Post-thoracotomy Pain Syndrome.

PURPOSE OF REVIEW: This article reviews PTPS demographics, diagnosis, pathophysiology, surgical and anesthetic techniques, and their role in preventing PTPS along with updated treatment options. RECENT FINDINGS: Post-thoracotomy pain syndrome (PTPS) can be incapacitating. The neuropathic type pain of PTPS is along the incision site and persists at least 2 months postoperatively. There is a wide reported range of prevalence of PTPS. There are several risk factors that have been identified including surgical technique and younger age. Several surgical and anesthetic techniques have been trialed to reduce pain after thoracotomy. Multimodal pain control is the suggested long-term treatment plan for patients with PTPS. There are several factors that can be modified to reduce pain and incidence of PTPS during the perioperative period and the use of multimodal analgesia is suggested for the treatment of PTPS.

[Decision support for patient admission in case of suspicion of COVID-19]. / Entscheidungshilfe zur Patientenzuweisung bei Verdacht auf COVID-19: Für die Anwendung im bayerischen Rettungsdienst.

During a pandemic situation, patients with suspected coronavirus disease (COVID-19) are also treated by emergency medical services (EMS). In order to establish an adequate procedure, a decision aid for the allocation of patients in case of suspicion of COVID-19 has been prepared for the ambulance staff as well as for the emergency physician in the Bavarian EMS. The decision-making aid includes the current guidelines and recommendations on COVID-19. A flowchart in A4 format was chosen for the presentation of the decision aid, which is structured according to the ABCDE scheme (A-Airway, B-Breathing, C-Circulation, D-Disability, E-Environment/Exposure) established in EMS. The flowchart allows patients to be categorized in three stages, based on (vital) parameters and criteria such as risk factors and specific framework conditions. The aim is to provide emergency physicians and ambulance staff with guidance for the assessment of patients and the resulting transport decision with a suitable target clinic if necessary.

Influence of denosumab on bone mineral density in a severe case of pregnancy-associated osteoporosis.

Pregnancy and lactation-associated osteoporosis (PLO) with predominantly subsequent vertebral fracture is a rare but severe disease with an estimated incidence of 0.4 in 100,000. In the past, patients with PLO have been predominantly treated with oral and i.v. bisphosphonates to reduce subsequent fracture risk. Hereby, the use of bisphosphonates in premenopausal women is controversial, as bisphosphonates know to persist in bone for many years and can be exposed and circulate in maternal serum and subsequently pass the placenta barrier and may have a detrimental effect on fetal bone health. Here we report the effects of denosumab on the bone mineral density (BMD) and subsequent fracture risk in PLO. In this case presentation, denosumab was administered postpartum with 3000 IE vitamin D and 1000 mg of calcium daily in a patient with PLO and vertebral fracture of L1 and L4. After 18 months of treatment with denosumab, we could demonstrate a clinical significant increase of BMD at the lumbar spine, femoral neck, and total hip of 32.2%, 13.0%, and 11.5% respectively with no further subsequent fractures. As the patient had regular menstrual cycles and considered a further pregnancy, denosumab treatment was terminated and soon a second pregnancy occurred. After the second pregnancy, BMD decreased at the lumbar spine, femur neck, and total hip by -8.8%, -6.9%, and -7.0% respectively compared to the maximum values during treatment with denosumab, but was still significantly higher compared to baseline levels with no further fractures.

[Regional anesthesia in daily clinical practice: an economic analysis based on case vignettes]. / Regionalanästhesie im klinischen Alltag: eine ökonomische Analyse anhand eines Versorgungsbeispiels.

BACKGROUND: The economic effect is a crucial aspect of every medical procedure. This article analyzes the economic implications of various methods in anesthesia based on three case vignettes. METHODS: The management of anesthesia of a forearm fracture with sufficient brachial plexus blockade, general anesthesia and insufficient brachial plexus blockade with subsequent general anesthesia was analyzed with respect to the relevant cost factors (personnel costs, durables, consumables, fixed assets costs, anesthesia-related overhead costs). RESULTS: Sufficient regional anesthesia was the least expensive method for a forearm fracture with 324.26 €, followed by general anesthesia with 399.18 € (+23% compared with regional anesthesia). Insufficient regional anesthesia was most the expensive method, which necessitated an additional general anesthesia (482.55 €, +49% compared with sufficient regional anesthesia). CONCLUSION: Even considering that this cost analysis was calculated based on data from only one medical institution (General Hospital of Vienna, Medical University of Vienna), regional anesthesia appeared to be cost efficient compared with other anesthesia procedures. Main cost drivers in this example were personnel costs.

[Advanced medical post within hospitals as possible tactical instrument for handling mass casualty incidents]. / Der Behandlungsplatz innerhalb eines Krankenhauses als mögliches taktisches Werkzeug zur Bewältigung eines Massenanfalls von Patienten.

BACKGROUND: An important instrument for handling mass casualty incidents in preclinical settings is the use of an advanced medical post. In certain circumstances, however, the establishment of such an advanced medical post on or close to the incident site is impossible. Terrorist attacks are a prime example for this. The highest priority for hospitals during mass casualty incidents is to adjust the treatment capacity to the acute rise in demand and to sustain its functionality throughout the duration of the incident. By establishing an advanced medical post within hospitals during certain types of mass casualty incidents these aims could potentially be accomplished. AIMS: The aims of this pilot study were to test the practicability of the establishment of an advanced medical post within a university hospital and to identify potential problems. The results provide the foundation of a generalized concept, which will then be integrated into the hospital emergency plans. METHODS: After the formation of a multiprofessional expert committee, different areas within the hospital were evaluated based on spatial and tactical considerations. Predefined questions were assessed and harmonized with respect to organization, vehicle management, communication, leadership and patient transport through the means of a practice run. RESULTS: The establishment and operation of an advanced medical post within the hospital were easily possible. The consequent deployment of section leaders enabled the smooth coordination of transport and an unobstructed simulated patient flow. The management of the treatment area by a senior emergency physician and a senior emergency medical service officer in close cooperation with the operational hospital lead proved to be a useful concept. Technical problems with communication within the hospital were resolved by using wireless phones and the installation of a digital radio repeater. DISCUSSION: During acute scenarios with only short prior notice, the authors prefer concepts that supplement the normal hospital operation through additional staff and material. In circumstances with prior notice of more than 60 min an advanced intrahospital advanced medical post, staffed by civil protection units, could be a concept that enables the absorption of the first patient arrivals within the first hour of a mass casualty incident without disturbing the functionality of hospitals to any great extent. Further practice runs are, however, necessary to further develop and adjust this concept to real-life circumstances.

Nanostructured Stealth Surfaces for Visible and Near-Infrared Light.

So far, all previous attempts to apply nanostructures for perfect transmission have not achieved maximum transmittance beyond 99.5% due to the limited regularity of the nanoscale surface geometry: too low for many high-end applications. Here we demonstrate a nanostructured stealth surface, with minimal reflectance (<0.02%) and maximal transmittance (>99.8%) for a wavelength range, covering visible and near-infrared. Compared to multilayer thin film coatings for near-infrared applications our antireflective surfaces operate within a much broader wavelength range, are mechanical stable to resist human touch or contamination, show a 44% higher laser-induced damage threshold, and are suitable for bended interfaces such as microlenses as well.

[Quality indicators for rescue operations in terrorist attacks or other threats : A pilot study after the Würzburg terrorist attack of July 2016]. / Qualitätsindikatoren für rettungsdienstliche Einsätze bei Terroranschlägen oder anderen Bedrohungslagen : Eine Pilotstudie nach dem Würzburger Terroranschlag vom Juli 2016.

BACKGROUND: Terrorist attacks have become reality in Germany. The aim of this work was, after the Würzburg terrorist attack, to define quality indicators and application characteristics for rescue missions in life-threatening situations. The results can be used to record data from future missions using this template in order to make them comparable with each other. METHODS: After approval of the local ethic committee, the first step was to designate a group of experts in order to define the template in a consensus process. The next step was to perform the consensus process by defining the template. An independent expert for emergency medicine and disaster management reviewed and approved the results afterwards. RESULTS: The expert group defined 13 categories and 158 parameters that will further serve the systematic evaluation of the rescue mission of the Würzburg terror attack. Preliminary results of this evaluation process are given in this paper; the full evaluation has not yet been completed. DISCUSSION: In this study we first describe quality indicators and parameters suitable for the German rescue system in order to evaluate rescue operations for violence caused mass casualties. There is similar international documentation, but it does not specifically focus on life-threatening operations and are not adapted to the German context. CONCLUSION: There is an important need to systematically evaluate rescue missions after mass killing incidents. In this study we report a template of parameters and quality indicators in order to systematically evaluate mass violence events. The presented template is the result of an expert consensus process and may serve as a basis for further development and research.

Cerclage Breakage in Trochanteric Revision - High Risk for Hip Endoprosthesis?

We report a 72-year-old man who underwent fixation with a multifilament cerclage system after a peri-prosthetic trochanteric fracture (Vancouver A1). Failure of cerclage occurred after 23 month and revision of trochanteric attachment was performed due to non-union. Intraoperatively fragments of the cable were found between prosthesis head and liner. Cup and head were changed and the greater trochanter was re-attached after allograft-impaction. Based on the present case report multifilament cerclage cables should be used with precaution and might require a close and frequent follow-up given the possibility of cerclage breakage and consecutive catastrophic wear by migration of cerclage particles. Key words: cerclage, cerclage breakage, greater trochanter, revision.

Top Quark Pair Production in Association with a Jet with Next-to-Leading-Order QCD Off-Shell Effects at the Large Hadron Collider.

We present a complete description of top quark pair production in association with a jet in the dilepton channel. Our calculation is accurate to next-to-leading order (NLO) in QCD and includes all nonresonant diagrams, interferences, and off-shell effects of the top quark. Moreover, nonresonant and off-shell effects due to the finite W gauge boson width are taken into account. This calculation constitutes the first fully realistic NLO computation for top quark pair production with a final state jet in hadronic collisions. Numerical results for differential distributions as well as total cross sections are presented for the Large Hadron Collider at 8 TeV. With our inclusive cuts, NLO predictions reduce the unphysical scale dependence by more than a factor of 3 and lower the total rate by about 13% compared to leading-order QCD predictions. In addition, the size of the top quark off-shell effects is estimated to be below 2%.

The relationship between negative symptom subdomains and cognition.

BACKGROUND: Negative symptoms and cognitive deficits in schizophrenia are partially overlapping. However, the nature of the relationship between negative symptoms and cognition remains equivocal. Recent reviews have demonstrated the presence of two negative symptom subdomains, diminished emotional expression (DEE) and avolition. In view of this, we sought to clarify the relationship between negative symptoms and cognitive domains. METHOD: A total of 687 participants with schizophrenia were assessed on measures of psychopathology and cognition. Three cognitive factors, namely executive function, fluency/memory and speed/vigilance were computed from the cognitive tests. Confirmatory factor analysis was utilized to examine if a one-factor or two-factor negative model was applicable to our sample. Subsequently, the relationships between negative symptoms and cognition were examined using structural equation modeling. RESULTS: Results demonstrated that the two-factor model fitted the data well. While negative symptoms were mildly to moderately associated with cognition, we found that DEE had unique associations with cognition compared to social avolition, contributing to the validity of the constructs and suggesting the possibility of common underlying substrates in negative symptoms and cognition. CONCLUSIONS: Our study highlighted the need to classify DEE and social avolition separately as both are necessary in refining the complex relationship between negative symptoms and cognition as well as potentially guiding treatment and management of schizophrenia.

Refining the latent structure of neuropsychological performance in schizophrenia.

BACKGROUND: Elucidating the cognitive architecture of schizophrenia promises to advance understanding of the clinical and biological substrates of the illness. Traditional cross-sectional neuropsychological approaches differentiate impaired from normal cognitive abilities but are limited in their ability to determine latent substructure. The current study examined the latent architecture of abnormal cognition in schizophrenia via a systematic approach. METHOD: Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were carried out on a large neuropsychological dataset including the Brief Assessment of Cognition in Schizophrenia, Continuous Performance Test, Wisconsin Card Sorting Test, Benton Judgment of Line Orientation Test, and Wechsler Abbreviated Scale of Intelligence matrix reasoning derived from 1012 English-speaking ethnic Chinese healthy controls and 707 schizophrenia cases recruited from in- and out-patient clinics. RESULTS: An initial six-factor model fit cognitive data in healthy and schizophrenia subjects. Further modeling, which accounted for methodological variance between tests, resulted in a three-factor model of executive functioning, vigilance/speed of processing and memory that appeared to best discriminate schizophrenia cases from controls. Factor analytic-derived g estimands and conventionally calculated g showed similar case-control discrimination. However, agreement analysis suggested systematic differences between both g indices. CONCLUSIONS: Factor structures derived in the current study were broadly similar to those reported previously. However, factor structures between schizophrenia subjects and healthy controls were different. Roles of factor analytic-derived g estimands and conventional composite score g were further discussed. Cognitive structures underlying cognitive deficits in schizophrenia may prove useful for interrogating biological substrates and enriching effect sizes for subsequent work.

[The utilization of MRI by orthopaedic surgeons: requirements and limitations]. / Fachbezogene Anwendung der MRT in Orthopädie und Unfallchirurgie: Voraussetzungen und Limitationen.

BACKGROUND: The tendency in surgical fields to subspecialize continues. Diagnostic possibilities and surgical indications are becoming more and more sophisticated. As a consequence, surgeons in Germany have the possibility to acquire qualifications in magnetic resonance imaging (MRI) and are allowed to employ MRI scanners without consulting radiologists. AIMS: This article aims to describe the requirements to achieve this special qualification and to give a summary on the legal issues in this matter.

[The role of MRI in dislocations of the patella and other knee pathologies]. / MRT des Kniegelenks unter besonderer Berücksichtigung der Patellaluxation.

In addition to ultrasound and conventional x-ray, magnetic resonance imaging (MRI) plays an important role in the visualization of lesions of the knee. It allows the orthopaedic surgeon to safely detect ruptures of the cruciate ligaments, the meniscus, osteochondral lesions and other ligamentary structures such as the collateral ligaments and the medial patellofemoral ligament (MPFL). In patellar dislocations, risk factors for recurrent dislocations can be determined and the therapy can be adjusted accordingly.This articles aims to give the reader a comprehensive overview on current concepts and techniques in the use of MRI for lesions of the knee. It focuses on patellar dislocations, where MRI plays a dominant role in supporting decision making for the best therapeutic strategy.

[Weightings and sequences in magnetic resonance imaging in orthopedic surgery]. / Wichtungen und Sequenzen der Magnetresonanztomographie in der Traumatologie.

Magnetic resonance imaging (MRI) plays a very important role in the diagnosis of musculoskeletal conditions; its importance in orthopedic trauma continues to grow. To ensure optimal imaging and to be able to answer all clinically relevant questions, some prerequisites must be taken into account. Of uttermost importance is a functioning communication between surgeons and radiologists. To adapt the best sequences, the radiologist needs to know all suspected injuries and the mechanism of trauma. Second, the surgeon must have basic knowledge regarding this technology to optimally use all its possibilities. The aim of this article is to familiarize the reader with basic MRI in traumatology focusing on weightings and sequences.

[MRI in musculoskeletal imaging: possibilities and limitations]. / MRT-Untersuchungen bei Muskelverletzungen: Was ist sinnvoll?

Muscle injuries are the most frequent sport injuries in athletes. In addition to a thorough clinical examination and the history of the trauma mechanism, imaging modalities are required to correctly classify the injury and plan the future treatment and rehabilitation. The two major modalities are ultrasound and magnet resonance imaging (MRI). This article aims to give a comprehensive overview on the possibilities and limitations of MRI imaging in musculoskeletal injuries as well as insight into current development, classifications and technologies.

[Use of magnetic resonance imaging in orthopaedic trauma surgery: global needs analysis]. / Anwendungsgebiete der Magnetresonanztomographie in der Traumatologie: Ergebnisse einer weltweiten Umfrage.

BACKGROUND: Magnetic resonance imaging (MRI) plays a very important role in traumatology; however, clear guidelines and standard operating procedures do not exist on a large scale. The aim of this worldwide needs analysis was to gather detailed information on this imaging modality in the daily work of trauma and orthopedic surgeons and trainees, and to identify ways to optimize its application. Using the network of the"Arbeitsgemeinschaft für Osteosynthesefragen - Association for the Study of Internal Fixation" (AO/ASIF), participants who registered for a webinar on this topic were asked to complete a structured set of questions and simulated cases online. METHODS: A total of 442 participants from 69 countries registered for the webinar and 361 (81.6%) completed all or the main parts of the survey. The main reported barriers to the optimal use of MRI were high cost, long waiting time, a lack of communication between surgeons and radiologists, and a lack of experience and training in this technology. CONCLUSIONS: To address these barriers, a more structured curriculum in the training period of orthopedic and trauma surgeons may be required as well as the development of resources for continuing and self-directed learning.

[Magnet resonance imaging in common injuries of the wrist]. / Magnetresonanztomographie bei häufigen Verletzungen des Handgelenks.

Falling on the outstretched hand is a common trauma mechanism. In contrast to fractures of the distal radius, which usually are diagnosed on plain film radiographs, identifying wrist injuries requires further diagnostic methods, e.g., MRI or CT. This article provides a review of the use of MRI in the most common traumatic wrist injuries, including scaphoid fractures, TFCC lesions, and tears of the scapholunate ligament. Early and selective use of MRI as a further diagnostic method in cases of adequate clinical suspicion helps to initiate the correct treatment and, thus, prevents long-term arthrotic injuries and reduces unnecessary absence due to illness. MRI shows a high reliability in the diagnosis of scaphoid fractures and the America College of Radiology recommends MRI as method of choice after X-ray images have been made. In the diagnosis of ligament and discoid lesions, MR arthrography (MRA) using intraarticular contrast agent has considerably higher accuracy than i.v.-enhanced and especially unenhanced MRI.

[Return to work after total hip arthroplasty]. / Rückkehr in das Erwerbsleben nach Hüfttotalendoprothese.

BACKGROUND: Return to work is an important prerequisite to achieve subjective success of an operation. The analysis of the routine data from the German Federal Pension Fund allows a comprehensive evaluation and investigation of factors which influence reintegration into employment. METHODS: A random 2 % sample of rehabilitants was drawn from the scientific use file "Abgeschlossene Rehabilitation im Versicherungsverlauf 2002-2009" (completed rehabilitation in the course of health insurance 2002-2009) of the German Federal Pension Fund. Patients were included if they were 18-60 years old and had participated in rehabilitation due to the diagnosis arthritis of the hip. To obtain information on employment status the national insurance contributions and labor force groups in the year before and 2 years after rehabilitation were used. Using regression analysis the influence of sociodemographic factors was analyzed. RESULTS: Of the 736 patients included in the survey 625 (84.9 %) were employed again 2 years after rehabilitation. Out of these 519 (83.0 %) returned to their previous profession and 228 (36.5 %) paid less insurance contributions. Increasing age and a manual job were identified as risk factors for re-entry into employment. CONCLUSION: In Germany a high percentage of 84.9 % of patients return to work after joint replacement due to coxarthrosis. Nevertheless, the results indicate that the social situation becomes worse for approximately one sixth of the patients.

Hierarchical temporal processing deficit model of reality distortion and psychoses.

We posit in this article that hierarchical temporal processing deficit is the underlying basis of reality distortion and psychoses. Schizophrenia is a prototypical reality distortion disorder in which the patient manifests with auditory hallucinations, delusions, disorganized speech and thinking, cognitive impairment, avolition and social and occupational dysfunction. Reality distortion can be present in many other disorders including bipolar disorder, major depression and even dementia. Conceptually, schizophrenia is a heterogeneous entity likely to be because of numerous causes similar to dementia. Although no single symptom or set of symptoms is pathognomonic, a cardinal feature in all patients with schizophrenia is chronic distortion of reality. The model that we have proposed accounts for the varied manifestations of reality distortion including hallucinations and delusions. In this paper we consider the implications of this model for the underlying biology of psychoses and also for the neurobiology of schizophrenia and suggest potential targets to consider for the etiology and pathophysiology of reality distortion, especially in the context of schizophrenia.