Intra-articular anaesthesia mitigates established pain in experimental osteoarthritis: a preliminary study of gait impulse redistribution as a biomarker of analgesia pharmacodynamics.

OBJECTIVE: Develop a sensitive, functional biomarker of persistent joint pain in a large animal model of experimental osteoarthritis. Evaluate Impulse Ratio as a measure of weight distribution among supporting limbs throughout the early natural history of osteoarthritis and with local anaesthesia and analgesia. DESIGN: The distribution of weight bearing in the trot of 11 skeletally-mature dogs was analyzed before and after unilateral surgical intervention (cranial cruciate transection or distal femoral focal impact). The short-term effects of two analgesic treatments (intra-articular lidocaine and intra-dermal meloxicam) were then evaluated as an index of pain relief based on the redistribution of weight-bearing impulse between normal and injured limbs. RESULTS: Impulse Ratio was able to resolve weight redistribution between limbs in both long-term (weekly for over 400 days) and short-term (15 min intervals) joint evaluations. Joint pain relief from lidocaine administration could be reliably tracked over its brief acting time course. Meloxicam administration resulted in ambiguous results, where average weight bearing in the injured limb did not increase, but the variability of limb use changed transiently and reversibly. CONCLUSION: Joint function and the role of persistent joint pain in the development of osteoarthritis can be investigated effectively and efficiently in a large animal model through the use of Impulse Ratio. Impulse Ratio can be a functionally relevant and sensitive biomarker of locomotion-related joint pain.

[Postoperative pain assessment in special patient groups: part II. Children with cognitive impairment]. / Postoperative Schmerzmessung bei speziellen Patientengruppen: Teil II: Das kognitiv beeinträchtigte Kind.

Postoperative pain assessment in children with cognitive impairment poses major challenges to healthcare professionals.Children with moderate to severe cognitive impairment are generally unable to communicate effectively and to self-report the level of pain. Difficulties assessing pain have led to their exclusion from clinical trials and rendered them vulnerable to insufficient treatment of pain.The realization of pain is a particularly important step forward for a better care of children with cognitive impairment.Scales based on a child's own perception of pain and its severity play a limited role in this vulnerable population and pain assessment tools which rely on observing pain behavior are essential. The r-FLACC, which is reliable and valid, includes specific behavioral descriptors and can be used simply and effectively postoperatively in clinical practice. Our task has to be assessing pain as a routine procedure in cognitively impaired children as a keystone for an improved and successful pain management in this very sensitive patient population.

[Postoperative pain assessment in special patient groups: part I: children without cognitive impairment]. / Postoperative Schmerzmessung bei speziellen Patientengruppen: Teil I: Das kognitiv unbeeinträchtigte Kind.

The intensity of pain cannot be measured directly but can only be described subjectively. This obviously complicates the assessment especially in the younger age group. Pain evaluation and documentation are essential for good results in pain therapy. Pain can be measured by pain scales which should fulfill the requirements of practicability, reliability and validity. In neonates and children up to 4 years of age, standardized scales have been developed for observation of their activities. Children in the age group 4-6 years old are able to communicate about pain. At this age self-report scales can be used to assess pain sensations."Quality Improvement in Postoperative Pain Management in Infants" (QUIPSInfant) represents a new tool for pediatric outcome evaluation, consisting of standardized data acquisition of outcome and process quality indicators.

Implementation of a standardized pain management in a pediatric surgery unit.

Postoperative pain is still a major complication causing discomfort and significant suffering, especially for children. Therefore, every effort should be made to prevent pain and treat it effectively once it arises. Under-treatment of pediatric pain is often due to a lack of both knowledge about age-specific aspects of physiology and pharmacology and routine pain assessment. Factors for long term success require regularly assessing pain, as routinely as the other vital signs together with documentation of side effects. The fear of side effects mostly prevents the adequate usage of analgesics. Essential is selecting and establishing a simple concept for clinical routine involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids and regional anesthesia.

[Endocarditis prophylaxis in children and adolescents : implementation of the current guidelines in the Department of Paediatric Surgery at the Medical University Graz]. / Endokarditisprophylaxe bei Kindern und Jugendlichen : Umsetzung der aktuellen Leitlinien an der Universitätsklinik für Kinderchirurgie in Graz.

The timely administration of endocarditis prophylaxis means an additional stress situation for many children and their parents in an already stressful preoperative period. In addition it causes an increased organizational effort most of all in the day care department. Over many decades the use of prophylactic antibiotics to prevent infective endocarditis was recommended in patients with underlying cardiac conditions undergoing medical procedures which could lead to bacteraemia. However, transient bacteraemia occurs commonly during routine daily activities such as cleaning teeth or chewing. Most cases of endocarditis are not related to a medical procedure. There are currently no randomized and carefully controlled human trials to definitely prove the effectiveness and efficiency of endocarditis prophylaxis. Therefore, the new guidelines recommend the use of antibiotic prophylaxis only for cardiac conditions associated with the highest risk of adverse outcome from endocarditis. In paediatric surgery and paediatric anaesthesiology this applies mainly to patients with congenital heart disease. The implementation of the new guidelines in the Department of Paediatric Surgery at the Medical University Graz is illustrated in the following article.

[Improvement of CME questions from Der Nervenarzt]. / Verbesserung der formal-didaktischen Qualität der CME-Fragen aus Der Nervenarzt.

BACKGROUND: Multiple choice questions play an important role in training and continuing education. Der Nervenarzt has been publishing articles for continuing medical education (CME) since 2002 which usually have ten multiple choice questions. Studies from other fields have shown that CME questions are often formulated awkwardly from a didactic standpoint. In this study we analyzed the CME questions contained in Der Nervenarzt to assess their instructional quality. MATERIALS AND METHODS: The standardized evaluation was performed by semiskilled nonprofessionals. The setup permitted differentiation of 15 known quality criteria for multiple choice questions from the educational medical literature. RESULTS: Of the 796 questions studied that had been posed in 2002-2008 (370 neurology, 346 psychiatry, and 80 interdisciplinary), 518 questions had an awkward construction for didactic purposes. A negative wording of the stem, followed by unintentional cues and obsolete combination formats were most frequently observed. The proportion of precisely phrased questions has increased significantly since 2006. CONCLUSION: The CME questions in the German medical journal Der Nervenarzt have improved regarding their instructional quality since the beginning of the program.

Aerial strategies advance volcanic gas measurements at inaccessible, strongly degassing volcanoes.

Volcanic emissions are a critical pathway in Earth's carbon cycle. Here, we show that aerial measurements of volcanic gases using unoccupied aerial systems (UAS) transform our ability to measure and monitor plumes remotely and to constrain global volatile fluxes from volcanoes. Combining multi-scale measurements from ground-based remote sensing, long-range aerial sampling, and satellites, we present comprehensive gas fluxes-3760 ± [600, 310] tons day-1 CO2 and 5150 ± [730, 340] tons day-1 SO2-for a strong yet previously uncharacterized volcanic emitter: Manam, Papua New Guinea. The CO2/ST ratio of 1.07 ± 0.06 suggests a modest slab sediment contribution to the sub-arc mantle. We find that aerial strategies reduce uncertainties associated with ground-based remote sensing of SO2 flux and enable near-real-time measurements of plume chemistry and carbon isotope composition. Our data emphasize the need to account for time averaging of temporal variability in volcanic gas emissions in global flux estimates.

Deliberating about bioethics.

In some sense, bioethics was built on conflicts. Abortion, physician-assisted suicide, patients' demand for autonomy all are staple and contentious issues. And the controversies continue to proliferate. What forum best serves such debates? A look at political theories of democracy can help answer that question. The most promising for bioethics debates are theories that ask citizens and officials to justify any demands for collective action by giving reasons that can be accepted by those who are bound by the action. This conception has come to be known as deliberative democracy.

The effect of stride length on the dynamics of barefoot and shod running.

A number of interventions and technique changes have been proposed to attempt to improve performance and reduce the number of running related injuries. Running shoes, barefoot running and alterations in spatio-temporal parameters (stride frequency and stride length) have been associated with significant kinematic and kinetic changes, which may have implications for performance and injury prevention. However, because footwear interventions have been shown to also affect spatio-temporal parameters, there is uncertainty regarding the origin of the kinematic and kinetic alterations. Therefore, the purpose of this study was to independently evaluate the effects of shoes and changes in stride length on lower extremity kinetics. Eleven individuals ran over-ground at stride lengths ± 5 and 10% of their preferred stride length, in both the barefoot and shod condition. Three-dimensional motion capture and force plate data were captured synchronously and used to compute lower extremity joint moments. We found a significant main effect of stride length on anterior-posterior and vertical GRFs, and sagittal plane knee and ankle moments in both barefoot and shod running. When subjects ran at identical stride lengths in the barefoot and shod conditions we did not observe differences for any of the kinetic variables that were measured. These findings suggest that barefoot running triggers a decrease in stride length, which could lead to a decrease in GRFs and sagittal plane joint moments. When evaluating barefoot running as a potential option to reduce injury, it is important to consider the associated change in stride length.

Transorbital impalement injury with massive intracranial lesion not detected by cranial CT scan.

An extraordinary case of transorbital penetration injury is presented. A 24-year-old male patient was involved in a fight and was pushed against a shelf. He immediately lost consciousness and was brought to hospital. A cranial computed tomogaphy (CT) scan showed a hemorrhage and brain edema over the left hemisphere with orbital roof fracture. A decompressive craniectomy was performed. Intraoperatively, an orbital roof fracture with penetration of the frontobasal dura could be seen which could not be explained by the trauma mechanism. The postoperative magnetic resonance imaging (MRI) with susceptibility-weighted image (SWI) showed two injury tracks from the orbit through the brain which appeared to be penetration injuries. The forensics department was consulted and penetration by a falling candleholder was found to be the cause of the injuries. In this case, the cranial CT alone did not show any indication of a penetration injury. Only MRI revealed the penetration track, which stresses the diagnostic value of this modality and especially the SWI in cases where the trauma mechanism does not correspond to the injury shown in the CT scan.

Verbal operants in mothers' speech to nonretarded and Down's syndrome children matched for linguistic level.

Verbal response classes produced by mothers speaking to 21 nonretarded children were compared with those of mothers speaking to 21 Down's syndrome children matched with them on mean length of utterance. As mean length of utterance increased, total verbal response classes increased for both groups of mothers and children. Nonretarded children and their mothers produced more echoics; retarded children and their mothers produced more intraverbals. The implications of these findings were discussed in relation to previous research and the teaching of language.

Experiences with Redy-dialysis on a camper.

In April 1976 a dialysis camper with Redy-dialysis equipment was put into service by the Institute of Nephrology of the 4th Department for Internal Medicine of the City Hospital Nürnberg. In the following six years of service the bus was rented 40 times by 20 different home dialysis patients and was driven more than 100 000 km in Europe on 700 days. Two hundred and eighty haemodialyses with the Redy-system showed that this kind of dialysis during the holidays can be carried out without running a greater risk than with home dialysis itself. A home dialysis patient describes his own experiences with the 'Redy-bus'.

The presence of N-terminal methionine on nascent protein of rat liver and rabbit reticulocytes and its cleavage during polypeptide-chain elongation.

1. The size of nascent globin peptides from which the N-terminal methionine residue is cleaved has been investigated by comparing the proportion of N-terminal methionine and valine in short and long chains. Nascent chains were labelled in rabbit reticulocyte lysates, fractionated according to length by chromatography on Sephadex G-50, and analysed by the Edman degradation of selected pooled fractions. It was found that different peptide fractions contained either methionine or valine, but not both, as the N-terminal residue. Methionine was present at the N-terminus of globin chains containing up to approx. 50 amino acids whereas valine was found to be the N-terminal amino acid of longer peptides. 2. In similar experiments with nascent proteins of rat liver, labelled either in vivo or in a cell-free system containing microsomal material and cell sap, evidence was obtained for the presence of methionine at the N-terminus of nascent chains up to approx. 65 amino acid residues long. Thus protein synthesis in liver appears to be initiated also by methionine, but in this case cleavage takes place somewhat later during peptide elongation than in globin synthesis.

Two propofol formulations are equivalent in small children aged 1 month to 3 years.

BACKGROUND: Propofol has been widely used in general anesthesia. Although it is also often used in pediatric anesthesia, there has been only limited scientific evidence on the use of propofol in children up to 3 years. METHODS: A prospective, randomized, double-blind, therapeutic equivalence study comparing two propofol 1% emulsions (Propofol 1% Fresenius vs. Diprivan 1%) was performed in 60 patients scheduled for routine surgery or for diagnostic laparoscopic procedures requiring anesthesia. To guarantee comparability of age distribution between the two groups, a stratified randomization with patients younger than 12 months of age in a low age group and with patients aged 12 months to 3 years in a high age group was used. The average propofol induction dose and the average propofol infusion dose were analyzed to prove equivalence. The side-effects profile was analyzed to compare the safety profiles of the two propofol formulations in this study. RESULTS: There were no differences in baseline characteristics between the two treatment groups of high and low age. Medications used for induction and maintenance of anesthesia, and side-effects profiles were comparable, as were the average propofol dose for induction of anesthesia (range of the mean dose 4.0-4.2 mg/kg) and for maintenance of anesthesia (range of the mean dose in the first hour 8.74-9.42 mg x kg(-1) x h(-1)). CONCLUSIONS: The two 1% propofol formulations were equally effective in our patient population of infants and young children between 1 month and 3 years of age. No differences between the two propofol formulations were found with regard to the circulatory reaction, lipid metabolism, dosages, and recovery profile in the studied age groups.