Evaluation of the practice of reprocessing ORs in German hospitals from an infection prevention and control perspective.

BACKGROUND: The aim of this study was to analyze the cleaning and disinfection of operating rooms (ORs) status quo focusing on hygiene plans in German hospitals. METHODS: In 2016, a structured online survey was sent to infection prevention and control (IPC) specialists at the cost calculation hospitals of the Institute for the Hospital Remuneration System (InEK) and all university hospitals in Germany (n = 365). RESULTS: With a response rate of 27.4%, 78% stated that written hygiene plans were available. After cleaning and disinfecting an OR with a "septic" patient, 55% waited until surfaces were dry before reusing in accordance with national recommendations, 27% waited > 30 min. Additionally, 28% of hospitals had ORs only for "septic" patients. In 56% "septic" patients were only operated on at the end of the program. Postoperative monitoring of patients with bacteria with special IPC requirements took place in the post anesthesia care unit (PACU) (29%), operating room (OR) (52%), intensive care unit (ICU) (53%), and in the intermediate care unit (IMC) (19%). DISCUSSION AND CONCLUSIONS: Despite written hygiene plans in place the partly long duration of OR nonuse time following IPC measures, the consistent continued use of stratification for "septic" patients and the postoperative follow-up care of patients with colonizing/infecting bacteria with special IPC requirements in the OR and high care areas represent relevant potential for improvement.

Quality of analgesic care in labor: A cross-sectional study of the first national register-based benchmarking system.

OBJECTIVE: Unlike other types of acute pain, labor pain is considered physiological. Due to the heterogeneous management during labor, there is a lack of intention to define quality of care of peripartal analgesia. This study presents the first results of the national register for this evaluation. METHODS: This prospective cross-sectional study, conducted in five different German level-three hospitals, included women after vaginal childbirth between January 2020 and January 2022. A validated questionnaire was completed 24 h postpartum, including information about labor pain, satisfaction, and expectations regarding analgesia. Data were centrally recorded with obstetric records using the database of the QUIPS (Quality Improvement in Postoperative Pain Management) Project. RESULTS: A total of 514 women were included. On an 11-point Numerical Rating Scale, pain intensity during labor was severe (8.68 ± 1.8) while postpartal pain was 3.9 (±2.1). The second stage of labor was considered the most painful period. Only 62.6% of the parturients obtained pharmacological support, with epidural being the most effective (reduction of 3.8 ± 2.8 points). Only epidural (odds ratio [OR] 0.22) and inhalation of nitrous oxide (OR 0.33) were protective for severe pain. In benchmarking, a relation between satisfaction, pain intensity, and the use of epidural was found; 40.7% of the women wished they had received more analgesic support during labor. CONCLUSION: This study highlights deficiencies in analgesic management in high-level perinatal centers, with more than 40% of parturients considering actual practices as insufficient and wishing they had received more analgesic support, despite the availability of analgesic options. Using patient-reported outcomes can guarantee qualitative tailored analgesic care in women.

Spatiotemporal dynamics of self-organized branching in pancreas-derived organoids.

The development dynamics and self-organization of glandular branched epithelia is of utmost importance for our understanding of diverse processes ranging from normal tissue growth to the growth of cancerous tissues. Using single primary murine pancreatic ductal adenocarcinoma (PDAC) cells embedded in a collagen matrix and adapted media supplementation, we generate organoids that self-organize into highly branched structures displaying a seamless lumen connecting terminal end buds, replicating in vivo PDAC architecture. We identify distinct morphogenesis phases, each characterized by a unique pattern of cell invasion, matrix deformation, protein expression, and respective molecular dependencies. We propose a minimal theoretical model of a branching and proliferating tissue, capturing the dynamics of the first phases. Observing the interaction of morphogenesis, mechanical environment and gene expression in vitro sets a benchmark for the understanding of self-organization processes governing complex organoid structure formation processes and branching morphogenesis.

Fluvial Depositional Systems of the African Humid Period: An Analog for an Early, Wet Mars in the Eastern Sahara.

A widely hypothesized but complex transition from widespread fluvial activity to predominantly aeolian processes is inferred on Mars based on remote sensing data observations of ancient landforms. However, the lack of analysis of in situ martian fluvial deposits hinders our understanding of the flow regime nature and sustainability of the martian fluvial activity and the hunt for ancient life. Studying analogs from arid zones on Earth is fundamental to quantitatively understanding geomorphic processes and climate drivers that might have dominated during early Mars. Here we investigate the formation and preservation of fluvial depositional systems in the eastern Sahara, where the largest arid region on Earth hosts important repositories of past climatic changes. The fluvial systems are composed of well-preserved single-thread sinuous to branching ridges and fan-shaped deposits interpreted as deltas. The systems' configuration and sedimentary content suggest that ephemeral rivers carved these landforms by sequential intermittent episodes of erosion and deposition active for 10-100s years over ∼10,000 years during the late Quaternary. Subsequently, these landforms were sculpted by a marginal role of rainfall and aeolian processes with minimum erosion rates of 1.1 ± 0.2 mm/yr, supplying ∼96 ± 24 × 1010 m3 of disaggregated sediment to adjacent aeolian dunes. Our results imply that similar martian fluvial systems preserving single-thread, short distance source-to-sink courses may have formed due to transient drainage networks active over short durations. Altogether, this study adds to the growing recognition of the complexity of interpreting climate history from orbital images of landforms.

[Frequency distribution and coordination of emergency operations in German hospitals (FACE) : Analysis in 26 hospitals depending on the level of care]. / Häufigkeitsverteilung und koordinative Umsetzung von Notfalloperationen in deutschen Krankenhäusern : Analyse in 26 Krankenhäusern in Abhängigkeit von der Versorgungsstufe.

BACKGROUND: Timely emergency surgery is vital as this often has a direct impact on morbidity and mortality. The joint recommendations of the German Associations of Anesthesiologists (BDA), Surgeons (BDC), and Operating Room Management (VOp.M) for coordinative implementation have been available since 2016: N0 (surgery immediately), N1 (surgery start in the next free operating room), N2 (surgery start ≤ 6 h), N3 (surgery at the end of the elective schedule), N4/Urgent (surgery within 12-24 h). The aim of this study was to describe the situation of care in German hospitals of different sizes for the first time using routine data. METHODS: The data were collected in 26 hospitals with different levels of care over a period of 10 days. The frequency distribution of the individual emergency categories and the duration from the notification of the operation to the start of anesthesia or surgery were examined for the hospital as a whole and for the four operating departments with a typically high ratio of emergencies: general surgery, trauma surgery, gynecology/obstetrics and urology. RESULTS: A total of 1603 emergency surgical interventions were analyzed. The number of N0 cases was very low due to the specific entity of these emergencies, N1 made up approximately 13-15% of emergencies and categories N2-N4/Urgent comprised approximately 25-32% of emergencies each. The average duration between the notification of the operation and the start of anesthesia or surgery was (min): N0 20.7 ± 14.3 and 43.6 ± 31.8, N1 61.5 ± 48.7 and 90.1 ± 56.1, N2 187.9 ± 152.0 and 220.5 ± 153.4, N3 394.5 ± 392.3 and 428.3 ± 397.9 and N4/Urgent 494.8 ± 484.4 and 519.6 ± 486.6, respectively. The distribution of the emergency categories did not differ significantly between community hospitals compared to tertiary care hospitals, including university hospitals (p = 0.731) and also the duration between notification and start of anesthesia and operation was similar. Significant differences depending on the service level were only found for N1 until the start of anesthesia and for N3 until the start of anesthesia and of surgery. General surgery classified as N3 has a significantly shorter implementation time in community hospitals compared to tertiary care hospitals, including university hospitals, both at the start of anesthesia (mean 287.8 min versus 417.1 min; p = 0.045) and at the start of surgery (mean 316.3 min versus 459.0 min; p = 0.032). The implementation of trauma surgery emergencies classified as N1 took place, based on the start of surgery in community hospitals with an average duration of 91.2 min, statistically significantly faster than in hospitals with a maximum care of 133.0 min (p = 0.036). In urology, there were notable variations between smaller and larger hospitals in emergency interventions with the classification N4/Urgent for both periods of time, both up to the start of anesthesia (p = 0.012) and up to the start of surgery (p = 0.007). At an average of 291.8 min (start of anesthesia) or 294.4 min (start of surgery), the implementation time in hospitals with maximum care, including university hospitals, was shorter than in urological clinics of community providers (626.5 min and 645.6 min, respectively). In gynecology/obstetrics, there was no statistically significant difference between the two groups. CONCLUSION: Cases with high urgency were surgically treated within a short time period. Overall, differences in time management of emergencies were only small between hospital types. The gradations in the temporal implementation of the individual emergency categories were due particularly to distinctions in the resources available, such as the number of operating theaters, including the run times.

Increased prevalence of metabolic syndrome in patients with bipolar disorder compared to a selected control group-a Northern Netherlands LifeLines population cohort study.

OBJECTIVES: Metabolic syndrome (MetS) is highly prevalent among patients with bipolar disorder (BD). The aims of this cross-sectional study were to determine the prevalence of MetS in Dutch BD subjects and compare it with a control group, to examine the association of demographic and clinical characteristics with MetS in BD, and to determine the extent to which metabolic dysregulation is treated in those patients. METHODS: 493 Dutch adult patients (≥ 18 years) with BD receiving psychotropic drugs and 493 matched control subjects were compared using data from the biobank Lifelines. We determined MetS according to the National Cholesterol Education Program Adult Treatment Panel III-Adapted (NCEP ATP III-A) criteria. The difference in the prevalence of MetS and the associations with characteristics were analyzed with logistic regression. RESULTS: BD subjects (30.6%) showed a significantly higher prevalence of MetS compared to the control group (14.2%) (p < .001, OR:2.67, 95% CI:1.94-3.66). Univariate analysis showed that smoking, body mass index (BMI) and antidepressant drug use were associated with MetS. Multivariate analysis showed that smoking (OR:2.01) was independently associated with MetS in BD. For hypertension, hyperglycemia and lipid disorder pharmacological treatment was provided to respectively 69.5%, 24% and 18.4% of the BD subjects in our sample. LIMITATIONS: Duration of illness of BD subjects was unknown. CONCLUSIONS: This study demonstrated a higher prevalence of MetS in Dutch BD subjects compared to persons without BD. In addition, a remarkable undertreatment of some of the components of MetS was found.

Effects of supplementing a CP-reduced diet with rumen-protected methionine on Fleckvieh bull fattening.

The objective of this study was to evaluate the effect of supplementing a CP-reduced diet with rumen-protected methionine on growth performance of Fleckvieh bulls. A total of 69 bulls (367 ±â€¯25 kg BW) were assigned to three feeding groups (n = 23 per group). The control (CON) diet contained 13.7% CP and 2.11 g methionine/kg diet (both DM basis) and was set as positive control. The diet reduced in CP (nitrogen) (RED) diet as negative control and the experimental RED + rumen-protected methionine (MET) diet were characterised by deficient CP concentrations (both 9.04% CP). The RED + MET diet differed from the RED diet in methionine concentration (2.54 g/kg DM vs. 1.56 g/kg DM, respectively) due to supplementation of rumen-protected methionine. Rumen-protected lysine was added to both RED and RED + MET at 2.7 g/kg DM to ensure a sufficient lysine supply relative to total and metabolisable protein intake. Metabolisable energy (ME) and nutrient composition were similar for CON, RED, and RED + MET. Bulls were fed for 105 days (d) on average. Individual feed intake was recorded daily; individual BW was recorded at the beginning of the experiment, once per month, and directly before slaughter. At slaughter, blood samples were collected and carcass traits were assessed. Reduction in dietary CP concentration reduced feed intake, and in combination with lower dietary CP concentration, daily intake of CP for RED and RED + MET was lower compared with CON (P < 0.01). Daily ME intake was reduced in RED and RED + MET compared with CON (P < 0.01). Consequently growth performance and carcass weights were reduced (both P < 0.01) in both RED and RED + MET compared with CON. Supplemental rumen-protected methionine was reflected in increased serum methionine concentration in RED + MET (P < 0.05) as compared to RED but it did not affect growth performance, carcass traits and serum amino acid (AA) concentrations, except for lysine which was reduced (P < 0.01) compared to CON and RED. In conclusion, bulls fed RED or RED + MET diets were exposed to a ruminal CP deficit and subsequently a deficit of prececal digestible protein, but methionine did not appear to be the first-limiting essential AA for growth under the respective experimental conditions.

Case delay in the OR morning start in hospitals of different size and academic status : Results from a German multicenter study to identify incidence and causes of delayed anesthesia ready time.

BACKGROUND: Delays in the start of morning operations cause a loss of expensive OR capacity as well as frustration and potential conflicts among the different professions involved. There are a lot of reasons which can lead to delayed anesthesia ready time (ART). This is the first large multicenter study to identify incidence, extent and reasons of delay in ART. METHODS: First case delays in ART were studied in all regular ORs in 36 hospitals of different sizes (smaller community hospitals, larger community hospitals and university hospitals) over a period of 2 weeks. We analyzed the results comparing the 3 hospital types regarding incidence, extent and reasons for delay. RESULTS: A total of 3628 first of day cases were included in the study. Incidences of delayed ART (delay >5 min) ranged from 26.5% in university hospitals to 40.8% in larger community hospitals. However, university hospitals had higher incidences than smaller community hospitals of delays greater than 15 and 30 min. The main reasons for delays were prolonged induction of anesthesia, patient in-hospital logistics and delayed patient arrival at the hospitals. The highest mean delay of delayed cases was found in university hospitals with 21.7 min ± 14.7 min (SD). CONCLUSIONS: Delays in anesthesia ready time have a high prevalence in most hospitals, however the reasons for delay are manifold, making interventions to reduce delay complex.

[Delayed incision time of the first case : Analysis of incidences and causes and the effect of list planning instability]. / Verzögerungen der Schnittzeit des ersten Falles : Analyse von Inzidenzen und Ursachen sowie des Effektes von Planinstabilität.

BACKGROUND: Delays in beginning operations in the morning lead to a loss of valuable operating time and can cause frustration among the medical personnel involved. OBJECTIVE: So far there are no prospective, multicentric investigations of the incidence and reasons for delayed first incision times in the morning. The effect of planning list instability of first cases on late operating room starts has not yet been evaluated. MATERIAL AND METHODS: In this multicenter prospective study delays in surgical incision time in all first cases of the day were investigated in 36 German and Swiss hospitals (14 surgical specialties) over a period of 2 weeks. RESULTS: A total of 3628 first of the day cases were included in the study. Looking at all subspecialties combined 50.8% of the first cases of the day were delayed by more than 5 min and in 30.2% of cases longer than 15 min. Incidences of delayed surgical incision time >5 min ranged from 40.0% (gynecology) to 66.8% (neurosurgery). The main reasons for delays in ascending order were prolonged induction of anesthesia compared to the planned time, the delayed appearance of the surgeon and prolonged preparation for surgery. The incidence of delays in incision times for planning list instability was increased by 10% and the average delay increased by 7 min. CONCLUSION: Delays in surgical incision times of the first operation of the day have a high incidence in most surgical specialties; however, the reasons for delays are manifold. Plan instability of operating room lists with respect to the first cases has a negative effect on the punctuality of the incision time and should therefore be avoided.

Placental production of progestins is fully effective in villous cytotrophoblasts and increases with the syncytiotrophoblast formation.

Placental syncytiotrophoblast (ST) is considered as the main placental endocrine tissue secreting progesterone, a steroid essential for maintenance of pregnancy. However, each step of progestins production has been poorly investigated in villous cytotrophoblast (VCT) regarding ST formation. We aimed to characterize progestins production during human differentiation of VCT into ST. VCTs were isolated from term placenta and cultivated, with or without forskolin (FSK), to stimulate trophoblast differentiation. Secreted progestins concentrations were determined by immuno-assay and Gas Chromatography-tandem mass spectrometry. Intracellular expression of cholesterol transporter and enzymes involved in steroidogenesis were studied by immunofluorescence, western-blot, and RT-qPCR. Progesterone and pregnenolone are produced by VCT and their secretion increases with VCT differentiation while 17-hydroxyprogesterone concentration remains undetectable. HSD3B1 enzyme expression increases whereas MLN64, the cholesterol placental mitochondrial transporter and P450SCC expressions do not. FSK induces progestins production. Progestins placental synthesis is effective since VCT and increases with ST formation thanks to mitochondria.

[Does hospital volume correlate with surgical process time? : Retrospective analysis of the five most common procedures for visceral surgery, trauma and orthopedic surgery and gynecology/obstetrics from the benchmarking program of the Berufsverband Deutscher Anästhesisten (BDA), Berufsverband Deutscher Chirurgen (BDC) and Verband für OP-Management (VOPM)]. / Korreliert die Leistungsmenge eines Krankenhauses mit der chirurgischen Prozesszeit? : Retrospektive Analyse der jeweils fünf häufigsten Prozeduren aus den Bereichen Viszeralchirurgie, Unfall­/orthopädische Chirurgie und Gynäkologie/Geburtshilfe aus dem Benchmarking-Programm von BDA, BDC und VOPM.

BACKGROUND: Minimum volume thresholds for specific surgical procedures in German hospitals were established in 2004 but remain controversial. For the first time, this study investigated the relationship between hospital performance volume and surgical procedure duration in a multicenter approach. The question here was whether a concentration on frequently performed procedures leads to a reduction in surgical process times. METHODS: In a retrospective analysis, the 5 most common procedures from visceral, trauma/orthopedic and gynecological/obstetrics surgery were examined in hospitals participating in a benchmarking program. For each procedure performed between 2013 and 2015, hospitals were divided into 4 groups depending on the hospital volume provided. The average surgical duration of incision to suture time was calculated between the group with "very low" hospital volume and the other three groups ("low", "high" and "very high"). RESULTS: OR cases from 75 hospitals were analyzed. The number of included cases per procedure ranged from 31,940 to 2705. The average number of operations performed in a specific procedure was 3-4 times higher in high-volume hospitals compared to very low-volume hospitals. A linear relationship between hospital volume and surgical process time only appeared to be clearly seen in laparoscopic cholecystectomy, appendectomy and arthroscopic meniscus surgery: a higher case load led to a reduction in incision to suture time. For the other procedures, the surgical process times were inconsistent between the hospital groups. CONCLUSION: The case volume only appeared to have a direct but limited influence on incision to suture times in laparoscopic and arthroscopic procedures. Overall, the hospital performance volume appeared to be of subordinate importance in terms of OR-economics.

A cross-sectional study on preoperative anxiety in adults.

OBJECTIVE: The main objective of this study was a detailed comparison of the level of anxiety about surgery and anesthesia. Other objectives included the assessment of the prevalence and intensity of preoperative anxiety. METHODS: This cross-sectional single-center survey used the validated Amsterdam anxiety and information scale (APAIS) and a modified numeric rating scale (mNRS) to assess preoperative anxiety, anxiety about surgery and anxiety about anesthesia. Prevalences and intensities of anxieties were predominantly analyzed descriptively. RESULTS: 3200 patients were enrolled and 3087 (57% females) were analyzed. 92.6% reported preoperative anxiety according to APAIS scores. The average total APAIS anxiety score (APAIS-A-T) was 9.9 (SD 3.6). 40.5% reported high anxiety (defined as APAIS-A-T > 10). Mean anxiety about surgery (APAIS-A-Su) was higher than mean anxiety about anesthesia (APAIS-A-An): 5.5 (SD 2.1) vs. 4.3 (SD 1.9), p < 0.0001. Accordingly, more patients were substantially more afraid (score difference > 2) of surgery (642, 20.8%, 95% CI 19.4-22.3) than of anesthesia (48, 1.6%, 95% CI 1.2-2.1). CONCLUSION: Preoperative anxiety is still very common among adult patients scheduled to undergo an elective procedure. Therefore, it should be evaluated routinely. Anxiety about surgery and anxiety about anesthesia differ in many patients. For this reason, anxiety about surgery and anxiety about anesthesia should be assessed separately. This would allow providing a more individualized support of patients to cope with their anxiety and could require particular attention by the surgeon or the anesthetist.

Epidemiology and outcomes of Clostridium difficile infection in allogeneic hematopoietic cell and lung transplant recipients.

BACKGROUND: Clostridium difficile infection (CDI) is a common complication of lung and allogeneic hematopoietic cell (HCT) transplant, but the epidemiology and outcomes of CDI after transplant are poorly described. METHODS: We performed a prospective, multicenter study of CDI within 365 days post-allogeneic HCT or lung transplantation. Data were collected via patient interviews and medical chart review. Participants were followed weekly in the 12 weeks post-transplant and while hospitalized and contacted monthly up to 18 months post-transplantation. RESULTS: Six sites participated in the study with 614 total participants; 4 enrolled allogeneic HCT (385 participants) and 5 enrolled lung transplant recipients (229 participants). One hundred and fifty CDI cases occurred within 1 year of transplantation; the incidence among lung transplant recipients was 13.1% and among allogeneic HCTs was 31.2%. Median time to CDI was significantly shorter among allogeneic HCT than lung transplant recipients (27 days vs 90 days; P = .037). CDI was associated with significantly higher mortality from 31 to 180 days post-index date among the allogeneic HCT recipients (Hazard ratio [HR] = 1.80; P = .007). There was a trend towards increased mortality among lung transplant recipients from 120 to 180 days post-index date (HR = 4.7, P = .09). CONCLUSIONS: The epidemiology and outcomes of CDI vary by transplant population; surveillance for CDI should continue beyond the immediate post-transplant period.

Fluorescent markers of various organelles in the wheat pathogen Zymoseptoria tritici.

Development of novel strategies to control fungal plant pathogens requires understanding of their cellular organisation and biology. Live cell imaging of fluorescent organelle markers has provided valuable insight into various aspects of their cell biology, including invasion strategies in plant pathogenic fungi. Here, we introduce a set of 17 vectors that encode fluorescent markers to visualize the plasma membrane, endoplasmic reticulum (ER), chromosomes, the actin cytoskeleton, peroxisomes and autophagosomes in the wheat pathogen Zymoseptoria tritici. We fused either enhanced green-fluorescent protein (eGFP) or a codon-optimised version of GFP (ZtGFP) to homologues of a plasma membrane-located Sso1-like syntaxin, an ER signalling and retention peptide, a histone H1 homologue, the LifeAct actin-binding peptide, a mitochondrial acetyl-CoA dehydrogenase, a peroxisomal import signal and a homologue of the ubiquitin-like autophagosomal protein Atg8. We expressed these markers in wildtype strain IPO323 and confirmed the specificity of these markers by counterstaining or physiological experiments. This new set of molecular tools will help understanding the cell biology of the wheat pathogen Z. tritici.

LEA29Y expression in transgenic neonatal porcine islet-like cluster promotes long-lasting xenograft survival in humanized mice without immunosuppressive therapy.

Genetically engineered pigs are a promising source for islet cell transplantation in type 1 diabetes, but the strong human anti-pig immune response prevents its successful clinical application. Here we studied the efficacy of neonatal porcine islet-like cell clusters (NPICCs) overexpressing LEA29Y, a high-affinity variant of the T cell co-stimulation inhibitor CTLA-4Ig, to engraft and restore normoglycemia after transplantation into streptozotocin-diabetic NOD-SCID IL2rγ-/- (NSG) mice stably reconstituted with a human immune system. Transplantation of INSLEA29Y expressing NPICCs resulted in development of normal glucose tolerance (70.4%) and long-term maintenance of normoglycemia without administration of immunosuppressive drugs. All animals transplanted with wild-type NPICCs remained diabetic. Immunohistological examinations revealed a strong peri- and intragraft infiltration of wild-type NPICCs with human CD45+ immune cells consisting of predominantly CD4+ and CD8+ lymphocytes and some CD68+ macrophages and FoxP3+ regulatory T cells. Significantly less infiltrating lymphocytes and only few macrophages were observed in animals transplanted with INSLEA29Y transgenic NPICCs. This is the first study providing evidence that beta cell-specific LEA29Y expression is effective for NPICC engraftment in the presence of a humanized immune system and it has a long-lasting protective effect on inhibition of human anti-pig xenoimmunity. Our findings may have important implications for the development of a low-toxic protocol for porcine islet transplantation in patients with type 1 diabetes.

rFSH in medically assisted procreation: Evidence for ovarian follicular hyperplasia and interest of mass spectrometry to measure 17-hydroxyprogesterone and Δ4-androstenedione in serum.

Ovarian monitoring requires the determination of serum estradiol and progesterone levels. We investigated whole follicular steroidogenesis under rFSH in medically assisted procreation (MAP: 26 IVF, 24 ICSI) compared to 11 controls (IUI). Estrone, estradiol, Δ4-androstenedione, testosterone, progesterone and 17-hydroxyprogesterone were measured by immunoassay and mass spectrometry except for estrogens. At the start of a spontaneous or induced cycle, steroids levels fluctuated within normal ranges: estradiol (314-585 pmol/L), estrone (165-379 pmol/L) testosterone (1.3-1.6 nmol/L), Δ4-androstenedione (4.5-5.6 nmol/L), 17-hydroxyprogesterone (2.1-2.2 nmol/L) and progesterone (1.8-1.9 nmol/L). 17-hydroxyprogesterone, Δ 4-androstenedione and estradiol predominated. Then estradiol and oestrone levels rise, but less markedly for oestrone in IUI. In MAP, rFSH injections induce a sharp increase in estrogens associated with a rise in 17-hydroxyprogesterone and Δ4-androstenedione levels, disrupting oestrogen/androgen ratios. rFSH stimulation induces an ovarian hyperplasia and Δ4pathway which could become abnormal. Determining 17-hydroxyprogesterone and Δ4-androstenedione levels with LC-MS/MS may therefore be useful in managing recurrent MAP failures.

[Palliative therapy concepts in intensive care medicine]. / Palliative Therapiekonzepte in der Intensivmedizin.

Involvement of palliative care is so far not common practice for critically ill patients on surgical intensive care units (ICUs) in Germany. The objectives of palliative care concepts are improvement of patient quality of life by relief of disease-related symptoms using an interdisciplinary approach and support of patients and their relatives considering their current physical, psychological, social and spiritual needs. The need for palliative care can be identified via defined screening criteria. Integration of palliative care can either be realized using a consultative model which focusses on involvement of palliative care consultants or an integrative model which embeds palliative care principles into the routine daily practice by the ICU team. Early integration of palliative care in terms of advance care planning (ACP) can lead to an increase in goals of care discussions and quality of life as well as a decrease of mortality and length of stay on the ICU. Moreover, stress reactions of relatives and ICU staff can be reduced and higher satisfaction with therapy can be achieved. The core of goal of care discussions is professional and well-structured communication between patients, relatives and staff. Consideration of palliative care principles by model-based integration into ICU practice can improve complex intensive care courses of disease in a productive but dignified way without neglecting curative attempts.