[Algorithm-based preventive strategies for avoidance of residual neuromuscular blocks]. / Algorithmusbasierte Präventionsstrategien zur Vermeidung neuromuskulärer Restblockaden.

BACKGROUND: Postoperative residual neuromuscular block (train of four ratio <0.9) is an outcome-relevant problem in balanced anesthesia, which increases postoperative morbidity and mortality. Implementation of medium and short-acting muscle relaxants, quantitative neuromuscular monitoring and pharmacological reversal of muscle relaxation reduce the incidence of residual neuromuscular block. The question arises whether this is suitable to create a pragmatic algorithm integrating these three individual methods to reduce paralysis-associated complications? METHODS: A selective literature search was carried out in PubMed and guidelines of national specialist societies were searched using special terms. RESULTS: The incidence of residual neuromuscular block varied among the studies but was as high as 93%. Using calibrated acceleromyography it is possible to identify a residual relaxation with a negative predictive value of 97% (95% confidence interval, CI 83-100%). Reversal by administration of the acetylcholinesterase inhibitor neostigmine reduces the incidence of residual neuromuscular block to 15.4%, in combination with calibrated acceleromyography to 3.3%. Reversal with sugammadex can nearly completely eliminate residual neuromuscular block. Quantitative neuromuscular monitoring and pharmacological reversal can be suitably integrated into a stage-based, pragmatic treatment algorithm. CONCLUSION: The algorithm-based concept of quantitative neuromuscular monitoring and pharmacological reversal using neostigmine and sugammadex enables residual neuromuscular block to be treated within 10 min before extubation of the patient. Ongoing educational programs are essential for implementation of modern muscle relaxant management concepts. Quantitative neuromuscular monitoring should be mandatory for all patients receiving neuromuscular blocking drugs. It would be desirable that German-speaking societies for anesthesiology make appropriate recommendations in guidelines.

[Nonoperating room anesthesia]. / Dezentrale Arbeitsplätze in der Anästhesiologie.

Anesthesia services outside central surgical facilities (nonoperating room anesthesia, NORA) have become more important. Nonoperating room anesthesia is a challenging field with a wide range of patient ages and interventions. The anesthesiologist is caught between the existing expertise in sedation, respiratory and emergency management and the fact that it may be a potentially avoidable cost factor. The efforts of some specialist departments to carry out sedation themselves even with more complex interventions have therefore increased. In order to permanently establish anesthesia here, apart from the pure anesthesiological expertise, a pronounced willingness to interdisciplinary communication and cooperation is necessary. Only in this way can the participating specialist disciplines be convinced of the anesthesiological added value for the patient. Groups of patients requiring special attention include pediatric patients. The care especially for children under 2 years old also requires the particular anesthesiological expertise of the supervising anesthesiologist; however, profound knowledge, for example in cardiac anesthesia, is also required if special interventions are decentrally managed in the cardiac catheterization laboratory.

[Influence of social characteristics on the duration of treatment, severity of the disease and social support of patients in a surgical intensive care unit]. / Einfluss sozialer Charakteristika auf die Behandlungsdauer, Erkrankungsschwere und soziale Unterstützung von Patienten einer operativen Intensivstation.

BACKGROUND: In critical illnesses low socioeconomic status (SES) is associated with higher morbidity and mortality. In addition to the SES, further factors at an individual level (e.g., sex, health insurance status and place of residence) may influence the severity of illness and medical treatment. We investigated these additional parameters in a secondary analysis of the ECSSTASI data. METHODS: Within the framework of the ECSSTASI study, 996 patients were recruited from a surgical intensive care unit. We examined the influence of sex, insurance status and place of residence on health-related behavior, disease severity, duration of intensive care and ventilation (28 ventilator-free days score, 28-VFDS) and social support by the next of kin. Multivariate-adjusted logistic regression analyses were carried out and odds ratios (OR) are presented with corresponding 95% confidence intervals. RESULTS: Among patients admitted to the intensive care unit, the disease severity (SOFA score >5) was significantly lower in women than in men (OR 0.62 [0.45-0.87]). Increasing size of the patient's town of residence was associated with a significantly shorter duration of treatment on the intensive care unit (OR 0.54 [0.32-0.91]). An increasing number of persons in the household was associated with a significantly increased risk of being ventilated longer compared to 1­person households (p = 0.028). Patients with private insurance (OR 1.87 [1.28-2.70]), patients from households with ≥4 persons (OR 1.92 [1.1-3.33]) and patients without German citizenship (OR 2.56 [1.39-4.55]) were visited significantly more often by next of kin. CONCLUSION: In addition to the SES, sociodemographic characteristics of the individual patient are associated with the course of treatment in intensive care medicine. The extent of social support by the next of kin depends on intercultural and individual patient characteristics. An increasing size of the town of residence and private health insurance status positively influence intensive care outcomes. In order to evaluate these data, further epidemiological studies in intensive care medicine are necessary.

[Outpatient palliative medicine : Attitudes in the care of palliative emergencies. Prospective questionnaire-based investigation]. / Ambulante Palliativmedizin : Einstellungen in der Versorgung palliativer Notfälle. Prospektive Fragebogenuntersuchung.

BACKGROUND: The right to adequate outpatient palliative care has existed for several years in Germany. In recent years outpatient palliative care has developed very positively. Nevertheless, in emergency situations paramedics and emergency physicians were often included in the care of palliative care of patients. The aim of our study was to investigate the cooperation between outpatient palliative care teams and the emergency medical services. Another aim was to identify structural realities and based on these to discuss the possibilities in the optimization of outpatient palliative medical emergency situations. METHODS: A standardized self-designed questionnaire was distributed to specialized outpatient palliative care teams (SPCS) in Germany. For this purpose, closed and open questions (mixed methods) were used. The evaluation was carried out according to the questionnaire categories in quantitative and qualitative forms. The questionnaire was subdivided into general information and specific questions. RESULTS: The survey response rate was 79% from a total of 81 SPCS in 2011. The following standards in palliative emergency care were recommended: (1) early integration of outpatient palliative care services and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, emergency drug boxes, do not attempt resuscitation orders and (4) emergency medical training (physicians and paramedics). CONCLUSION: Outpatient palliative care in Germany has developed very positively during the last years; however, there are still deficits in terms of optimal patient care, one of which refers to the treatment of palliative care emergencies. In this context, optimization in the cooperation between outpatient palliative care services and emergency medical services should be discussed.

[Analysis and options for optimization of preoperative assessment for anesthesia at a university hospital]. / Analyse und Möglichkeiten der Optimierung von Prämedikationsgesprächen an einem Universitätsklinikum.

BACKGROUND: Risk assessment prior to elective surgery is an important tool in the context of perioperative patient care; however, only a few studies have been carried out to address the processes and problems during preoperative assessment for anesthesia. AIM: Over a period of several weeks all preoperative anesthesia evaluations prior to elective surgery were prospectively recorded in order to generate a data pool with a view to identifying options for process optimization. MATERIAL AND METHODS: All preoperative evaluations over a period of 38 working days at the University Medical Center Regensburg were recorded and analyzed with respect to waiting time for the patient and the duration of the preoperative consultation on medication. Also documented were the patient age, ASA score, the faculty carrying out the operation, type and risk of surgery, planned time of surgery, professional experience of the anesthesiologist and the approval status for surgery. In addition, all problems which occurred during the preoperative anesthesia evaluation were documented using a questionnaire. RESULTS: Overall 2233 preoperative assessments for anesthesia were recorded and analyzed. The number of patients attending the preoperative assessment clinic differed markedly in the course of a day and was lower at the end of the week. Approval for surgery with no reservations was given more frequently by anesthesiologists with more than 5 years professional experience and consultants compared to younger colleagues. The main reason for approval with reservations or no approval was the lack of patient records and test results, which should have been presented according to the in-house standard for preoperative assessment for anesthesia. The mean waiting time was 58.6 ± 30.3 min, the mean duration of the patient documentation review and physician-patient consultation together was 33.6 ± 16.3 min. Anesthesiologists with 2-5 years professional experience needed significantly less time for patient documentation reviews and physician-patient consultations than younger and more experienced colleagues. The duration of the preoperative assessment for anesthesia correlated with the ASA score and risks of surgery. CONCLUSION: The analysis of processes and problems in the context of preoperative assessment for anesthesia revealed several options for optimization. Major efforts should be the implementation of an appointment system for the preoperative assessment clinic in order to generate a homogeneous distribution of patients during the course of a day. Furthermore, surgeons and case managers should be requested to refer patients to the preoperative assessment clinic only with complete records and test results according to the in-house standard.

[Use of near-infrared spectroscopy for control of limb perfusion during venoarterial ECMO treatment : Application and limitations]. / Verwendung der Nahinfrarotspektroskopie zur Kontrolle der Extremitätenperfusion unter venoarterieller ECMO-Therapie : Einsatz und Limitationen.

Patients undergoing peripheral venoarterial extracorporeal membrane oxygenation have a high risk of lower limb ischemia. In general, regular controls are carried out based on clinical and laboratory parameters in order to quickly detect and treat complications. These controls are challenging due to states of shock, nonpulsatile flow and vasopressor therapy. As additional monitoring the use of near-infrared spectroscopy (NIRS) is described in the literature as being very successful in detecting ischemia. The present article describes the use and possible limitations of NIRS for the diagnostics of peripheral ischemia.

Performance of a new-generation continuous autotransfusion device including fat removal and consequences for quality controls.

BACKGROUND AND OBJECTIVES: Cell salvage plays a key role in blood conservation. To maintain high performance, quality management is recommended. Accordingly, a new-generation autotransfusion device was tested for its performance and compared with its predecessor. Two different calculations of quality parameters were applied. MATERIALS AND METHODS: In an experimental study, the continuous autotransfusion devices CATSmart and Continuous Autotransfusion System (C.A.T.S) plus were tested using banked blood adjusted to a haematocrit of 20% and anticoagulated with heparin 5 U/L. Test blood was processed using an emergency programme, a high-quality programme/smart wash programme and a low-volume wash programme. Samples were taken after the production of 200 mL of red blood cells (RBC) and after the final emptying of the separation chamber. In an additional set of tests, blood containing 1·25% fat was processed with both devices to examine fat removal. RESULTS: Both devices demonstrated an equally high performance with regards to product hematocrit (Hct); RBC recovery; and elimination rates of protein, heparin and fat. The high fat elimination rate (>99·8%) reported for C.A.T.S plus was confirmed for CATSmart, regardless of the used programme. Samples taken during the ongoing process show a higher haematocrit and RBC recovery rate than samples taken after the final emptying of the separation chamber. Interface sensors were not affected by fat in the blood. CONCLUSIONS: The new-generation autotransfusion device CATSmart is not inferior to its predecessor and shows high performance with regards to RBC recovery, plasma and fat elimination in all programme modes. Samples for quality controls should be taken during blood processing.

[Extracorporeal CO2 removal as an alternative to tracheotomy in a patient with extubation failure]. / Extrakorporale CO2-Elimination als Alternative zur Tracheotomie bei Weaningversagen.

We report a patient with chest trauma who was admitted to the ICU after surgery. As he fulfilled protocol-based criteria, he was extubated 7 days after admission. However, despite intermittent non-invasive ventilation, the patient had to be re-intubated on day 10 owing to progressive hypercapnia. We decided to support the patient with a mid-flow veno-venous extracorporeal carbon dioxide removal (ECCO2­R) system instead of a tracheotomy. Sufficient CO2 removal was established with a blood flow of 1.5 l/min and the patient was successfully extubated within a few hours. After 5 days of ECCO2­R the patient could be weaned and transferred to a general ward in a stable condition.

Anti-Aspergillus immunoglobulin-G testing in serum of hematopoietic stem cell transplant recipients.

BACKGROUND: Pulmonary invasive aspergillosis (IA) is a major clinical problem in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). Acquisition of IA during allo-HSCT by inhalation of spores is the rationale for the widespread use of air filtration systems. Recent data suggest that activation of fungal growth in already colonized patients is a relevant factor, and a recent study found a positive correlation of serum immunoglobulin responses against purified recombinant Aspergillus fumigatus proteins before allo-HSCT with the incidence of IA after allo-HSCT. METHODS: To investigate the clinical utility of this approach, we performed a prospective study. We used a commercially available and standardized assay for detection of anti-Aspergillus immunoglobulin-G (aA-IgG) in serum (Platelia(™) Aspergillus IgG) that has previously demonstrated high sensitivity and specificity. RESULTS: In a cohort of 104 allo-HSCT recipients, we measured aA-IgG and Aspergillus antigen serum levels before allo-HSCT, and weekly during hospital stay. Overall prevalence of possible, probable, and proven IA during hospital stay was 10%, 6%, and 0%. We found no correlation between aA-IgG levels before allo-HSCT, or after allo-HSCT, and the prevalence of IA during hospital stay. Furthermore, median aA-IgG levels did not differ between patients with history of probable or proven IA, as compared to patients without history of IA. CONCLUSIONS: Taken together, our data argue against the clinical utility of measuring aA-IgG levels for diagnosis or prediction of IA in patients undergoing allo-HSCT.

[The challenge of acute kidney injury : Cross-sectional study on prevalence and costs in a university intensive care unit]. / Die Herausforderung akute Nierenschädigung : Querschnittsstudie zu Prävalenz und Kosten auf einer universitären Intensivstation.

BACKGROUND AND OBJECTIVES: The prognosis of intensive care patients with acute kidney injury (AKI), which is associated with increased mortality is still poor. Current data on the prevalence and the resulting costs of AKI and an overview of the most common diagnoses associated with AKI in German intensive care units (ICU) are lacking. PATIENTS AND METHODS: In this retrospective study all adult admissions (> 18 Jahre) in the five ICUs at the University Clinic Regensburg (in total 78 beds) from1 January 2011 to 31 December 2013 were evaluated. The ICU diagnoses commonly associated with AKI were identified using the international classification of diseases 10 (ICD 10). The length of ICU and hospital stays and AKI-associated hospital costs in the diagnosis-related groups (DRG) based reimbursement system were compared. RESULTS: A total of 891 ICU patients with AKI were classified according to the ICD 10 code. Acute respiratory distress syndrome (ARDS), myocardial infarction (MI) and sepsis were the three most common ICU conditions associated with AKI. A total of 1103 patients were admitted with 1 of these 3 main diagnoses and 249 (22.6 %) of these patients developed AKI. Patients with AKI had significantly longer mean ICU and hospital stays compared to patients without AKI (18.6 vs 5.1 days and 23.8 vs. 10.4 days, respectively, p < 0.001). The presence of AKI in critically ill patients with ARDS, MI and sepsis resulted in additional costs of 2,019,120.42 € at the University Hospital of Regensburg in 2013. CONCLUSION: Acute kidney injury in critically ill patients represents a significant medical and socioeconomic burden. Early recognition of patients at risk, coordinated research into novel interventions and establishment of the National Acute Kidney Injury Network for implementation of evidence-based therapies may be the next steps to decrease the incidence and severity of AKI and save costs for the national healthcare system.

Robot-assisted microwave thermoablation of liver tumors: a single-center experience.

PURPOSE: To evaluate and compare the needle placement accuracy, patient dose, procedural time, complication rate and ablation success of microwave thermoablation using a novel robotic guidance approach and a manual approach. METHODS: We performed a retrospective single-center evaluation of 64 microwave thermoablations of liver tumors in 46 patients (10 female, 36 male, mean age 66 years) between June 2014 and February 2015. Thirty ablations were carried out with manual guidance, while 34 ablations were performed using robotic guidance. A 6-week follow-up (ultrasound, computed tomography and MRI) was performed on all patients. RESULTS: The total procedure time and dose-length product were significantly reduced under robotic guidance (18.3 vs. 21.7 min, [Formula: see text]; 2216 vs. 2881 mGy[Formula: see text]cm, [Formula: see text]). The position of the percutaneous needle was more accurate using robotic guidance (needle deviation 1.6 vs. 3.3 mm, [Formula: see text]). There was no significant difference between both groups regarding the complication rate and the ablation success. CONCLUSION: Robotic assistance for liver tumor ablation reduces patient dose and allows for fast positioning of the microwave applicator with high accuracy. The complication rate and ablation success of percutaneous microwave thermoablation of malignant liver tumors using either CT fluoroscopy or robotic guidance for needle positioning showed no significant differences in the 6-week follow-up.

[Anesthesia management in implantation of baroreceptor stimulators]. / Anästhesiologisches Management bei Implantation von Barorezeptorstimulatoren.

Baroreceptor stimulators are novel implantable devices that activate the carotid baroreceptor reflex. This results in a decrease in activity of the sympathetic nervous system and inhibition of the renin-angiotensin-aldosterone system. In patients with drug-resistant hypertension, permanent electrical activation of the baroreceptor reflex results in blood pressure reduction and cardiac remodeling. For correct intraoperative electrode placement at the carotid bifurcation, the baroreceptor reflex needs to be activated several times. Many common anesthetic agents, such as inhalation anesthetics and propofol dampen or inhibit the baroreceptor reflex and complicate or even prevent successful placement. Therefore, a specific anesthesia and pharmacological management is necessary to ensure successful implantation of baroreceptor reflex stimulators.

[Patients with implanted ventricular assist devices : Challenge for emergency medicine]. / Patienten mit implantierten Herzunterstützungssystemen : Herausforderung in der Notfallmedizin.

Due to a huge increase in the implantation of ventricular assist devices (VAD) over the last few years and the enormous technical advances in functional safety, a growing number of patients with VAD are discharged from hospital, who are still considered to be severely ill. This results in an increased probability of these patients interacting with emergency services where personnel are unaware of the presence of a VAD, creating anxiety and uncertainty regarding how to treat these patients. This article presents an overview of the most common problems and pitfalls regarding VADs. It also presents an algorithm for dealing with emergencies involving these patients including the diagnostics, treatment and primary transport.

Effects of ropivacaine, bupivacaine and sufentanil in colon and pancreatic cancer cells in vitro.

The perioperative period is supposed to be a vulnerable period for cancer progression. Results of clinical studies indicate that the use of regional anesthesia can influence and improve oncological outcome of cancer patients. Uncontrolled cell proliferation and resistance to apoptotic cell death are important characteristics of solid tumors. The aim of this study was to investigate the effects of the clinically used local anesthetics ropivacaine or bupivacaine and the opioid analgesic sufentanil on cell proliferation, cell cycle distribution and apoptosis of colon (HT 29 and SW 480) and pancreatic (PaTu 8988t and PANC 1) cancer cell lines in vitro. Cell proliferation was measured by Cell Proliferation ELISA BrdU Assay. Apoptosis was analyzed by annexin V staining and cell cycle distribution was detected by flow cytometry. Ropivacaine, bupivacaine and sufentanil did not change apoptosis rate and cell cycle distribution in clinically concentration. Only high concentrations of ropivacaine or bupivacaine revealed antiproliferative potency. Protective effects of epidural anesthesia observed in clinical studies seem not to be based on direct effects of these drugs on cancer cells.

Magnesium-induced recurarisation after reversal of rocuronium-induced neuromuscular block with sugammadex.

A 61-year-old woman (57 kg, 171 cm) underwent surgery under general anaesthesia with desflurane 5.8-6.1 vol. % end-tidal, remifentanil 0.2-0.4 µg/kg/min and rocuronium 35 mg (0.61 mg/kg). On return of the second twitch in the train-of-four (TOF) stimulation measured by acceleromyography, sugammadex 120 mg (2.1 mg/kg) was given. After complete neuromuscular recovery, magnesium sulphate 3600 mg (60 mg/kg) was injected intravenously over 5 min to treat atrial fibrillation. This was associated with recurarisation with a nadir [first twitch=25%, TOF ratio (TOFR)=67%] 7 min after the start of the magnesium sulphate infusion (magnesium plasma level: 2.67 mM). A spontaneous twitch value and a TOFR of >90% were observed 45 min after the beginning of the magnesium sulphate infusion under general anaesthesia. Rapid infusion of magnesium sulphate may re-establish a sugammadex-reversed, rocuronium-induced neuromuscular block during general anaesthesia, probably because of the high plasma level of magnesium (2.67 mM). Desflurane and a small fraction of unbound rocuronium may amplify the known muscle relaxing effects of magnesium. Intravenous injection of magnesium sulphate is not recommended in patients after general anaesthesia with neuromuscular relaxants, particularly after sugammadex reversal. Quantitative neuromuscular monitoring should be used for reversing aminosteroid muscle relaxants with sugammadex--particularly in combination with magnesium injection--to prevent post-operative residual curarisation.

Prevalence of Scedosporium species and Lomentospora prolificans in patients with cystic fibrosis in a multicenter trial by use of a selective medium.

OBJECTIVE: Detection of hyphomycetes of the Scedosporium apiospermum complex and Lomentospora prolificans (Sac-Lp) is not yet standardized. Prevalence rates in patients with cystic fibrosis (CF) and the resistance pattern of these pathogens in Germany are unknown. METHODS: In a one-year prospective study 11 laboratories used a selective medium for isolation of Sac-Lp, examining >11,600 respiratory samples from 2346 patients with CF. Isolates were identified by molecular methods and tested for susceptibility to antifungal drugs. RESULTS: The prevalence of Sac-Lp in patients with CF in Germany varied from 0.0 to 10.5% (mean: 3.1%) among the clinical centres. The benefit of the selective medium SceSel(+) compared to standard media for fungi was documented for >5000 samples. High antifungal resistance was detected in the S. apiospermum complex, and the multiresistance of L. prolificans was confirmed. CONCLUSION: Microbiology laboratories should be aware of these resistant species in patients with CF and consider using a selective medium.

Comparing cold-air analgesia, systemically administered analgesia and scalp nerve blocks for pain management during photodynamic therapy for actinic keratosis of the scalp presenting as field cancerization: a randomized controlled trial.

BACKGROUND: Photodynamic therapy (PDT) using methyl aminolaevulinate (MAL) is an effective treatment for extensive actinic keratosis (AK). However, pain is a major side-effect of this therapy. OBJECTIVES: To investigate whether scalp nerve blocks (group 1) provide adequate pain relief during MAL-PDT of the scalp and forehead in 32 men with baldness. METHODS: The patients received intravenous (IV) analgesia [piritramide 7.5 mg IV, plus oral metamizole (40 drops 30 min prior to PDT)] in combination with cold-air analgesia (group 2; IV analgesia) and cold-air analgesia alone (group 3). Maximum pain was evaluated by means of a visual analogue scale (VAS) during and up to 300 min after PDT. Pain during PDT was further analysed according to a pain perception scale. Furthermore, we measured haemodynamics and investigated stress hormone levels in blood samples at different time points. RESULTS: Maximum pain during PDT (primary end point) was significantly reduced in the treatment group receiving scalp nerve blocks (VAS 2.1 ± 1.3) compared with the treatment groups receiving IV analgesia (VAS 7.3 ± 1.1) and cold-air analgesia (VAS 8.4 ± 2.0; P < 0.05). No significant difference was found between groups 2 and 3 with regard to pain relief (P = 0.32). The increase in systolic blood pressure during the first 3 min of PDT was significantly lower for group 1 than for groups 2 and 3 (P < 0.001). No correlation between stress hormone levels and pain were found. CONCLUSIONS: Scalp nerve blocks provide an effective method for pain management during PDT for patients with extensive AK.

[Anesthesiological management of awake craniotomy : Asleep-awake-asleep technique or without sedation]. / Anästhesiologisches Management zur Wachkraniotomie : Schlaf-Wach-Schlaf-Technik oder ohne Sedierung.

Awake craniotomy is indicated in deep brain stimulation (DBS) for treatment of certain movement disorders, such as in Parkinson disease patients or in the surgery of brain tumors in close vicinity to the language area. The standard procedure is the asleep-awake-asleep technique where general anesthesia or analgosedation is intermittently interrupted for neurological testing. In DBS the intraoperative improvement of symptoms, stereotactic navigation and microelectrode reading guide to the optimal position. In brain tumor resection, reversible functional impairments during electrical stimulation on the brain surface (brain mapping) show the exact individual position of eloquent or motoric areas that should be protected.The anesthesiology procedures used are very variable. It is a balancing act between overdosing of anesthetics with impairment of respiration and alertness and underdosing with pain, strain and stress for the patient. For the asleep-awake-asleep technique high acceptance but also frequent and partly severe complications have been reported. The psychological stress for the patient can be immense. Obviously, a feeling of being left alone and being at someone's mercy is not adequately treated by drugs and performance of the neurological tests is undoubtedly better and more reliable with less pharmacological impairment. Cranial nerve blocks can reduce the amount of anesthetics as they provide analgesia of the scalp more efficiently than local infiltration. With these nerve blocks, a strong therapeutic relationship and a specific communication, sedatives can be avoided and the need for opioids markedly reduced or abolished. The suggestive communication promotes for instance dissociation to an inner safe refuge, as well as reframing of disturbing noises and sensations. Each of the methods applied for awake craniotomy can profit from the principles of this awake-awake-awake technique.

[Simulation as possible training for palliative emergencies: prospective initial data analysis of participants from two simulation training sessions]. / Simulation als Möglichkeit zum Training palliativer Notfälle : Prospektive erste Datenanalyse von Teilnehmern zweier Simulationstrainings.

BACKGROUND: Palliative emergencies describe an acute situation in patients with a life-limiting illness. At present defined curricula for prehospital emergency physician training for palliative emergencies are limited. Simulation-based training (SBT) for such palliative emergency situations is an exception both nationally and internationally. AIM: This article presents the preparation of recommendations in the training and development of palliative care emergency situations. MATERIAL AND METHODS: A selected literature search was performed using PubMed, EMBASE, Medline and the Cochrane database (1990-2013). Reference lists of included articles were checked by two reviewers. Data of the included articles were extracted, evaluated und summarized. In the second phase the participants of two simulated scenarios of palliative emergencies were asked to complete an anonymous 15-item questionnaire. The results of the literature search and the questionnaire-based investigation were compared and recommendations were formulated based on the results. RESULTS: Altogether 30 eligible national and international articles were included. Overall, training curricula in palliative emergencies are currently being developed nationally and internationally but are not yet widely integrated into emergency medical training and education. In the second part of the investigation, 25 participants (9 male, 16 female, 20 physicians and 5 nurses) were included in 4 multiprofessional emergency medical simulation training sessions. The most important interests of the participants were the problems for training and further education concerning palliative emergencies described in the national and international literature. CONCLUSION: The literature review and the expectations of the participants underlined that the development and characteristics of palliative emergencies will become increasingly more important in outpatient emergency medicine. All participants considered palliative care to be very important concerning the competency for end-of-life decisions in palliative patients. For this reason, special curricula and simulation for dealing with palliative care patients and special treatment decisions in emergency situations seem to be necessary.

Compounds leached from quinoa seeds inhibit matrix metalloproteinase activity and intracellular reactive oxygen species.

OBJECTIVE: Quinoa (Chenopodium quinoa Willd.) is a seed crop rich in bioactive compounds including phytoecdysones (especially 20-hydroxyecdysone, 20HE), polyphenols, proteins and essential fatty acids. We previously reported a method to leach and concentrate quinoa bioactives into a complex phytochemical mixture termed quinoa leachate (QL). Here, we aimed to determine the effect of QL and its chemically distinct fractions on five biochemical endpoints relevant to skin care applications: (i) cell viability, (ii) matrix metalloproteinase (MMP) mRNA expression, (iii) MMP enzymatic activity, (iv) tyrosinase enzymatic activity and (v) intracellular reactive oxygen species (ROS) production. METHODS: Quinoa leachate was fractionated and chemically characterized using column chromatography and liquid chromatography-mass spectrometry (LC-MS). Cell viability was determined using a MTT assay in four mammalian cell lines. MMP-1 mRNA expression was assessed in human dermal fibroblasts (HDF) via qRT-PCR. The enzymatic activity of MMP-9 and tyrosinase was measured using fluorometric and colorimetric in vitro assays, respectively. Lipopolysaccharide (LPS)-induced ROS production was determined in human dermal fibroblasts by fluorescence intensity of an oxidant-sensitive probe. RESULTS: Quinoa leachate was separated into three fractions: (i) carbohydrate-rich fraction (QL-C; 71.3% w/w of QL); (ii) phytoecdysone, polyphenol and protein-rich fraction (QL-P, 13.3% w/w of QL); (iii) oil-rich fraction (QL-O, 10.8% w/w of QL). QL did not reduce cell viability in any of the four cell lines tested. QL, QL-P and QL-O each significantly inhibited MMP-1 mRNA expression in HDF at a concentration of 5 µg mL(-1) . QL and QL-P also significantly inhibited MMP-9 enzymatic activity, whereas QL-P demonstrated significant tyrosinase enzymatic inhibition. Furthermore, QL, QL-P, QL-O and 20HE significantly inhibited intracellular ROS production. CONCLUSION: This study is the first to demonstrate the MMP, tyrosinase and ROS inhibiting properties of multiple different phytochemical components derived from quinoa seeds. Our work indicates that quinoa phytochemicals may play a role in the treatment and prevention of skin ageing through a multiplicity of effects.