["Why mothers die". Learning from the analysis of anaesthesia-related maternal deaths (1985-2013)]. / "Why mothers die". Was wir von der Analyse anästhesiebedingter mütterlicher Sterbefälle (1985-2013) gelernt haben.

Every day, more than 800 women die from causes related to pregnancy or childbirth. Since 1952 the Confidential Enquiry of Maternal Deaths Reports (CEMD) have collected and analysed data on maternal mortality in the United Kingdom and Northern Ireland. This publication analyses the CEMD from 1985-2013 regarding anaesthesia- and analgesia related maternal deaths during pregnancy or peripartum. During this period, there has been a reduction in directly anaesthesia-related maternal deaths to 4.3%. Yet, an increase in anaesthesia-associated maternal deaths has been recorded. The rate of fatal complications during obstetric regional anaesthesia doubled in recent years, while the fatality risk for obstetric general anaesthesia has decreased. Many of the reported maternal deaths could presumably have been avoided. The anaesthesiologist has to be familiar with state-of-the-art, guideline-based concepts for anaesthesia during pregnancy, childbirth or post partum, especially using tools like simulation. Vital sign monitoring after obstetric anaesthesia has to be identical to other postoperative monitoring, and Modified Early Warning Scores should be used for this purpose. In regional anaesthesia, current standards for hygiene have to be adhered to and patients have to be visited after spinal/epidural anaesthesia. Interdisciplinary communication and collaboration still have to be improved; careful interdisciplinary planning of childbirth in high-risk obstetric patients is strongly advised.

[Patient safety in anesthesiology : Multimodal strategies for perioperative care]. / Patientensicherheit in der Anästhesie : Multimodale Strategien für die perioperative Versorgung.

The concept of patient safety is more of a presence in modern day medicine than ever before. All measures and processes aiming at preempting and preventing critical incidents and accidents in patient care are collectively grouped under this concept. With the Declaration of Helsinki in 2010 modern anesthesiology has undertaken a fundamental role in the clinical implementation and perioperative clinicians are confronted with a multitude of theories, models, methods and tools targeted at improving or facilitating optimized patient safety. One of the biggest challenges lies in their synergistic combination to create a functioning concept for perioperative risk management while also incorporating individual strengths and weaknesses. The aim of the present paper is to provide a structured overview of the various components presently available for increasing perioperative patient safety.

Wiki-based clinical practice guidelines for the management of adult onset sarcoma: a new paradigm in sarcoma evidence.

In 2013 Australia introduced Wiki-based Clinical Practice Guidelines for the Management of Adult Onset Sarcoma. These guidelines utilized a customized MediaWiki software application for guideline development and are the first evidence-based guidelines for clinical management of sarcoma. This paper presents our experience with developing and implementing web-based interactive guidelines and reviews some of the challenges and lessons from adopting an evidence-based (rather than consensus-based) approach to clinical sarcoma guidelines. Digital guidelines can be easily updated with new evidence, continuously reviewed and widely disseminated. They provide an accessible method of enabling clinicians and consumers to access evidence-based clinical practice recommendations and, as evidenced by over 2000 views in the first four months after release, with 49% of those visits being from countries outside of Australia. The lessons learned have relevance to other rare cancers in addition to the international sarcoma community.

Quasiballistic transport of Dirac fermions in a Bi2Se3 nanowire.

Quantum coherent transport of surface states in a mesoscopic nanowire of the three-dimensional topological insulator Bi(2}Se(3) is studied in the weak-disorder limit. At very low temperatures, many harmonics are evidenced in the Fourier transform of Aharonov-Bohm oscillations, revealing the long phase coherence length of spin-chiral Dirac fermions. Remarkably, from their exponential temperature dependence, we infer an unusual 1/T power law for the phase coherence length L(φ)(T). This decoherence is typical for quasiballistic fermions weakly coupled to their environment.

Lower shedding of strongylid eggs by Warmblood horses with recurrent airway obstruction compared to unrelated healthy horses.

An association between equine recurrent airway obstruction (RAO) and increased resistance to intestinal parasites has been demonstrated in descendants of an RAO-affected stallion. It was hypothesised that members of another high-incidence RAO family (F) and unrelated RAO-affected Warmblood horses (UA) would shed fewer strongylid eggs than unrelated RAO-unaffected pasture mates (PM) under the same environmental conditions. Faecal worm egg counts were performed on faecal samples (63 F, 86 UA, 149 PM) and classified into three categories: 0, 1-100 and >100 eggs per gram. While results for F did not differ from PM, UA were 2.5-times less likely to shed strongylid eggs than PM. RAO-affected Warmblood horses may be more resistant to strongylid nematodes than unrelated unaffected pasture mates and a family history of RAO does not necessarily confer protection against helminth infections.

Increased parasite resistance and recurrent airway obstruction in horses of a high-prevalence family.

BACKGROUND: Equine recurrent airway obstruction (RAO) shares many characteristics with human asthma. In humans, an inverse relationship between susceptibility to asthma and resistance to parasites is suspected. HYPOTHESIS/OBJECTIVES: Members of a high-incidence RAO half-sibling family (F) shed fewer strongylid eggs compared with RAO-unaffected pasture mates (PM) and that RAO-affected horses shed fewer eggs than RAO-unaffected half-siblings. ANIMALS: Seventy-three F and 73 unrelated, age matched PM. METHODS: Cases and controls kept under the same management and deworming regime were examined. Each individual was classified as RAO affected or RAO unaffected and fecal samples were collected before and 1-3 weeks and 3 months after deworming. Samples were analyzed by combined sedimentation-flotation and modified McMaster methods and classified into 3 categories of 0 eggs per gram of feces (EpG), 1-100 EpG, and > 100 EpG, respectively. RESULTS: PM compared with RAO-affected F had a 16.7 (95% confidence interval [CI]: 2.0-136.3) times higher risk for shedding > 100 EpG compared with 0 EpG and a 5.3 (95% CI: 1.0-27.4) times higher risk for shedding > 100 EpG compared with 0 EpG. There was no significant effect when RAO-unaffected F were compared with their PM. RAO-unaffected compared with RAO-affected offspring had a 5.8 (95% CI: 0.0-1.0) times higher risk for shedding 1-100 EpG. Age, sex, breed, and sharing pastures with other species had no significant confounding effects. CONCLUSION AND CLINICAL IMPORTANCE: RAO is associated with resistance against strongylid parasites in a high-prevalence family.

Evaluation and comparison of two prognostic scores and the physicians' estimate of survival in terminally ill patients.

BACKGROUND: Most terminally ill patients request information about their remaining life span. Professionals are not generally willing to provide prognosis on survival, even though they are expected to be able to do so from their clinical experience. This study aims to find out whether the standardized instruments Palliative Prognostic Index (PPI) and the Palliative Prognostic Score (PaP-S) are appropriate, specific, and sensitive to estimate survival time in patients receiving inpatient palliative care in Germany. METHOD: PPI and PaP-S were assessed in addition to the core documentation data set of the Hospice and Palliative Care Evaluation for patients admitted to the palliative care units in Aachen, Bonn, and Cologne. Time of survival was assessed with repeated phone calls to the family and was defined as the difference between the day of completion of the instruments (excluded) and the day of death (included). RESULTS: Survival time was compared with physicians' estimations and prognostic scores in 83 patients. Whereas the estimates of the PPI and the PaP-S correlate highly, even higher correlations are found for the physicians' prognosis and the scores. Correlations between survival time and the prognostic scores or physicians' prognosis were lower. Physicians' estimations overestimated survival time on average fourfold. Estimations were more often correct for very good and very bad prognosis. DISCUSSION: The prognostic scores are not able to produce a precise reliable prognosis for the individual patient. Nevertheless, they can be used for ethical decision making and team discussions. Estimating survival time from clinical experience seems to be easier for very bad or very good prognosis for physicians.

Treatment and outcome of radiation-induced soft-tissue sarcomas at a specialist institution.

BACKGROUND: Radiation-induced sarcoma (RIS) is a rare late complication of therapeutic irradiation with a reputation for aggressive pathology and poor outcome. METHODS: We retrospectively reviewed histopathological features, surgery and outcome in 67 patients with RIS treated between 1990 and 2005 at a single tertiary referral center. RESULTS: Previous breast cancer was the most common indication for radiotherapy. The median interval from irradiation to development of RIS of was 11 years (3-36 years). Median tumour size was 7 cm with 56% classified as high grade, 31% intermediate grade and 13% low grade. The commonest histology was leiomyosarcoma. The only relationship for histology with site was for angiosarcoma (n=9), all of which developed on the chest wall/breast after irradiation for breast cancer. Of 67 patients, 34 underwent potentially curative surgery, and microscopically clear margins were achieved in 75% of cases. Pedicled or free tissue transfer was required in 12 patients and abdominal or chest wall mesh reconstructions were required in 8 patients. No patient received adjuvant radiotherapy but 7 received adjuvant/neoadjuvant chemotherapy. Median follow up is 53 months. Median sarcoma specific survival was 54 months (2- & 5-year survival: 75% & 45%). The local relapse rate was 65%. Negative histopathological margins were a significant predictor of sarcoma specific survival (HR 3.0 95% CI 1.1-8.6 p=0.04). Grade and size of tumour approached, but did not attain significance. CONCLUSION: RIS is a biologically aggressive tumour with high rates of local relapse despite aggressive attempts at curative surgery.

Surgical management of soft tissue sarcoma in patients over 80 years.

AIMS: To report outcome on patients over 80years of age with soft tissue sarcoma (STS), with respect to surgical treatment, co-morbidity, complications and survival. METHODS: From a prospective database of 3400 patients with STS presenting over a 13-year period, all patients over 80years of age were identified and reviewed, with respect to tumour characteristics morbidity, mortality and outcome. RESULTS: 128 patients over 80years were treated for STS with 63 referred for treatment of primary disease, of whom 50 underwent resectional surgery. The remaining 65 patients were treated for recurrent or incompletely excised disease. Of the 50 patients treated primarily with surgery, 56% of tumours where high grade and 56% were greater than 10cm in diameter. The overall complication rate was 34%, with a 30-day mortality of 4%. Two- and 5-year survival rates were 56% and 46%, with a local recurrence rate of 22% at a mean follow-up of 22months. CONCLUSION: This patient group presented with poor prognosis tumours that were associated with poor outcomes in the medium to long term. Age need not be considered a contra-indication to radical surgery with curative intent.

A description of the standardized measurement procedures and recommended threshold limit values for biological hazards in Germany.

On the basis of EU directives 89/391/EEC (to encourage improvements in the safety and health of workers at work) and 2000/54/EC (on the protection of workers from risks related to exposure to biological agents at work), biological hazards at work have to be assessed and preventive measures have to be introduced in all member states of the EU. In Germany, national legislation (Biological Agents Ordinance - BioStoffV and Technical Rules on Biological Agents, TRBA) and recommendations of workers' compensation boards define standardized methods for the assessment of airborne mold, bacteria, and endotoxins. This article describes policies and practices in Germany for measurement of airborne bioaerosols and for interpretation of measurements relative to the standards. As an example, methods and results of measurements in agriculture are shown. The standardized measurement procedures proved suitable for use in livestock buildings. The results of the exploratory measurements in different livestock buildings confirmed the often high concentrations of airborne biological hazards in agriculture that are reported in the literature.

Surgical management of primary and recurrent retroperitoneal liposarcoma.

BACKGROUND: Surgery plays a dominant role in the initial and subsequent treatment of retroperitoneal liposarcoma (RPLS). This study was a review of outcomes of patients treated at the Royal Marsden Hospital. METHODS: Records of all patients who had surgery for RPLS since 1990 were reviewed, with particular attention to local recurrence and disease-specific survival. Patients with primary RPLS and those with recurrent RPLS, who had palliative surgery after a variable number of operations performed elsewhere, were considered separately. RESULTS: Seventy-two patients had surgery for primary RPLS, over half of whom underwent resection of a contiguous organ to achieve clearance. Follow-up of at least 12 months was available for 58 patients. Thirty-four patients had no evidence of recurrence after median follow-up of 26 (range 12-151) months. Low-grade tumour and macroscopic clearance of tumour were significantly associated with a reduced risk of local recurrence and improved survival. Forty-seven patients had palliative surgery for recurrent RPLS. Median survival from time of last operation to death was 27 (range 0-79) months. Follow-up was to a median of 68 (range 14-261) months. CONCLUSION: Patients with low-grade RPLS that has been completely resected at the initial operation have the most favourable prognosis. Palliative resection is worthwhile to treat troublesome symptoms of recurrence.

Pneumoperitoneum and peritoneal surface changes: a review.

BACKGROUND: Recent evidence suggests that the use of carbon dioxide to create a pneumoperitoneum during laparoscopy can lead to adverse structural, metabolic, and immune derangements within the peritoneal cavity, and that these can be dependent on the specific insufflation gas used. These changes include structural alterations in the mesothelial lining, pH disturbances, and alterations in peritoneal macrophage responsiveness. This contrasts with an apparent systemic benefit associated with laparoscopic, as compared with open, surgery. METHODS: Recently published clinical and experimental studies related to the effect of pneumoperitoneum on the peritoneal surface are reviewed, and their relevance is discussed. RESULTS: Structural changes in the peritoneal mesothelial surface layer such as widening of the intercellular junctions can be demonstrated with electron microscopy. Acidification of the peritoneum in response to carbon dioxide insufflation occurs not only at the peritoneal surface, but also in the underlying connective tissue, resulting in disturbances in the electrical surface charge and the release of various immune mediators such as endotoxin. Pneumoperitoneum also affects the local peritoneal immune environment resulting in alterations in cytokine production and phagocytic function, as well as diminished antitumor cell cytotoxicity. CONCLUSIONS: Ultrastructural, metabolic, and immune alterations are observed at the peritoneal surface in response to a pneumoperitoneum. Experimental evidence suggests that these changes are carbon dioxide-specific effects. The consequences of these alterations to the local peritoneal environment are not well understood, but they may facilitate tumor implantation within the peritoneal cavity and adversely affect the ability to clear intraperitoneal infections. Further investigation into this area is warranted.

Excision of laparoscopic port sites increases the likelihood of wound metastases in an experimental model.

BACKGROUND: Case reports of patients developing tumor metastases at port sites following laparoscopic surgery have prompted the development of preventive strategies to address this potential problem, including local excision of the port sites. While it has been suggested that this strategy could be used clinically, its efficacy has not been established. METHODS: Twenty four immune-competent Dark Agouti rats underwent laparoscopy and standardized intraperitoneal laceration of an implanted abdominal flank tumor, using an established laparoscopic cancer model. Rats were randomized to either control (n = 12) or wound excision (n = 12) groups. Both groups underwent laparoscopy using carbon dioxide (CO2) insufflation and two mini-laparoscopy ports. In the wound excision group, one of the port site wounds was excised following desufflation of the abdominal cavity. One week later, the port site wounds were excised for histological examination. RESULTS: Wound involvement with tumor was significantly more common following wound excision than with untreated control wounds (nine of 12 vs two of 12, p = 0.002). In the wound excision group, tumor metastases arose preferentially in the excised port site wound. CONCLUSION: This study suggests that excision of laparoscopy port site wounds following laparoscopic surgery for cancer does not prevent the subsequent development of port site tumors. Furthermore, the excision of port sites may actually increase the risk of tumor metastases arising in port sites, suggesting that the clinical application of this strategy should be avoided pending further evaluation.

Oncologic implications of laparoscopic and open surgery.

Although instrumental manipulation and mechanical tumor cell spillage seem to play the major role in port-site metastases from laparoscopic cancer surgery, minimally invasive procedures are used more and more in the resection of malignancies. However, port-site metastases also have been reported after resection of colon cancer in International Union Against Cancer (UICC) stage I [2, 14]. Therefore, changes in the peritoneal environment during laparoscopy also might influence intra- and extraperitoneal tumor growth during laparoscopy and pneumoperitoneum. Different results of experimental studies presented at the Third International Conference for Laparoscopic Surgery are analyzed and discussed.

Helium and other alternative insufflation gases for laparoscopy.

BACKGROUND: Carbon dioxide (CO(2)) is currently the insufflation gas of choice for laparoscopy. It fulfills most of the requirements for an ideal insufflation gas, being colorless, noninflammable, and rapidly excreted from the circulation. However, its use is associated with adverse cardiorespiratory effects, especially in patients with preexisting cardiorespiratory compromise. METHODS: The descriptive review of relevant literature, moreover, has been proposed that it increases the incidence of port site (wound) metastases from abdominal cancers when used during oncological surgery. In addition, it may cause postoperative pain due to peritoneal irritation, and its use is associated with physiological and immunological impairment. Hence, there is scope for the investigation of alternative insufflation gases. Other possibilities include gasless laparoscopy, helium, nitrous oxide, (N(2)O), and argon. Helium insufflation has been used extensively in animal models but only to a limited extent in humans. In experimental studies, it has been shown to produce fewer changes in cardiorespiratory and intraperitoneal immunological status than CO(2) insufflation, and its use is associated with less spread of tumors to port sites in a variety of small animal tumor models. However, helium also has the potential for some adverse effects. Helium pneumothorax probably resolves more slowly than CO(2) pneumothorax, and helium gas embolism is tolerated poorly in animal models. The clinical significance of these potential problems has yet to be determined. CONCLUSIONS: Although the use of alternative gases appears to be promising, further evaluation is needed within both clinical and laboratory settings before their routine clinical use can be supported.

Metabolic and immunologic consequences of laparoscopy with helium or carbon dioxide insufflation: a randomized clinical study.

BACKGROUND: Previous studies using animal models have demonstrated that carbon dioxide (CO2) pneumoperitoneum during laparoscopy is associated with adverse physiological, metabolic, immunological and oncological effects, and many of these problems can be avoided by the use of helium insufflation. The present study was performed in patients to compare the effect of helium and CO2 insufflation on intraperitoneal markers of immunological and metabolic function. METHODS: Eighteen patients undergoing elective upper gastrointestinal laparoscopic surgery were randomized to have insufflation achieved by using either helium (n = 8) or CO2 (n = 10) gas. Intraperitoneal pH was monitored continuously during surgery, and peritoneal macrophage function was determined by harvesting peritoneal macrophages at 5 min and 30 min after commencing laparoscopy, and then assessing their ability to produce tumour necrosis factor-alpha (TNF-alpha), and their phagocytic function. RESULTS: Carbon dioxide laparoscopy was associated with a lower intraperitoneal pH at the commencement of laparoscopy, although this difference disappeared as surgery progressed. The production of TNF-alpha was better preserved by CO2 laparoscopy, but the insufflation gas used did not affect macrophage phagocytosis. Patients undergoing helium laparoscopy required less postoperative analgesia. CONCLUSION: The choice of insufflation gas can affect intraperitoneal macrophage function in the clinical setting, and possibly acid-base balance. The present study suggested no immunological advantages for the clinical use of helium as an insufflation gas. The outcomes of the present study, however, are different to those obtained from previous laboratory studies and further research is needed to confirm this outcome.

An unusual case of port site seeding.

We present an unusual case of a port site tumor from a colonic adenocarcinoma following laparoscopic cholecystectomy. A 66-year-old woman with a previous renal transplant underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis. Three months later, she re-presented with pain localized to the right lateral port wound. Subsequent investigation revealed an adenocarcinoma in the ascending colon with no evidence of local spread or liver metastases. The patient was enrolled in the ALCCAS trial (an Australasian multicenter prospective randomized clinical study comparing laparoscopic and conventional open surgical treatments of colon cancer in adults) and randomized to the laparoscopic arm. At laparoscopy, nodules of tumor were located at the sites of the previous right flank and umbilical trocar sites. The procedure was converted to an open hemicolectomy with excision of port sites. To our knowledge, only one other case of a colon carcinoma metastasizing to a port site following laparoscopic cholecystectomy has been reported. This case illustrates a number of points: (a) This was an advanced tumor at the time of diagnosis and was undoubtedly present at laparoscopic cholecystectomy. (b) This tumor was not manipulated at the time of laparoscopic cholecystectomy. (c) The patient was immunosuppressed at the time of laparoscopic cholecytstectomy. (d) The patient developed clinical recurrence in her laparotomy wound within 3 months of her open procedure. This case supports current arguments that the etiology of port site metastases is likely to be mulifactorial.

Influence of gases on intraperitoneal immunity during laparoscopy in tumor-bearing rats.

Laparoscopy has been associated with metastases to abdominal wall wounds. In addition, many recent experimental studies suggest that laparoscopy is associated with increased tumor dissemination. It is possible that immune or metabolic disturbances due to the use of a pneumoperitoneum could contribute to this problem. To investigate this possibility, we studied the effect of two insufflation gases and gasless laparoscopy on in vivo peritoneal macrophage function and intraperitoneal pH in an experimental model. A carcinoma was implanted into the flank of 32 experimental rats that underwent laparoscopic surgery in one of four treatment groups: anesthesia alone, gasless laparoscopy, helium insufflation, and CO2 insufflation. Intraperitoneal pH was monitored during surgery, and peritoneal macrophage function was determined 3 days after surgery by harvesting peritoneal macrophages and then examining their ability to produce tumour necrosis factor-alpha (TNF-alpha). CO2 insufflation was associated with a consistent fall in intraperitoneal pH and a significant reduction in TNFalpha production. These findings did not occur in the other study groups. The results of this study demonstrate that CO2 insufflation results in depressed intraperitoneal macrophage activity. It is possible that it is mediated by pH changes. In addition, it could be a contributing factor to the development of port-site metastases. Further studies are needed to determine whether the factors identified act during clinical surgery.