median [Interquartile range]. RESULTS: Helium treatment resulted in significantly less apoptosis (TUNEL positive cells/100 pixel 73.5 [60.3-78.6] vs.78.2 [70.4-92.9] P = 0.023). Changes in Caveolin-3 expression in the membrane fraction and Hexokinase-II in the mitochondrial fraction were observed in the heart. Caveolin-1 expression of treated animals significantly differed from control animals in the membrane fraction of the heart and brain after ROSC. CONCLUSION: Treatment with helium reduced apoptosis in our resuscitation model. Differential expression levels of Caveolin-1, Caveolin-3 and Hexokinase II in the heart were found after helium pre- and post-conditioning. No beneficial effects were seen on neurofunctional outcome.

[Approaches to pre-hospital bleeding management : Current overview on civilian emergency medicine]. / Ansätze zur prähospitalen Gerinnungstherapie : Aktuelle Übersicht für die zivile Notfallmedizin.

Severe bleeding is a typical result of traumatic injuries. Hemorrhage is responsible for almost 50% of deaths within the first 6 h after trauma. Appropriate bleeding control and coagulation therapy depends on an integrated concept of local hemostasis by primary pressure with the hands, compression, and tourniquets accompanied by prevention of hypothermia, acidosis and hypocalcemia. Additionally, permissive hypotension is accepted for suitable patients and tranexamic acid should be administered early. Multiple publications prove that prehospital transfusion of blood products (e. g. red blood cells and plasma) and coagulation factors (e. g. fibrinogen) is feasible and safe, but only required for <5% of polytrauma patients in the civilian setting.

BEESCOUT: A model of bee scouting behaviour and a software tool for characterizing nectar/pollen landscapes for BEEHAVE.

Social bees are central place foragers collecting floral resources from the surrounding landscape, but little is known about the probability of a scouting bee finding a particular flower patch. We therefore developed a software tool, BEESCOUT, to theoretically examine how bees might explore a landscape and distribute their scouting activities over time and space. An image file can be imported, which is interpreted by the model as a "forage map" with certain colours representing certain crops or habitat types as specified by the user. BEESCOUT calculates the size and location of these potential food sources in that landscape relative to a bee colony. An individual-based model then determines the detection probabilities of the food patches by bees, based on parameter values gathered from the flight patterns of radar-tracked honeybees and bumblebees. Various "search modes" describe hypothetical search strategies for the long-range exploration of scouting bees. The resulting detection probabilities of forage patches can be used as input for the recently developed honeybee model BEEHAVE, to explore realistic scenarios of colony growth and death in response to different stressors. In example simulations, we find that detection probabilities for food sources close to the colony fit empirical data reasonably well. However, for food sources further away no empirical data are available to validate model output. The simulated detection probabilities depend largely on the bees' search mode, and whether they exchange information about food source locations. Nevertheless, we show that landscape structure and connectivity of food sources can have a strong impact on the results. We believe that BEESCOUT is a valuable tool to better understand how landscape configurations and searching behaviour of bees affect detection probabilities of food sources. It can also guide the collection of relevant data and the design of experiments to close knowledge gaps, and provides a useful extension to the BEEHAVE honeybee model, enabling future users to explore how landscape structure and food availability affect the foraging decisions and patch visitation rates of the bees and, in consequence, to predict colony development and survival.

SAPHIRE: Stress and Pulmonary Hypertension in Rheumatoid Evaluation-A Prevalence Study.

Pulmonary artery hypertension (PAH) is a disorder of elevated resistance in the pulmonary arterial vessels, reflected by elevation of measured pulmonary artery pressure (PAP), and presenting with breathlessness and, if untreated, progressing to right heart failure and death. The heightened prevalence of PAH in populations with underlying systemic autoimmune conditions, particularly scleroderma and its variants, is well recognised, consistent with the proposed autoimmune contribution to PAH pathogenesis, along with disordered thrombotic, inflammatory, and mitogenic factors. Rheumatoid arthritis (RA) is one of a group of systemic autoimmune conditions featuring inflammatory symmetrical erosive polyarthropathy as its hallmark. This study explored the prevalence of PAH in a population of unselected individuals with RA, using exercise echocardiography (EchoCG). The high prevalence of EchoCG-derived elevation of PAP (EDEPP) in this population (14%) suggests that, like other autoimmune conditions, RA may be a risk factor for PAH. Patients with RA may therefore represent another population for whom PAH screening with noninvasive tools such as EchoCG may be justified.

[Anesthesiological approach to postpartum hemorrhage]. / Anästhesiologisches Vorgehen bei peripartaler Blutung.

Peripartum hemorrhage (PPH) is a frequent obstetric emergency situation with increasing incidence in the last decades. It requires a fast, coordinated and interdisciplinary management. This life-threatening situation is often recognized too late and not adequately treated (too little is done too late); therefore, it is important to be aware of the most important risk factors for PPH known as the 4 Ts (i.e. tonus, trauma, tissue and thrombin). Due to the special patient population there is only little evidence-based data on hemostatic therapy in this situation; therefore, the currently available studies on the therapy of PPH is discussed.

Clinical epidemiology of human AE in Europe.

This review gives a critical update of the situation regarding alveolar echinococcosis (AE) in Europe in humans, based on existing publications and on findings of national and European surveillance systems. All sources point to an increase in human cases of AE in the "historic endemic areas" of Europe, namely Germany, Switzerland, Austria and France and to the emergence of human cases in countries where the disease had never been recognised until the end of the 20th century, especially in central-eastern and Baltic countries. Both increase and emergence could be only due to methodological biases; this point is discussed in the review. One explanation may be given by changes in the animal reservoir of the parasite, Echinococcus multilocularis (increase in the global population of foxes in Europe and its urbanisation, as well as a possible increased involvement of pet animals as definitive infectious hosts). The review also focuses onto 2 more original approaches: (1) how changes in therapeutic attitudes toward malignant and chronic inflammatory diseases may affect the epidemiology of AE in the future in Europe, since a recent survey of such cases in France showed the emergence of AE in patients with immune suppression since the beginning of the 21st century; (2) how setting a network of referral centres in Europe based on common studies on the care management of patients might contribute to a better knowledge of AE epidemiology in the future.