[Central neurological complication of an interscalene plexus catheter]. / Zentralneurologische Komplikation einer interskalenären Plexuskatheteranlage.

A 78-year-old patient received an interscalene plexus catheter for perioperative pain therapy during implantation of an inverse shoulder prothesis. After stimulation-assisted puncture under sonographic control, 25 ml of local anesthetic (LA) were first administered and then the catheter was placed using the through the needle technique. Immediately after the administration of another 5 ml of local anesthetic via the inserted catheter, the patient showed symptoms of total spinal anesthesia, so that she had to be intubated and ventilated. The following computed tomographic diagnostics of the neck revealed an intrathecal misalignment of the plexus catheter, the tip of which was lying dorsal to the vertebral artery at the level of the 5/6 cervical vertebrae. The catheter could then be removed without any problems and there were no neurological sequelae. The use of ultrasound with clear identification of the nerve roots C5-C7 and the surrounding structures provides additional security when installing an intrascalene catheter. The spread of the LA should be traceable at all times using ultrasound and should otherwise be immediately terminated. Furthermore, a strict adherence to the needle position while inserting the catheter without manipulation of the needle depth is necessary. The first injection of the catheter has to be performed under controlled conditions, preferably connected to surveillance monitors with neurological monitoring of the awake patient and control of vital signs with direct access to the emergency equipment.

Reconciliation with non-binary species trees.

Reconciliation is the process of resolving disagreement between gene and species trees, by invoking gene duplications and losses to explain topological incongruence. The resulting inferred duplication histories are a valuable source of information for a broad range of biological applications, including ortholog identification, estimating gene duplication times, and rooting and correcting gene trees. Reconciliation for binary trees is a tractable and well studied problem. However, a striking proportion of species trees are non-binary. For example, 64% of branch points in the NCBI taxonomy have three or more children. When applied to non-binary species trees, current algorithms overestimate the number of duplications because they cannot distinguish between duplication and deep coalescence. We present the first formal algorithm for reconciling binary gene trees with non-binary species trees under a duplication-loss parsimony model. Using a space efficient mapping from gene to species tree, our algorithm infers the minimum number of duplications and losses in O(|V(G)| . (k(S) + h(S))) time, where V(G) is the number of nodes in the gene tree, h(S) is the height of the species tree and k(S) is the width of its largest multifurcation. We also present a dynamic programming algorithm for a combined loss model, in which losses in sibling species may be represented as a single loss in the common ancestor. Our algorithms have been implemented in NOTUNG, a robust, production quality tree-fitting program, which provides a graphical user interface for exploratory analysis and also supports automated, high-throughput analysis of large data sets.