[Use of regional anesthesia for preoperative analgesia for proximal femoral fractures in the emergency department : A survey on current practice in German-speaking countries and the United Kingdom]. / Anwendung regionalanästhesiologischer Verfahren zur präoperativen Analgesie bei proximalen Femurfrakturen in der Notaufnahme : Eine Umfrage zur Praxis im deutschsprachigen Raum und in Großbritannien.

BACKGROUND: Regional anesthesia (RA) techniques such as femoral nerve block (FNB) or fascia iliaca compartment block (FICB) are effective analgesia techniques in the treatment of pain from proximal femoral fractures (PFF). While in Great Britain (GB) these are already frequently used in the emergency department for preoperative analgesia, in the German-speaking D­A-CH area (Germany, Austria, Switzerland) this seems to occur much less frequently. Therefore, the aim of this study was to survey the type and frequency of RA procedures used and to compare international practice. MATERIAL AND METHODS: In the D­A-CH area as well as in GB, registered emergency departments were contacted and invited to participate in an online survey. The survey included questions on the frequency and type of RA procedures, reasons for non-use, equipment used, person performing the procedure and medications used. RESULTS: The participation rate was 17.4% (142/818 emergency departments). RA procedures for preoperative analgesia in PFF were used in 18.3% (21/115) of hospitals in the D­A-CH region and in 96.3% (26/27) in GB. The most commonly used block was the FICB in GB at 96.2% (25/26) and the FNB in Germany at 66.7% (14/21). In the D­A-CH area, RA procedures are primarily performed by anesthesiology specialists 71.4% (15/21), and in GB by emergency department residents 65.4% (17/26). DISCUSSION: RA procedures are still performed too rarely following PFF in emergency departments in the D­A-CH area. In international comparison with GB there is potential for improvement.

Influence of melatonin treatment on human circadian rhythmicity before and after a simulated 9-hr time shift.

The hormone melatonin is currently proposed by some investigators to be an efficient means for decreasing the impairing effects of jet lag. Eight healthy male subjects, aged 20 to 32, underwent a 9-hr advance shift in the isolation facility of our institute during two periods each of 15 days' duration. In a double-blind, crossover design, subjects took either melatonin or placebo at 1800 hr local time for 3 days before the time shift and at 1400 hr for 4 days afterwards. The time shift was simulated on days 7 and 8 by shortening the sleep period by 6 hr and the following wake period by 3 hr. Body temperature was recorded every 90 min, and urine was collected at 3-hr intervals all day and night. Melatonin treatment enhanced the resynchronization speed of some, but not all, hormone and electrolyte excretion rates for several days after the time shift. The adaptation speed of the temperature rhythm significantly increased during one postshift day. In addition, the circadian temperature rhythm had a significantly higher amplitude under melatonin treatment than under placebo after the time displacement. For the placebo group, the rhythm of 6-hydroxymelatoninsulfate excretion exhibited an advance shift in five subjects, whereas the other three showed a delay shift, and adjustment did not achieve more than one-half of the expected value within 8 days. A significantly different adjustment could be observed in the melatonin-treated group: Seven subjects underwent an advance shift of the expected 9 hr within an average of 8 days. The results suggest that melatonin treatment can accelerate resynchronization of the melatonin excretion rhythm after eastward time zone transitions. The improvement is not, however, sufficiently great that we can recommend melatonin for the alleviation of jet lag.

Transition between advance and delay responses to eastbound transmeridian flights.

In response to eastbound transmeridian flights, which result in zeitgeber phase advance shifts, adaptation of the circadian system to the new time zone by phase delays and advances are observed. The delay response to an advance zeitgeber shift has been called an antidromic response. For the shift at which the transition from an advance to an antidromic response occurs, the term critical shift is introduced. For the study of critical shifts, a flight experiment across nine time zones and numerical simulations of a van der Pol equation have been evaluated. The interest is focussed on the determination of a range for critical abrupt shifts. An abrupt shift means that the ensemble of zeitgebers including geophysical zeitgebers and the rest-activity cycle is shifted immediately in the new time zone. The range of critical advance shifts has been estimated to reach from +7 to +10 hr. In the literature, results were reported which would imply a much wider range. The discussion of these observations shows that the actual shifts were presumably not abrupt in the quoted experiments. The consequences of critical shifts for jet lag symptoms are investigated. If reduced circadian amplitudes and long times taken for the resynchronization contribute to the feeling of jet lag, the symptoms will be worst for shifts close to the critical one, as numerical simulations revealed. Manipulations of such shifts with the aim to alleviate jet lag are discussed.

Bright light: a countermeasure for jet lag?

After time-zone flights, the environmental time is shifted abruptly. The sleep-wake cycle and the circadian system cannot follow this sudden phase shift. Therefore, some or several days are necessary to achieve complete adjustment to a new time zone. The effects resulting from the displacement between internal and external time are well known as jet lag. In principle, timed bright light is able to enhance the resynchronization process of the circadian system after advance or delay shifts. In this report, the effects of bright light exposure on circadian phases and amplitudes after real or simulated time zone transitions are reviewed from the accessible literature and are critically discussed. It can be concluded that laboratory studies have not been unequivocally successful to support the hypothesis that bright light alleviates jet lag. The sparse number of field studies do not yet allow a clear judgment on the beneficial effect of bright light treatment on jet lag.

Aircrew fatigue in long-haul operations.

The studies were conducted on the transmeridian routes Düsseldorf (DUS)-Atlanta (ATL) and Hamburg (HAM)-Los Angeles (LAX), and on the north-south route Frankfurt (FRA)-Mahe (SEZ). Scheduled flight duration was between 8:50 hours (ATL-DUS) and 11:50 hours (HAM-LAX). In total, 25 rotations (50 flights) have been investigated by pre-, in- and post-flight data collection of sleep, taskload, fatigue and stress by electroencephalogram and electrocardiogram measurements and subjective ratings. Inflight ratings of taskload showed low perceived exertion during the Atlantic flights, and were moderate during the north-south transitions. Fatigue ratings increased with progressing flight duration. Towards the end of long U.S.-westcoast flights performed at day-time, and in all night flights, fatigue was elevated compared to the 'baseline' ratings collected during the day-time DUS-ATL flights. Fatigue was rated as being 'critical' by several pilots, particularly during the return flight SEZ-FRA when fatigue was severely pronounced. From the findings it is concluded that duty schedules, as performed on the route HAM-LAX (because of long duty hours), and particularly on the route FRA-SEZ (because of consecutive night work), may place excessive demands on mental and physiological capacity. With respect to legal aspects, the results are significant and should promote further deliberations for advanced schemes of flight duty time limitations and rest requirements.

Serotonin and dopamine synthesis in phenylketonuria.

Two regulation systems of the serotonin and dopamine biosynthesis in patients with classical and atypical PKU were investigated. In classical PKU, the serotonin and dopamine biosynthesis is inhibited by high L-phenylalanine in blood and tissues. The dopamine formation in vivo was inhibited by phenylalanine blood concentrations higher than 25 mg/dl: the serotonin formation was inhibited even at a phenylalanine blood concentration of only 8 mg/dl. In two patients with dihydrobiopterin synthetase deficiency, the dopamine, and even more pronounced the serotonin, excretions are considerably reduced. The dopamine excretion was reduced to about 50% and the serotonin excretion to only 10% compared to controls. Under BH4 therapy (16 mg daily), the dopamine values increased about twice, serotonin threefold and the phenylalanine blood concentration normalized to 1-1.5 mg/dl. On loading a patient with BH2 synthetase deficiency with 50 mg/kg deuterated tryptophan-d5 and 150 mg/kg deuterated tyrosine d2 (phenylalanine blood concentration of 16 mg/dl), deuterated dopamine d1 and serotonin d4 could only be formed in detectable amounts after BH4 administration. During BH4 therapy the amount of dopamine d1 and serotonin d4 formed was lower than but comparable to normal controls.

Sleep and circadian rhythms of an airline pilot operating on the polar route: a case study.

This study was planned and performed as a first step to assess sleep behaviour and circadian rhythmicity in aircrews operating on regular passenger flights between Germany and Japan via Anchorage, AK. Sleep patterns as well as continuous recordings of ECG and temperature were obtained from a B747 captain during a period of 13 d, including a preceding control day, 8 d on duty and 4 d at home base after return. Sleep behaviour and circadian rhythms changed dramatically due to adverse effects from the duty roster on the polar route. Sleep periods became fragmented into several sleep periods per day in a very irregular manner. Total sleep duration was shortened and sleep deficits occurred between flights. After return to the home base, sleep distribution remained divided into two intervals per day. The circadian system was considerably disrupted on route. Effects associated with irregular duty and sleep patterns intensified desynchronization. Readjustment was extremely slow resulting in a phase-displacement of at least 10 h even after being home for 4 d. Altogether, the results give reason for serious concerns and for the conclusion to strongly recommend more extensive studies on this route.

Response of the circadian system to 6 degrees head-down tilt bed rest.

The influence of simulated microgravity and reduced zeitgebers on the circadian system was examined in eight subjects. The 12-d study included a 3-d period for baseline measurements, 7 d of 6 degrees head-down bed rest, and 2 d for recovery. The sleep-wake cycle was kept constant during the study. The state of the circadian system was assessed from continuous measurements of temperature and ECG, and collections of urine at 3-h intervals for the determination of hormone and electrolyte excretions. Results indicate that only minor changes occurred in rhythm acrophases, whereas daily means for several physiological functions and their circadian amplitudes were significantly altered during the bed-rest phase. These studies using head-down tilt confirm previous findings with horizontal bed rest and indicate that rhythm disturbances can occur without change in the sleep-wake cycle. To the degree that bed-rest studies simulate manned spaceflights, results indicate that variations in circadian cycles can occur even during short-term missions and must be taken into account when interpreting subsequently obtained physiological data.

Athletic endurance training - advantage for space flight?: The significance of physical fitness for selection and training of spacelab crews.

While intensive physical exercise has been part of the conditioning of astronauts and consmonauts for spaceflights, its benefits have been questioned. After reviewing the pertinent literature, it is concluded that the morphological and functional changes obtained with athletic endurance training are rather specific and of no general advantage for the tolerance to space stresses. Particularly during gravitational loads, in the relaxed subject, these changes allow a more pronounced shift of fluid into the lower extremities, with the possible consequence of a reduced tolerance. This unfavourable response, obviously, is accentuated through immersion and weightlessness. The aerobic work capacity is also more impaired in athletes. Based on these conclusions, recommendations for crews and passengers of future Spacelab missions are given with respect to selection and pre-and in-flight physical exercise.

Flight, flight duty, and rest times: a comparison between the regulations of different countries.

Flight time, flight duty limitations, and rest requirements are compared between the regulations from nine different countries. Twelve factors are identified which played a role in formulating restrictions and criteria. Duration of flight duty and crew augmentation are the factors considered by most countries; time of day, night flight, night sleep, and time zones are the factors least considered. Conformity exists in the necessity to prescribe maximum permissible flight or duty times and minimum rest requirements on a daily basis. Agreement was also observed in grading the standards according to more or less fatiguing conditions. Six out of nine regulations define night hours, but fail to agree upon beginning, end, and duration of night. All countries but one limit flying hours on a monthly and yearly basis, although the limits diverge. A brief outline of the German provisions is presented as an example for a compact and practicable regulation.

Models to predict operational loads of flight schedules.

Several concepts have been presented in the literature which have the potential to predict the operational load on aircrews during long-distance flights. They are briefly described and applied to a flight duty pattern actually scheduled for an airline route. For each model relative and absolute difficulty grades for the different segments of the pattern are evaluated and compared. Relative ranking results in an excellent agreement between the various models. Absolute classification into "normal," "heavy," and "definitely severe" segments reveals less conformity. From our observations on this route, it is concluded that the index of Mohler's model reflects the most realistic load estimates. Finally, a new approach is introduced which considers duty period, night flying, number of transits, preceding layover time, and preceding time-zone transitions as those elements constituting a computable and essential part of the operational load.

Sleep patterns in aircrew operating on the polar route between Germany and east Asia.

The study was performed as the second part of an investigation to assess sleep behavior and circadian rhythmicity in aircrew operating regular passenger flights between Germany and East Asia via Anchorage (ANC). Continuous records of sleep and ratings of sleep quality were obtained by sleep logs from 101 B747-cockpit crewmembers, starting at least 3 d before commencing flight duty, continuing during days on duty (the duration depending on the flight schedule) and finishing 4 d after return, at the earliest. Regardless of the specific duty roster, sleep deficit occurred mainly after the first flight leg to ANC, presumably due to the 10-h time zone difference and the short layover time. During the layover in the Far East, the sleep deficit diminished partly because of additional naps. Sleep was often disturbed and scattered over days and nights. Another pronounced sleep deficit occurred after the first return flight from South Korea or Japan to ANC. Compared to the outgoing layover period in ANC, the number and duration of naps increased during this layover and, additionally, on the first 2 d after returning home. Poorer sleep quality ratings were associated with accumulated sleep deficit and increased napping, but significant decrements in sleep quality were seen only during two out of the six different duty rosters. All six of the polar route duty rosters may lead to significant sleep disturbances. During some flight schedules the sleep deficit is large enough to raise operational implications.

Cardiovascular and biochemical response to simulated space flight entry.

Twelve men and 12 women were exposed to two types of short-duration (6 h) space flight entry simulation: bedrest (no head-down tilt) and water immersion (to the neck). Preceding and following the simulation, orthostatic tolerance testing using LBNP (Lower Body Negative Pressure) was performed. Male LBNP tolerance was greater than female LBNP tolerance at all four comparison points (pre- and post-bedrest, pre- and post-water immersion); whereas the short-duration bedrest reduces female LBNP tolerance about as effectively as water immersion, only water immersion leads to marked LBNP intolerance in the male subjects. If the water immersion model simulates zero G, loss of male and female orthostatic tolerance will be about equal after short-duration space flight. On the other hand, the bedrest simulation would indicate a greater loss of orthostatic tolerance for females.

A model for prediction of resynchronization after time-zone flights.

Utilizing experimental data from three flight studies, a concept was developed which allows appraising average resynchronization for any day after arrival in a new time-zone. The course of adaptation is nonlinear and can be mathematically represented by an exponential function. The model predicts higher initial resynchronization rates when more time zones are crossed, but total time for complete reentrainment is essentially the same and, thus is independent of the number of time-zones. The equation derived from experimental data is converted into an e-function and the resulting time constants are presented as they evolved for different functions and flight directions.

International cooperative study of aircrew layover sleep: operational summary.

The findings of this cooperative study of layover sleep have direct implications for flight operations. In the consensus view of the principal investigators, these can be divided into their relevance for eastward or westward flight. Eastward flight produced more sleep disruption than westward. Different sleep and scheduling strategies are recommended for each flight direction, and the importance of individual crewmember factors is discussed in relation to age and circadian type. Despite the limitations of this study with regard to trip simplicity and the baseline data, the results for each airline are highly consistent and should be applicable to a wide range of long-haul crewmembers and carriers.

Sleep, sleepiness, and circadian rhythmicity in aircrews operating on transatlantic routes.

This study was performed on B-747 aircrews operating on regular passenger flights between Frankfurt and the U.S. west coast (9 h time difference). In an initial phase, sleep behavior was surveyed by daily logs in 38 crewmembers. The results for the layover period indicate congruent sleep patterns with shifts in sleep onset distinctly less than 9 h. In comparison with preflight control data, sleep duration was significantly prolonged and, on average, no sleep deficits were experienced before commencing the return flight. The main part of the study consisted of polygraphic sleep recordings and multiple sleep latency tests (MSLT) applied to four complete cockpit crews (12 members total) in a baseline period, during layover, and after return to homebase. In addition, body temperature and ECG were continuously recorded. During layover, mean bed times were shifted by 4.5 h at maximum. Sleep was disturbed by early and prolonged awakenings which led to a reduction of sleep efficiency. In contrast, no sleep deficits nor increases in daytime sleepiness occurred. Night duty associated with the return flight caused sleep deprivation which conversely resulted in good sleep during the first night back in Germany. However, during the second night after return, impaired sleep was observed, at least in part caused by the rhythm disturbances. As predicted by our resynchronization model, ECG and rectal temperature recordings gave evidence for a desynchronization of the circadian system and an internal dissociation of different body functions.

Two-crew operations: stress and fatigue during long-haul night flights.

BACKGROUND: As part of a research program concerning legal aspects of two-pilot operations on long-haul routes, the purpose of the study was to investigate two-crew extended range operations during a flight roster with two consecutive night flights and a short layover. HYPOTHESIS: Present flight time regulations may not be adequate for two-crew minimum operations. METHODS: The study was conducted in cooperation with a German airline company on the route Frankfurt (FRA)-Mahe (SEZ). There were 11 rotations (22 flights) that were investigated by pre-, in- and post-flight data collection each time from the two pilots. Recordings included sleep, taskload, fatigue and stress by measurement of EEG, ECG, motor activity, and subjective ratings. The average actual flight times were 9:15 h (FRA-SEZ) and 9:53 h (SEZ-FRA). All flights took place at night. The layover duration in Mahe was 13:30 h during day-time. RESULTS: During layover, sleep was shortened by 2 h on average compared with 8-h baseline sleep. The two consecutive night duties resulted in a sleep loss of 9.3 h upon return to home base. Inflight ratings of taskload showed moderate grades, but for fatigue ratings an increasing level was observed. Fatigue was more pronounced during the return flight and several pilots scored their fatigue at a critical level. Motor activity, brainwave activity (occurrences of micro-events) and heart rate indicated drowsiness and a low state of vigilance and alertness during both night flights, but these effects were more pronounced during the second flight. CONCLUSIONS: From the findings it is concluded that a duty roster, as conducted in this study, may impose excessive demands on mental and physiological capacity.

Air operations and circadian performance rhythms.

This paper reviews experimental results and pertinent data from the literature on circadian behavioural rhythms and their modifications through various factors. It relates them to the operation of aircrews "round the clock" and on transmeridian routes and discusses some possibilities of an appropriate scheduling.

Bioinstrumentation for evaluation of workload in payload specialists: results of ASSESS II.

ASSESS II (Airborne Science/Spacelab Experiments System Simulation) was a cooperative NASA-ESA project which consisted of a detailed simulation of Spacelab operations using the NASA Ames Research Center CV-990 aircraft laboratory. The Medical Experiment reported on in this paper was part of the complex payload consisting of 11 different experiments. Its general purpose was to develop a technology, possibly flown on board of Spacelab, and enabling the assessment of workload through evaluating changes of circadian rhythmicity, sleep disturbances and episodical or cumulative stress. As parameters the following variables were measured: Rectal temperature, ECG, sleep-EEG and -EOG, the urinary excretion of hormones and electrolytes. The results revealed evidence that a Spacelab environment, as simulated in ASSESS II, will lead to internal dissociation of circadian rhythms, to sleep disturbances and to highly stressful working conditions. Altogether these effects will impose considerable workload upon Payload Specialists. It is suggested that an intensive pre-mission system simulation will reduce these impairments to a reasonable degree. The bioinstrumentation applied in this experiment proved to be a practical and reliable tool in assessing the objectives of the study.