[Value of clinical key symptoms in the primary treatment of severely injured patients]. / Wertigkeit klinischer Leitsymptome bei der Primärversorgung schwerverletzter Patienten.

BACKGROUND: The initial diagnostic procedure of severely injured patients in the emergency room (ER) during the primary survey is first and foremost a clinical examination. The clinical S3 guidelines provide recommendations for the treatment of patients with severe and multiple injuries. OBJECTIVES: The study was performed to investigate the reliability of clinical key symptoms or red flags registered in the ER that lead to further diagnostic or therapeutic procedures. MATERIAL AND METHODS: An evaluation of key symptoms as a synopsis of the current literature considering aspects of probability calculation and medical experience was carried out. RESULTS: Key symptoms registered during the clinical examination are not sufficiently safe to be solely relied upon for further diagnostic and therapeutic decisions. This confirms the sense of purpose of the strict approach according to the advanced trauma life support (ATLS) algorithm. Red flags can serve as a warning to focus on relevant injuries early on. A rational imaging diagnostic procedure must follow.

Monitoring of the recurrent laryngeal nerve in totally endoscopic thyroid surgery.

We tested the feasibility of the sublingual transoral access for thyroid resection including the monitoring of the recurrent laryngeal nerve (RLN) in a porcine model. We performed a prospective, nonrandomized proof-of-concept experimental investigation on transoral thyroid resection in a porcine model with monitoring of the RLN. Ten endoscopic transoral thyroidectomies were performed in 10 pigs using a neuromonitoring system. First, the RLN was identified visually and then confirmed with the neuromonitoring system bilaterally. A complete transoral thyroid resection was achieved in all living pigs. The average operation time was 50 min. The neuromonitoring system permitted to prove the regular function of the RLN on both sides after the removal of the thyroid gland. The pigs were observed for another 2 h postoperatively. Consequent monitoring of the RLN in endoscopic transoral thyroid resection is possible. This system can be a helpful support to identify the nerve when the anatomic situation due to using an endoscopic access is more complicated. It proved to be a safe procedure in living pigs. Our results might be useful for using the neuromonitoring system as a standard system in endoscopic thyroid surgery for the maximal safety of the patient in these new procedures.

The effect of ultrasound dissection in thyroid surgery.

BACKGROUND: One of the most important aspects of thyroid surgery is hemostasis. The ultrasonically activated scalpel is described as a very useful instrument in thyroid surgery for the dissection and sealing of vessels. Our study compares the short-term results of endocrine surgery, with and without the use of ultrasonic devices. METHODS: In a prospectively randomized trial, 96 patients with endemic goiter were operated by the same surgeon, one study group (n = 54 patients) being operated with the ultrasonic scalpel as an additional instrument. We measured the operating time, the number of ligatures needed as well as intraoperative and postoperative bleeding as surrogate markers for improvement of the surgical technique. RESULTS: The ultrasound dissection technique significantly reduces surgery time (p = 0.048; ultrasound procedure average 68 min, conventional procedure average 83 min), intraoperative bleeding (p = 0.028) and the number of ligatures (p = 0.008; ultrasound procedure average 8.2, conventional procedure average 26.4). CONCLUSIONS: The use of an ultrasonically activated scalpel significantly improves bleeding control during thyroid resections and may also be beneficial with respect to cost reduction. Clinical application and further studies to characterize its role are justified.

Transoral access for endoscopic thyroid resection.

BACKGROUND: Endoscopic neck surgery is requested by an increasing number of patients. The access trauma of the axillary, breast, and chest approaches is greater than with open or video-assisted surgery. The authors tested the feasibility of the sublingual transoral access, which they believe is the most promising minimally invasive endoscopic access to the thyroid gland from outside the neck region. METHODS: The sublingual transoral access was first evaluated in two fresh human cadavers. An experimental investigation then was performed using a porcine model. A total of 10 endoscopic transoral thyroidectomies were performed in 10 pigs using a modified axilloscope with an obturator, ultrasonic scissors, and a neuromonitoring system to identify the recurrent laryngeal nerve. RESULTS: A complete transoral thyroid resection was achieved with both the human cadavers and all the living pigs. Despite the complexity of the anatomic region, the transoral procedure was astonishingly easy to perform. In the animal study, the time from the introduction of the obturator just above the larynx to its removal was 59 s. The average overall operation time was 50 min. The neuromonitoring system permitted the regular function of the recurrent laryngeal nerves on both sides to be proved after removal of the thyroid gland. The pigs were observed for another 2 h after the operation. No complications occurred during the operation or afterward. CONCLUSIONS: Endoscopic transoral thyroid resection is possible. It proved to be a safe procedure in living pigs and astonishingly easy to perform. The results may be helpful for thyroid resections in humans using a similar access, as suggested by the thyroidectomies in human cadavers preceding this study.

[The natural orifice surgery concept. Vision and rationale for a paradigm shift]. / "Natural-Orifice-Surgery- (NOS-)Konzept". Vision und Rationale für einen Paradigmenwechsel.

BACKGROUND: During the 20th Century, laparoscopic surgery achieved high standards and significantly reduced morbidity. In order to make surgery simpler and safer, a new concept, natural orifice surgery (NOS), has recently been introduced. The approach to the abdominal cavity may be transoral-transgastric, transvaginal-transdouglas or transanal-transrectal. This article describes the logic behind this approach and the expected challenges. METHODS: In order to realize this goal, we founded the first European based working group on NOS. This group concentrates on the development of transdouglas procedures in women by using the transdouglas endoscopic device (TED). This is a wide, multi-channel instrument, which will enable surgery to be performed via a single entry. RESULTS: Simulation of various intra-abdominal operations, such as staging, cholecystectomy, appendectomy, myomectomy und ovarectomy, using TED has already been carried out. Practical studies are planned in the near future. CONCLUSION: The feasibility of NOS has been demonstrated in various experimental studies. We believe that this technique will create a spectrum of innovative and high quality operations and will improve patient safety.

Molecular analysis of ammonia oxidation and denitrification in natural environments.

This review summarizes aspects of the current knowledge about the ecology of ammonia-oxidizing and denitrifying bacteria. The development of molecular techniques has contributed enormously to the rapid recent progress in the field. Different techniques for doing so are discussed. The characterization of ammonia-oxidizing and -denitrifying bacteria by sequencing the genes encoding 16S rRNA and functional proteins opened the possibility of constructing specific probes. It is now possible to monitor the occurrence of a particular species of these bacteria in any habitat and to get an estimate of the relative abundance of different types, even if they are not culturable as yet. These data indicate that the composition of nitrifying and denitrifying communities is complex and apparently subject to large fluctuations, both in time and in space. More attempts are needed to enrich and isolate those bacteria which dominate the processes, and to characterize them by a combination of physiological, biochemical and molecular techniques. While PCR and probing with nucleotides or antibodies are primarily used to study the structure of nitrifying and denitrifying communities, studies of their function in natural habitats, which require quantification at the transcriptional level, are currently not possible.

[Epiphysiolysis capitis femoris caused by a repeat minor trauma]. / 14-Jähriger mit Hüftschmerz nach Bagatelltrauma. Bleiben Sie am Ball--sonst wird's kompliziert.

We discuss the case of a 14-year-old boy who, after two episodes of mild recurrent sports trauma, presented with restricted mobility of the right hip due to substantial pain. Radiography revealed an acute slipped capital femoral epiphysis affecting the right femoral head. We report on the successful emergency osteosynthesis, and follow-up. On the basis of the current literature, we also discuss the clinical course of this lesion.

Polymerase chain reaction analysis of the Xba I polymorphism of the human complement C4 genes provides evidence for strong haplotype conservation.

The genes coding for the two isotypes of the fourth component of human complement, C4A and C4B, are located between the HLA-B and -DR loci of the MHC. We studied the linkage relationship of the previously described XbaI RFLP to obtain further insight into the evolution of the tandemly arranged C4 genes. Using exon-specific PCR amplification followed by restriction analysis and direct DNA sequencing, the polymorphic site could be located in exon 40 of the C4 gene (cDNA position 5095). The polymorphism does not change an amino acid residue. Using nested PCR amplification with isotype-specific primers to amplify either C4A or C4B alleles the haplotype arrangement of the XbaI sites in both isotypic C4 genes was analyzed independently. It was observed that the XbaI restriction site was either present or absent in both C4 genes of a given haplotype. In a study of 106 Caucasian haplotypes, only two different haplotypes could be identified carrying a C4A gene with and a C4B gene without the XbaI restriction site. Also, the XbaI site could only be detected in long C4 genes possessing the 6.5-kb insertion in intron 9. Our findings provide evidence that the mutation creating the XbaI polymorphism occurred in an ancestral C4 gene already carrying the long intron 9. The duplicating resulting in the presence of two isotypic genes, C4A and C4B, must have taken place subsequently giving rise to haplotypes with or without the XbaI site.

The influence of the mode of emergency ambulance transportation on the emergency patient's outcome.

Emergency transport by an ambulance can cause considerable psychical and physical stress for patients. We determined the haemodynamic and endocrinological values of 54 healthy volunteers subjected to one high speed emergency transport and one smooth transport. There were significant differences in all measurements: heart rate (p < or = 0.001), blood pressure, cortisol (p < or = 0.01), prolactin, somatotropine and ACTH between the two modes of transportation. We hypothesize that the additional stress of high speed ambulance transport particularly in patients with acute cardiac disease may result in additional morbidity.

[Emergency service utilization and athletic injuries--data collection from the Fulda district]. / Rettungsdiensteinsätze und Sportunfälle--eine Erhebung im Bezirk Fulda.

Throughout the period of one year all sports accidents, which implied the need of medical services (n = 59), in the district of Fulda with 195,000 inhabitants were analysed. The bulk of the accidents took place during soccer matches (37.3%). The share of women was 25.4%. A repeated trauma was registered in 69.5% of the cases. 16% of the casualties received outpatient treatment. The ambulance was already at the site of the accident in 35.6% of the cases. The greater part of the accidents happened in the afternoon (57.6%). The accident was caused due to another athlete in 44.1% of the accidents. An ambulance with a doctor on board was needed four times, because the injury demanded treatment by an internist. The principle measure of first aid, taken by the ambulance men, was the positioning of the injured limb on a splint (n = 44). The incidence of sports accidents with need for medical service is 30/100,000 inhabitants. The part of sports accidents in relation to all ambulance actions is 2.3% (internal medicine only 0.18% and surgery only 15.3%). The percentage of sports accidents demanding a doctor in relation to all rescues with the need for a doctor is 0.3%.

Recent progress in liquid chromatography-based separation and label-free quantitative plant proteomics.

Recent innovations in liquid chromatography-mass spectrometry (LC-MS)-based methods have facilitated quantitative and functional proteomic analyses of large numbers of proteins derived from complex samples without any need for protein or peptide labelling. Regardless of its great potential, the application of these proteomics techniques to plant science started only recently. Here we present an overview of label-free quantitative proteomics features and their employment for analysing plants. Recent methods used for quantitative protein analyses by MS techniques are summarized and major challenges associated with label-free LC-MS-based approaches, including sample preparation, peptide separation, quantification and kinetic studies, are discussed. Database search algorithms and specific aspects regarding protein identification of non-sequenced organisms are also addressed. So far, label-free LC-MS in plant science has been used to establish cellular or subcellular proteome maps, characterize plant-pathogen interactions or stress defence reactions, and for profiling protein patterns during developmental processes. Improvements in both, analytical platforms (separation technology and bioinformatics/statistical analysis) and high throughput nucleotide sequencing technologies will enhance the power of this method.

Stress during simulated emergency transportation in a rescue helicopter: cross-correlation between stress hormones, vital functions and subjective well-being.

Vital functions and stress hormone levels during simulated emergency helicopter transport in healthy volunteers. Twenty-three volunteers were subjected to a simulated 15 minute rescue helicopter transport. We determined vital functions, ACTH, cortisol and prolactin during the flight and filled in a standardized questionnaire before and after the flight. Data were analysed descriptively, by means of cross tabulation, Spearman rank correlation and cross-correlation technique. During take-off we recorded a significant increase of vital parameters such as heart rate. Prolactin concentration rose slightly after the start. Maximum cortisol and ACTH levels were found before take-off and then they decreased gradually. As expected, ACTH and cortisol cross-correlated significantly without any relevant time lag. Test items showed a feeling of fear and concern before take off. After the flight the volunteers reported having less stress than expected. Particularly, diastolic blood pressure and prolactin levels were markedly associated with questionnaire items such as behaviour of the staff or nausea. Heart rate significantly correlated with anxiety scores. Helicopter transportation induced a marked stress reaction in healthy volunteers, which speaks in favour of smooth transports in modern helicopters and adequate behaviour towards the patient of the staff.

[Risk management in hospitals: standard operating procedures in aviation as a model for structuring medical communication]. / Risikomanagement zur Fehlervermeidung im Krankenhaus: Standard Operating Procedures aus der Luftfahrt als Vorbild für eine strukturierte Kommunikation im Klinikalltag.

AIM: The working conditions for medical staff in German hospitals with emergency units are characterised by stress peaks. In such moments mistakes are more likely to be made. Communication problems and misunderstandings caused by these settings are the most frequent causes for blunders, errors and mistakes. The aim is to show an easy way to reduce the incidence of these problems. METHOD: Within this prospectively randomised trial we compare the ability of 50 physicians to remember standardised information on patient's data passed on to them in a briefing. Half of the subjects used the so called 5-finger method as an easy means of memorising standardised information. The other 25 physicians memorised the patient's data in the usual way. In order to assess the information recalled by the subjects, all of them were asked to answer 15 questions on the data they had been given an hour earlier. RESULTS: The subjects who used the 5-finger method were able to give on average 9.88 (of 15) correct answers and thus remembered significantly (p = 0.031) more information than the members of the control group. CONCLUSION: Communication errors caused by homophony, ambiguity, anticipation and mental models are can be avoided in well-structured communication situations. The rules for such a type of communication can easily be learned and applied. Standardised communication has already proved to reduce the error rates in aviation. We conclude that it can be helpful to introduce standardised communication rules such as the 5-finger method in medical communication.

[The present place of video-assisted procedures in thyroid surgery]. / Stand und Stellenwert der video-assistierten Schilddrüsenchirurgie.

BACKGROUND: Standardized surgical technique, the use of ultrasonic dissection and neuro- monitoring, have reduced morbidity in thyroid surgery, so that aesthetic aspects and endoscopic or minimally-invasive thyroid surgery have become more important for the patients. METHODS: We report on minimally-invasive and endoscopic procedures with either a cervical or extracervical access. Besides current literature we discuss our own results. RESULTS: The critical evaluation of these procedures shows that the standards of endocrine surgery are not at all times entirely observed. CONCLUSIONS: We therefore suggest requirements for endoscopic thyroid resection: The access trauma must be minimal, the aesthetic result must be optimal--without visible scars--and the size of the resected thyroid tissue should be the same as in open surgery. It has to be possible to resect the tissue en bloc. Only if the quality of the endoscopic thyroid resection is ensured aesthetic aspects may begin to play a role. If all these demands are fulfilled, the advantages of endoscopic resections do not only cover aesthetic aspects. The first results show less perioperative pain and a shorter stay in hospital. However, to prove this, further studies are necessary.