Systematic reviews and quality assessment of patient-reported outcome measures for physical function in comparative effectiveness studies regarding acute postoperative pain after total knee arthroplasty-Do we need to start all over again?

BACKGROUND AND OBJECTIVE: Recently, a consensus process specified a core outcome set (COS) of domains to be assessed in each comparative effectiveness research and clinical practice related to acute postoperative pain. Physical function (PF) was one of these domains. The aim of this review was to investigate which patient-reported outcome measures (PROMs) are used to assess PF after total knee arthroplasty (TKA) in clinical trials and if they fulfil basic requirements for a COS of PROMs based on their psychometric properties. METHODS: A systematic review of randomized controlled trials and observational studies based on a search in MEDLINE, EMBASE and CENTRAL was undertaken. PROMs and performance measures were extracted and investigated, including evaluation of psychometric properties of PROMs based on COSMIN recommendations. RESULTS: From initially 2896 identified records, 479 studies were included in the qualitative synthesis. Only 87 of these trials (18%) assessed PF using PROMs, whereas especially performance outcome measures were used in 470 studies (98%). Application of the 'COSMIN Risk-of-Bias-Box 1' to 13 of the 14 identified PROMs resulted in insufficient content validity of the included PROMs regarding the target population based on the inauguration or development articles. CONCLUSION: Our data indicate that a patient-centred postoperative assessment of PF in pain-related clinical trials early after TKA is not common, even though patient-reported assessment is widely recommended. In addition, none of the applied PROMs shows content validity based on their inauguration or development articles for the assessment of postoperative pain-related PF after TKA. SIGNIFICANCE: A systematic search for patient-reported outcome measures assessing postoperative, pain-related physical function after total knee arthroplasty in clinical trials and assessment of their content validity revealed none that fulfilled requirements based on COSMIN recommendations.

Depth as a driver of evolution and diversification of ancient squat lobsters (Decapoda, Galatheoidea, Phylladiorhynchus).

The exceptional hidden diversity included in the squat lobster genus Phylladiorhynchus and its wide bathymetric and geographic range make it an interesting group to thoroughly study its evolutionary history. Here we have analyzed the entire currently known species diversity of Phylladiorhynchus using an integrative approach that includes morphological and molecular characters. The aim was to establish whether depth range (bathymetry) has played a role in their morphological and molecular evolution and in their diversification pathways. Phylogenetic analyses recovered the genus as monophyletic and as the sister group of Coralliogalathea, conforming with current systematic hypotheses, although their placement in a monophyletic Galatheidae is doubted. All the analyzed species represent well-supported lineages, structured in ten clades, correlated in most part with the morphological phylogeny. The reconstruction of ancestral habitat showed that the most recent common ancestor of Phylladiorhynchus most likely lived in shallow water environments. The divergence time estimation analyses dated the origin of the genus back to the Upper Jurassic, preceding the origin of all the other galatheoid lineages. Morphological analyses suggested that species from deeper waters exhibit greater morphological divergences and lower genetic divergences in comparison to species from shallower waters. In Phylladiorhynchus, the colonization of deeper waters has taken place independently multiple times since the Lower-Cretaceous. Our reconstruction of ancestral habitat suggests that shallow water ancestors might show an acceleration in the molecular rate of evolution and a slowdown in the rates of morphological evolution in comparison to deep sea lineages. However, although lineages from shallow and deep sea habitats show slight differences in diversification trends, bathymetry does not significantly affect the diversification rate in Phylladiorhynchus according to our diversification analyses.

Development and national consensus finding on patient-centred high stakes communication skills assessments for the Swiss Federal Licensing Examination in Medicine.

OBJECTIVE: To describe and evaluate a consensus finding and expert validation process for the development of patient-centred communication assessments for a national Licensing Exam in Medicine. METHODS: A multi-professional team of clinicians and experts in communication, assessment and role-play developed communication assessments for the Swiss Federal Licensing Examination. The six-month process, informed by a preceding national needs-assessment, an expert symposium and a critical literature review covered the application of patient-centred communication frameworks, the development of assessment guides, concrete assessments and pilot-tests. The participants evaluated the process. RESULTS: The multiple-step consensus process, based on expert validation of the medical and communication content, led to six high-stakes patient-centred communication OSCE-assessments. The process evaluation revealed areas of challenge such as calibrating rating-scales and case difficulty to the graduates' competencies and integrating differing opinions. Main success factors were attributed to the outcome-oriented process and the multi-professional exchange of expertise. A model for developing high stakes patient-centred communication OSCE-assessments was derived. CONCLUSIONS: Consensus finding was facilitated by using well-established communication frameworks, by ensuring outcome-orientated knowledge exchange among multi-professional experts, and collaborative validation of content through experts. PRACTICE IMPLICATIONS: We propose developing high-stakes communication assessments in a multi-professional expert consensus and provide a conceptual model.

Effects of Immunization With the Soil-Derived Bacterium Mycobacterium vaccae on Stress Coping Behaviors and Cognitive Performance in a "Two Hit" Stressor Model.

Previous studies demonstrate that Mycobacterium vaccae NCTC 11659 (M. vaccae), a soil-derived bacterium with anti-inflammatory and immunoregulatory properties, is a potentially useful countermeasure against negative outcomes to stressors. Here we used male C57BL/6NCrl mice to determine if repeated immunization with M. vaccae is an effective countermeasure in a "two hit" stress exposure model of chronic disruption of rhythms (CDR) followed by acute social defeat (SD). On day -28, mice received implants of biotelemetric recording devices to monitor 24-h rhythms of locomotor activity. Mice were subsequently treated with a heat-killed preparation of M. vaccae (0.1 mg, administered subcutaneously on days -21, -14, -7, and 27) or borate-buffered saline vehicle. Mice were then exposed to 8 consecutive weeks of either stable normal 12:12 h light:dark (LD) conditions or CDR, consisting of 12-h reversals of the LD cycle every 7 days (days 0-56). Finally, mice were exposed to either a 10-min SD or a home cage control condition on day 54. All mice were exposed to object location memory testing 24 h following SD. The gut microbiome and metabolome were assessed in fecal samples collected on days -1, 48, and 62 using 16S rRNA gene sequence and LC-MS/MS spectral data, respectively; the plasma metabolome was additionally measured on day 64. Among mice exposed to normal LD conditions, immunization with M. vaccae induced a shift toward a more proactive behavioral coping response to SD as measured by increases in scouting and avoiding an approaching male CD-1 aggressor, and decreases in submissive upright defensive postures. In the object location memory test, exposure to SD increased cognitive function in CDR mice previously immunized with M. vaccae. Immunization with M. vaccae stabilized the gut microbiome, attenuating CDR-induced reductions in alpha diversity and decreasing within-group measures of beta diversity. Immunization with M. vaccae also increased the relative abundance of 1-heptadecanoyl-sn-glycero-3-phosphocholine, a lysophospholipid, in plasma. Together, these data support the hypothesis that immunization with M. vaccae stabilizes the gut microbiome, induces a shift toward a more proactive response to stress exposure, and promotes stress resilience.

Effects of maternal separation on serotonergic systems in the dorsal and median raphe nuclei of adult male Tph2-deficient mice.

Previous studies have highlighted interactions between serotonergic systems and adverse early life experience as important gene x environment determinants of risk of stress-related psychiatric disorders. Evidence suggests that mice deficient in Tph2, the rate-limiting enzyme for brain serotonin synthesis, display disruptions in behavioral phenotypes relevant to stress-related psychiatric disorders. The aim of this study was to determine how maternal separation in wild-type, heterozygous, and Tph2 knockout mice affects mRNA expression of serotonin-related genes. Serotonergic genes studied included Tph2, the high-affinity, low-capacity, sodium-dependent serotonin transporter (Slc6a4), the serotonin type 1a receptor (Htr1a), and the corticosterone-sensitive, low-affinity, high-capacity sodium-independent serotonin transporter, organic cation transporter 3 (Slc22a3). Furthermore, we studied corticotropin-releasing hormone receptors 1 (Crhr1) and 2 (Crhr2), which play important roles in controlling serotonergic neuronal activity. For this study, offspring of Tph2 heterozygous dams were exposed to daily maternal separation for the first two weeks of life. Adult, male wild-type, heterozygous, and homozygous offspring were subsequently used for molecular analysis. Maternal separation differentially altered serotonergic gene expression in a genotype- and topographically-specific manner. For example, maternal separation increased Slc6a4 mRNA expression in the dorsal part of the dorsal raphe nucleus in Tph2 heterozygous mice, but not in wild-type or knockout mice. Overall, these data are consistent with the hypothesis that gene x environment interactions, including serotonergic genes and adverse early life experience, play an important role in vulnerability to stress-related psychiatric disorders.

Treatment with a heat-killed preparation of Mycobacterium vaccae after fear conditioning enhances fear extinction in the fear-potentiated startle paradigm.

The hygiene hypothesis or "Old Friends" hypothesis proposes that inflammatory diseases are increasing in modern urban societies, due in part to reduced exposure to microorganisms that drive immunoregulatory circuits and a failure to terminate inappropriate inflammatory responses. Inappropriate inflammation is also emerging as a risk factor for anxiety disorders, affective disorders, and trauma-and stressor-related disorders, including posttraumatic stress disorder (PTSD), which is characterized as persistent re-experiencing of the trauma after a traumatic experience. Traumatic experiences can lead to long-lasting fear memories and fear potentiation of the acoustic startle reflex. The acoustic startle reflex is an ethologically relevant reflex and can be potentiated in both humans and rats through Pavlovian conditioning. Mycobacterium vaccae is a soil-derived bacterium with immunoregulatory and anti-inflammatory properties that has been demonstrated to enhance fear extinction in the fear-potentiated startle paradigm when given prior to fear conditioning. To determine if immunization with M. vaccae after fear conditioning also has protective effects, adult male Sprague Dawley rats underwent fear conditioning on days -37 and -36 followed by immunizations (3x), once per week beginning 24 h following fear conditioning, with a heat-killed preparation of M. vaccae NCTC 11659 (0.1 mg, s.c., in 100 µl borate-buffered saline) or vehicle, and, then, 3 weeks following the final immunization, were tested in the fear-potentiated startle paradigm (n = 12 per group). Rats underwent fear extinction training on days 1 through 6 followed by spontaneous recovery 14 days later (day 20). Rats were euthanized on day 21 and brain tissue was sectioned for analysis of Tph2, Htr1a, Slc6a4, Slc22a3, and Crhr2 mRNA expression throughout the brainstem dorsal and median raphe nuclei. Immunization with M. vaccae did not affect fear expression on day 1. However, M. vaccae-immunized rats showed enhanced enhanced within-session fear extinction on day 1 and enhanced between-session fear extinction beginning on day 2, relative to vehicle-immunized controls. Immunization with M. vaccae and fear-potentiated startle had minimal effects on serotonergic gene expression when assessed 42 days after the final immunization. Together with previous studies, these data are consistent with the hypothesis that immunoregulatory strategies, such as immunization with M. vaccae, have potential for both prevention and treatment of trauma- and stressor-related psychiatric disorders.

[Pathology didactics : Development and pilot study of a pathology didactics curriculum (PaDiCu)]. / Pathologiedidaktik : Entwicklung und Pilotierung eines Pathologiedidaktikcurriculums (PaDiCu).

BACKGROUND: Pathologists are lifelong teachers. However, specialist training contains hardly any didactic learning objectives. Here, the competency-based learning objectives that a pathology didactics curriculum could include were examined. MATERIALS AND METHODS: Learning objectives were determined through expert discussions and literature research. Four teaching units were designed: A) Interactive small-group seminars; B) The timely application of what has been learned under supervision; C) A longitudinal component by providing digital resources; D) Workshops and seminars by third-party providers. RESULTS: Initially, 11 small group seminars were designed: 1. + 2. General and special presentation techniques, 3. Public speaking, 4. Activation of audience, 5. Macro- and microphotography, image processing and graphic design, 6. Pathology teaching concept, 7. Standardized case conferences, 8. Standards for teaching events, 9. Standardized evaluation, 10. Research of pathology education, 11. Digitalization of teaching and pathology. Pilot seminars were appreciated and positively evaluated. CONCLUSION: For the first time, competence-based didactic learning objectives were identified for pathology. The pathology didactics curriculum (PaDiCu) could be disseminated with little effort.

How do Swiss medical schools prepare their students to become good communicators in their future professional careers: a questionnaire and interview study involving medical graduates, teachers and curriculum coordinators.

BACKGROUND: Since 2011, the Swiss Catalogue of Learning Objectives (SCLO) has provided the framework for assessing communication skills in the Swiss Medical Federal Licensing Examination (FLE). This study evaluates how far the communication curricula of five Swiss medical schools match the SCLO and international recommendations. It also explores their strengths, weaknesses, opportunities and threats (SWOT). METHODS: A mixed method approach was used. In a first step, curriculum coordinators/key communication skills teachers and medical graduates were asked to fill out a questionnaire based on communication related objectives from the SCLO and a review of European consensus statements on communication training. Second, information was collected from all Swiss medical schools to identify which communication skills were taught in which formats and at what time points within the 6-year curricula. Finally, 3-4 curriculum coordinators/key communication skills teachers from each medical school were interviewed about their communication curriculum, using SWOT analysis. RESULTS: Sixteen teachers/coordinators (response rate 100%) and 389 medical graduates (response rate 43%) filled out the questionnaire. Both the teachers/coordinators and the graduates considered that two thirds of the communication items listed in the questionnaire were covered in their curricula. Between sixty and two hundred structured hours were dedicated to communication, predominantly in small group and experiential formats. Assessment relied on both MCQs and OSCEs. Most of the training occurred during the first three years of medical school. Teachers felt that the need for communication skills training was now well-recognized by their institution and was taught with appropriate teaching methods. However, recruitment and training of teachers, continuity of communication skills training during clinical years, and the adoption of a common frame of reference among the five medical schools, remained a challenge. CONCLUSION: Although the Swiss medical schools all offered a partly longitudinal communication skills training, with appropriate teaching methods, this study indicates that the communication skills actually taught do not fully match the SCLO or international recommendations. There was less training for complex communication skills training during the clinical years, and ensuring quality and coherence in the teaching remained a challenge.

Incidence and viral aetiologies of acute respiratory illnesses (ARIs) in the United States: a population-based study.

We conducted prospective, community-wide surveillance for acute respiratory illnesses (ARIs) in Rochester, NY and Marshfield, WI during a 3-month period in winter 2011. We estimated the incidence of ARIs in each community, tested for viruses, and determined the proportion of ARIs associated with healthcare visits. We used a rolling cross-sectional design to sample participants, conducted telephone interviews to assess ARI symptoms (defined as a current illness with feverishness or cough within the past 7 days), collected nasal/throat swabs to identify viruses, and extracted healthcare utilization from outpatient/inpatient records. Of 6492 individuals, 321 reported an ARI within 7 days (4·9% total, 5·7% in Rochester, 4·4% in Marshfield); swabs were collected from 208 subjects. The cumulative ARI incidence for the entire 3-month period was 52% in Rochester [95% confidence interval (CI) 42-63] and 35% in Marshfield (95% CI 28-42). A specific virus was identified in 39% of specimens: human coronavirus (13% of samples), rhinovirus (12%), RSV (7%), influenza virus (4%), human metapneumovirus (4%), and adenovirus (1%). Only 39/200 (20%) had a healthcare visit (2/9 individuals with influenza). ARI incidence was ~5% per week during winter.

Mechanical embolectomy for acute ischemic stroke in the anterior cerebral circulation: the Gothenburg experience during 2000-2011.

BACKGROUND AND PURPOSE: Intra-arterial treatment of proximal occlusions in the cerebral circulation have become an important tool in the management of acute ischemic stroke. Our goal was to evaluate the safety and efficacy of intra-arterial acute ischemic stroke treatment performed in our institution in consecutive patients with anterior circulation occlusion during 2000-2011. MATERIALS AND METHODS: We identified, in our data base, 156 consecutive cases with anterior acute ischemic stroke treated intra-arterially during 2000-2011. Stroke severity was defined according to the National Institutes of Health Stroke Scale, the results of the procedure were defined according to the modified Thrombolysis in Cerebral Infarction score, and clinical outcome was defined according to the modified Rankin scale, with favorable outcome ≤2 at 90 days. RESULTS: The mean admission NIHSS score was 19.4 (median, 20), with a mean time from stroke onset to groin puncture of 197 minutes (median, 171 minutes). The embolectomy tool of choice was the Amplatz GooseNeck snare (83%). Successful recanalization (modified TICI 2b +3) was seen in 74% of cases. A mRS ≤ 2 at 90 days was seen in 42% with a mortality rate of 17% and symptomatic intracerebral hemorrhage in 4%. CONCLUSIONS: A high recanalization rate was obtained with the Amplatz GooseNeck snare without any device-related complications. Favorable outcome, mortality, and symptomatic intracerebral hemorrhage are comparable with results of newer embolectomy devices.

Assessing quality of life in long-term survivors after ¹²5I brachytherapy for low-grade glioma in childhood.

Quality of life (QOL) is important for the survivors of malignancies. We investigated health-related QOL in 51 patients treated with iodine-125 (¹²5I) brachytherapy for childhood low-grade gliomas. Instruments included a questionnaire on life situation, German versions of PEDQOL (8-18 years), EORTC QLQ-30 and head and neck module H&N-35 (>18 years), strength and difficulties questionnaire, "Fertigkeitsskala Münster Heidelberg", and an adapted Rankin score. The time lapsed since ¹²5I-brachytherapy was 134 months (median, range: 29-293 months). 57% of the patients were over 18 years of age, 34% were 11-17 years old and 8% were younger. 14 had undergone other treatments after ¹²5I brachytherapy. Over half of the >18 year olds reported residual problems; 68% were disabled, 38% to a severe degree. Many of the young adults still lived with their parents and 17% were jobless. 43% of the children/adolescents needed rehabilitative treatment, 20% visited special schools and 71% were disabled, 33% severely. The patients and their caregivers rated their QOL as not different from that of the normal population. However, many QOL dimensions correlated to the severity of disability. Comparison of QOL outcomes between different treatment measures would require a prospective study controlling for the most important factors of influence.

Galatheoidea are not monophyletic - molecular and morphological phylogeny of the squat lobsters (Decapoda: Anomura) with recognition of a new superfamily.

The monophyletic status of the squat lobster superfamily Galatheoidea has come under increasing doubt by studies using evidence as diverse as larval and adult somatic morphology, sperm ultrastructure, and molecular data. Here we synthesize phylogenetic data from these diverse strands, with the addition of new molecular and morphological data to examine the phylogeny of the squat lobsters and assess the status of the Galatheoidea. A total of 64 species from 16 of the 17 currently recognised anomuran families are included. Results support previous work pointing towards polyphyly in the superfamily Galatheoidea and Paguroidea, specifically, suggesting independent origins of the Galatheidae+Porcellanidae and the Chirostylidae+Kiwaidae. Morphological characters are selected that support clades resolved in the combined analysis and the taxonomic status of Galatheoidea sensu lato is revised. Results indicate that Chirostylidae are more closely related to an assemblage including Aegloidea, Lomisoidea and Paguroidea than to the remaining Galatheoidea and are referred to the superfamily Chirostyloidea to include the Chirostylidae and Kiwaidae. A considerable amount of research highlighting morphological differences supporting this split is discussed. The Galatheoidea sensu stricto is restricted to the families Galatheidae and Porcellanidae, and diagnoses for both Chirostyloidea and Galatheoidea are provided. Present results highlight the need for a detailed revision of a number of taxa, challenge some currently used morphological synapomorphies, and emphasise the need for integrated studies with wide taxon sampling and multiple data sources to resolve complex phylogenetic questions.

[Optimization of radiotherapy planning for non-small cell lung cancer (NSCLC) using 18FDG-PET]. / Optimierung der Bestrahlungsplanung beim nicht-kleinzelligen Bronchialkarzinom (NSCLC) mit Hilfe von 18FDG-PET.

AIM: In recent years, FDG-PET examinations have become more important for problems in oncology, especially in staging of bronchogenic carcinoma. In the retrospective study presented here, the influence of PET on the planning of radiotherapy for patients with non-small-cell lung cancer (NSCLC) was investigated. METHODS: The study involved 39 patients with NSCLC who had been examined by PET for staging. They received radiotherapy on the basis of the anterior/posterior portals including the primary tumour and the mediastinum planned according to CT- and bronchoscopic findings. The results of the PET examination were not considered in initial radiotherapy planning. The portals were retrospectively redefined on the basis of FDG uptake considering the size and localization of the primary tumour; and FDG activities outside the mediastinal part of the portals. RESULTS: In 15 out of 39 patients, the CT/PET-planned portals differed from the CT-planned ones. In most causes (n = 12) the CT/PET field was smaller than the CT field. The median geometric field size of the portals was 179 cm2, after redefinition using PET 166 cm2. In 20 patients with disturbed ventilation caused by the tumour (atelectasis, dystelectosis), a correction of the portal was suggested significantly more frequently than in the other patients (p = 0.03). CONCLUSIONS: Our results demonstrate the synergism of topographical (CT) and metabolic (FDG-PET) information, which could be helpful in planning radiotherapy of bronchial carcinoma, especially for patients with disturbed ventilation.

Impaired explicit memory after recovery from propofol/sufentanil anaesthesia is related to changes in the midlatency auditory evoked response.

BACKGROUND: Midlatency auditory evoked responses (MLAER) can distinguish different stages of anaesthesia. We studied MLAER during emergence from propofol/sufentanil anaesthesia in relation to recovery of explicit memory. METHODS: MLAER were recorded in 29 healthy patients before and during anaesthesia and during emergence until the patients opened their eyes spontaneously. After a structured interview the next day, patients were classified into those with and without explicit memory of the recovery period. Latencies Na, Pa and Nb and the peak-to-peak amplitudes NaPa and PaNb were compared between the groups by multivariate analysis of variance. Results are mean (SD). RESULTS: At eye opening (37 (12) min after the end of anaesthesia) the latency Nb (47 (5) compared with 41 (5) ms; P < 0.001) was prolonged and the amplitude PaNb (1.3 (0.8) compared with I (0.5) ms; P = 0.012) was greater than the baseline value, respectively. The Nb latency was significantly shorter in patients with explicit memory (49 (2) ms compared with 45 (I); P = 0.041). CONCLUSIONS: Large intra- and inter-individual variability in the MLAER values limited their ability to predict memory responses in individual patients during emergence from propofol/sufentanil anaesthesia.

Recovery of memory after general anaesthesia: clinical findings and somatosensory evoked responses.

BACKGROUND: Mid-latency somatosensory evoked responses are used to monitor the integrity of the sensory pathways intra-operatively. They can quantify the effects of anaesthetics on the central nervous system. Mid-latency auditory evoked responses have been related to cognition during anaesthesia, but there are no detailed studies using median nerve somatosensory evoked responses (MnSSER). METHODS: We studied 49 patients during recovery from general anaesthesia (isoflurane/nitrous oxide or propofol) to assess implicit and explicit memory function in relation to mid-latency MnSSER. The MnSSER recordings were made before anaesthesia, during steady-state anaesthesia, and at the end of the recovery period. The patients were interviewed 24 h later about their memory for the immediate wake up phase. Statistical analysis was by multivariate analysis of variance. RESULTS: Out of 49 patients, 23 recalled the recovery period, 11 had implicit memory for an object shown to them during the recovery period, and 15 did not have any memory for the recovery period. At RECOVERY the patients with recall had significantly shorter MnSSER latencies N45 and P50 and inter-wave conduction times LatN35-LatP45 than patients without memory (P<0.05). CONCLUSIONS: We conclude that MnSSER components warrant further investigation for studying the effects of anaesthetic drugs on cognitive function.

Incidence of recall, nightmares, and hallucinations during analgosedation in intensive care.

OBJECTIVE: To define the incidence of recall and dreams during analgosedation in critically ill patients. DESIGN: Prospective clinical study. SETTING: Anaesthesiological intensive care unit (ICU) in a university hospital. PATIENTS AND PARTICIPANTS: Two hundred and eighty-nine critically ill patients, who either arrived intubated and sedated at the ICU or required intubation, mechanical ventilation, and sedation during their ICU stay. INTERVENTIONS: none. MEASUREMENTS AND RESULTS: The patients were interviewed 48-72 h after discharge from the ICU. By a structured interview they were asked whether they recalled any event before they had regained consciousness at the ICU. Moreover they were asked for dreams. Descriptive statistics: 64.7% of all patients did not recall any event, before they regained consciousness. However, 17% ( n=49) of all patients indicated that they remembered the tracheal tube or being on the ventilator, before they woke up. Some patients (21.1%) reported dreams or dreamlike sensations. Some patients (9.3%) recalled nightmares, while 6.6% reported hallucinations. CONCLUSIONS: Critically ill patients reported a high incidence of recall for unpleasant events, which they thought to have taken place before they regained consciousness. The patients, who stayed longer than 24 h at the ICU, indicated vivid memory for nightmares and hallucinations. Further studies are suggested to evaluate: 1) whether there is an impact of the present findings on outcome; and 2) whether clinical scores for sedation or neurophysiological monitoring help to define the exact time, when recall happens, in order to guide therapeutic intervention.

Respiratory syncytial virus infections in previously healthy working adults.

During 1975-1995, a total of 2960 healthy adults, 18-60 years of age, were prospectively evaluated for respiratory virus infections. Of these subjects, 211 (7%) acquired respiratory syncytial virus (RSV) infection. The infections were symptomatic in 84% of subjects, involved only the upper respiratory tract in 74%, and included lower respiratory tract symptoms in 26%. Overall, 40% of the subjects were febrile. Lower respiratory tract signs developed in 26%. RSV illnesses were more prolonged than non-RSV respiratory illnesses. Compared with influenza, RSV infections were less frequently associated with fever and headache, but were associated significantly more often with nasal congestion, ear and sinus involvement, and productive cough. Absence from work during the acute phase of the illness resulted from 38% of RSV infections and 66% of influenza cases. The mean duration of RSV illness (9.5 days), however, was significantly longer than that of influenza (6.8 days). The occurrence of annual epidemics of RSV, the virus' potential to reinfect all age groups, and the morbidity associated with these reinfections suggest that RSV infections in working adults may result in appreciable costs for medical visits and absence from work.

Boost irradiation of breast carcinoma: teletherapy vs. brachytherapy.

BACKGROUND: The results of adjuvant radiotherapy including a boost dose after breast-conserving surgery of mamma carcinoma were retrospectively analysed to relate local tumor control, survival, and cosmetic results to the boost technique. MATERIAL AND METHODS: The study included 229 female patients who were treated in the period 1986--1997. Group A consisted of patients where the primary irradiation was hyperfractionated (two fractions per day) and the boost was applied by reduced portals, also at two fractions per day. In group B the 'boost' was applied interstitially intraoperatively and the 'primary' irradiation followed at one fraction per day. The cosmetic results and the late changes to the mamma were the subjects of follow-up examinations and were assessed using the EORTC score. RESULTS: 129 patients formed group A, median follow-up 4.2 years, and 100 patients with median follow-up of 9.4 years formed group B. 59% of group A and 60% of group B were in stage pT1, 38% and 39% were in pT2, and 25% and 39% were in stage N1 or N2 (no significant differences). Tumors were mostly poorly to moderately differentiated. The upper outer quadrant was most afflicted. Local recurrence occurred in two and five cases, lymph-node recurrence in two cases each, while there were ten and 12 cases of distant metastases. There were no deaths in group A and in group B six with obvious distant metastases and eight with other causes of death. The cosmetic results and late side-effects (induration, teleangiectasis, ulcers) were significantly worse in the interstitial group B. Multivariate analysis revealed that only the total applied dose significantly affected the severity of late radiation side-effects. The cosmetic results worsened with time, the tendency for lymph edemas in the irradiated side increased. Induration decreased continuously after pure teletherapy but increased continuously after interstitial therapy. These trends did not change in either group. CONCLUSIONS: Both therapy schemes resulted in successful local tumor control with good cosmetic results and few side effects, but the interstitial boost therapy was clearly less favourable. Longer-term follow-up is required to compare the late side-effects even further.

Median nerve evoked responses: stimulation modalities for midlatency cortical components.

PURPOSE: Median nerve somatosensory evoked responses (MnSSER) are frequently used clinically and scientifically. However, the stimulus-response interrelationship has not been documented for the midlatency components. Therefore we investigated the spinal and cortical midlatency MnSSER, to document the effect of different stimulus intensities. METHODS: Spinal and midlatency MnSSER were recorded following percutaneous electrical stimulation of the median nerve at the wrist in 32 neurological healthy females. Three different stimulation intensities were applied: threefold sensory threshold (INT 1), motor plus sensory threshold (INT 2), individual level of tolerance (INT 3). STATISTICS: Multivariate analyses of variance (independent variable: stimulation intensity). RESULTS: Three negative and two positive midlatency components were identified after median nerve stimulation. At INT 1 the early waves N20, P25 and N35 were identified in all of the patients. In contrast, the component P45 was identifiable in 23% of the sample at the lowest intensity level and N55, respectively, in 32%. At INT 2 the spinal and the midlatency cortical amplitudes (except amplitude N35P45) were significantly increased (p < 0.014). At INT 3 the amplitudes of the primary cortical complex did not increase further, but the components > 35 ms became identifiable in the whole sample except in one subject. In contrast, there was no change in the MnSSER latencies. The intensity was comfortable for all subjects. CONCLUSION: For monitoring the midlatency MnSSER components > 35 ms the authors suggest a stimulation intensity close to individual tolerance level for optimal cortical responses.

Cortical arousal in critically ill patients: an evoked response study.

OBJECTIVE: Assessing the level of sedation in critically ill patients remains a challenge for the intensivist in order to avoid over or under-sedation. Clinical scoring systems may fail in patients with concomitant neurological disorders or requiring muscle relaxants. We evaluated auditory (AER) and median nerve somatosensory evoked responses (MnSSER) in critically ill patients sedated with sufentanil and propofol, in order to quantify the level of sedation during therapeutic interventions. DESIGN: Prospective clinical study. SETTING: Anaesthesiological intensive care unit (ICU) in a university hospital. PATIENTS AND PARTICIPANTS: Thirty-two patients following major abdominal or thoracic surgery requiring sedation during their stay on the ICU. INTERVENTIONS: During physiotherapy and following nursing care (tracheal suctioning) AER and MnSSER were recorded. The level of sedation was evaluated clinically in relation to vital parameters. Data were analysed by multivariate analyses of variance (Hotellings T2), Friedman test. MEASUREMENTS AND RESULTS: In comparison to baseline levels the AER latency Nb decreased, while the amplitude NaPa increased during physiotherapy and after tracheal suctioning (p < 0.001). In contrast, the MnSSER latency P25 decreased and the amplitude P25N35 increased after tracheal suctioning only (p < or = 0.001). Clinical sedation scores decreased and mean arterial blood pressure increased during physiotherapy and nursing care. CONCLUSIONS: Changes of AER or MnSSER waves indicated cortical arousal in ICU patients during nursing care and physiotherapy. Further studies with evoked responses are recommended to evaluate whether bolus injections of sedatives and/or analgesics reduce cortical arousal and thereby minimise the patient's stress during nursing care.