Efficacy of pharmacological and interventional treatment for resistant hypertension: a network meta-analysis.

AIMS: Resistant hypertension is associated with a high risk of cardiovascular disease, chronic kidney disease, and mortality. Yet, its management is challenging. This study aims to establish the comparative effectiveness of pharmacologic and interventional treatments by conducting a network meta-analysis. METHODS AND RESULTS: MEDLINE, Cochrane Register of Controlled Trials, and Web of Science Core Collection were systematically searched in March 2022. Randomized controlled trials comparing treatment options for management of resistant hypertension were included. Outcomes were blood pressure (BP) changes, measured in the office and in 24 h ambulatory BP measurement. We applied a frequentist random effects model to perform a network meta-analysis combining placebo medication and sham procedure as the reference comparator. From 4771 records, 24 studies met the inclusion criteria with 3458 included patients in total. Twelve active treatment alternatives [spironolactone, doxazosin, ß-blocker, clonidine, darusentan, guanfacine, various types of renal sympathetic denervation, lifestyle intervention, continuous positive airway pressure, and baroreflex activation therapy (BAT)] were analysed. Among all comparators, spironolactone had the highest ranking probability and was considered the most effective treatment to reduce office systolic blood pressure (sBP) [-13.30 mmHg (-17.89; -8.72); P < 0.0001] and 24 h sBP [-8.46 mmHg (-12.54; -4.38); P < 0.0001] in patients with resistant hypertension. Lifestyle interventions were the most effective non-pharmacological treatment, lowering office sBP by -7.26 mmHg (-13.73; -0.8), whereas BAT lowered office sBP by -7.0 (-18.59; 4.59). Renal denervation lowered office sBP by -5.64 mmHg (-12.95; 1.66) and -3.79 mmHg (-11.39; 3.8) depending on the type of the procedure. CONCLUSION: Among all pharmacologic and interventional treatments, spironolactone is the most effective treatment in reducing BP in patients with resistant hypertension. More comparative trials and especially trials with long-term follow-up are needed. In the meanwhile, we have to conclude that a combination of spironolactone and lifestyle modification are the most effective treatments in resistant hypertension.

[Management of COVID-19 mass casualty incidents in nursing and retirement homes]. / Managementstrategie für den Massenanfall von Erkrankten/Infizierten in Alten- und Pflegeheimen im Kontext der COVID-19-Pandemie.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, outbreaks in inpatient care facilities, which grow into a large-scale emergency scenario, are frequently observed. A standardized procedure analogous to algorithms for mass casualty incidents (MCI) is lacking. METHODS: Based on a case report and the literature, the authors present a management strategy for infectious MCI during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and distinguish it from traumatic MCI deployment tactics. RESULTS: This management strategy can be divided into three phases, beginning with the acute emergency response including triage, stabilization of critical patients, and transport of patients requiring hospitalization. Phase 2 involves securing the facility's operational readiness, or housing residents elsewhere in case staff are infected or quarantined to a relevant degree. Phase 3 marks the return to regular operations. DISCUSSION: Phase 1 is based on usual MCI principles, phase 2 on hospital crisis management. Avoiding evacuation of residents to relieve hospitals is an important operational objective. The lack of mission and training experience with such situations, the limited applicability of established triage algorithms, and the need to coordinate a large number of participants pose challenges. CONCLUSION: This strategic model offers a practical, holistic approach to the management of infectious mass casualty scenarios in nursing facilities.

Measured and predicted acute toxicity of phenanthrene and MC252 crude oil to vertically migrating deep-sea crustaceans.

Deep-water column micronekton play a key role in oceanic food webs and represent an important trophic link between deep- and shallow-water ecosystems. Thus, the potential impacts of sub-surface hydrocarbon plumes on these organisms are critical to developing a more complete understanding of ocean-wide effects resulting from deep-sea oil spills. This work was designed to advance the understanding of hydrocarbon toxicity in several ecologically important deep-sea micronekton species using controlled laboratory exposures aimed at determining lethal threshold exposure levels. The current study confirmed the results previously determined for five deep-sea micronekton by measuring lethal threshold levels for phenanthrene between 81.2 and 277.5 µg/L. These results were used to calibrate the target lipid model and to calculate a critical target lipid body burden for each species. In addition, an oil solubility model was used to predict the acute toxicity of MC252 crude oil to vertically migrating crustaceans, Janicella spinacauda and Euphausiidae spp., and to compare the predictions with results of a 48-h constant exposure toxicity test with passive-dosing. Results confirmed that the tested deep-sea micronekton appear more sensitive than many other organisms when exposed to dissolved oil, but baseline stress complicated interpretation of results.

Leptospiral antibody prevalence and surgical treatment outcome in horses with Equine Recurrent Uveitis (ERU) in Switzerland.

OBJECTIVE: To evaluate leptospiral antibody prevalence in 65 horses with ERU and compare outcome in 36 surgically treated eyes (2010-2015). PROCEDURES: Retrospective data analysis of horses with ERU (n = 65). C-value calculation with microagglutination assay titer (MAT) results for Leptospira spp. Evaluation of follow-up data after pars plana vitrectomy (PPV, n = 21 eyes) and suprachoroidal cyclosporine device implantation (SCDI, n = 15 eyes). Differences between groups were statistically analyzed using Fishers exact test, significance set at P < .05. RESULTS: Positive leptospiral titers were found in 28/65 blood, 31/65 aqueous humor (AH), and 19/20 vitreal (post-PPV) samples. The most common intraocular serovars were Leptospira interrogans grippotyphosa, pomona, and bratislava. Intraocular antibody production was suspected in samples of 22 horses (c-values > 1). Mean follow-up of surgical cases was 3.8 years (PPV) and 3.4 years (SCDI). PPV was performed in 21 eyes with positive, SCDI in 15 eyes with negative leptospiral test results. Uveitis recurred less often after PPV (2/21) compared to SCDI (6/15, P = .04). Retinal detachment occurred after PPV only (5/21, SCDI 0/15, P = .06), whereas only SCDI-treated eyes were enucleated (PPV 0/21, SCDI 3/15, P = .06). Blindness or visual impairment was equally likely to occur in both treatment groups after surgery (PPV 7/21, SCDI 7/15, P = .5). CONCLUSIONS: Leptospiral antibody prevalence is high in horses with ERU in Switzerland. Recurrence of uveitis is uncommon following PPV in the present study; an increased risk of retinal detachment exists. Enucleation is more often warranted in horses after SCDI in this study due to a higher uveitis recurrence.

[Self-hypnosis training for in-hospital chronic pain patients : A retrolective observational study]. / "Selbsthypnosetraining" bei chronischen stationären Schmerzpatienten : Eine retrolektive Beobachtungsstudie.

BACKGROUND: Hypnosis is probably one of the oldest therapies known to man. In the last decades modern hypnosis has mainly been used by psychotherapists; however, hypnosis is becoming increasingly more important as a therapeutic method in medicine. Hypnosis can be used for a variety of medical indications. In the literature there is much evidence for the effectiveness of hypnosis. The aim of the present investigation was to demonstrate the effectiveness of hypnosis in inpatient treatment of chronic pain patients and to present a self-hypnosis program, which can be easily integrated into pain therapy. METHODS: From October 2012 to April 2013 all inpatient chronic pain patients were included (group 1: non-hypnosis group, group 2: hypnosis group). Concerning group 2 a standardized protocol for hypnotherapy was integrated in addition to the standardized pain management program. The main goal of hypnotherapy was to integrate a self-hypnosis training so that further implementation in a domestic setting could be guaranteed. By means of standardized test procedures, e. g. Patient Health Questionnaire (PHQ-9), Pain Disability Index (PDI), Generalized Anxiety Disorder (GAD-7) and Numerical Rating Scales (NRS) for pain and general well-being, data were evaluated before and after the pain therapy. RESULTS: The prestandardized and poststandardized test procedures of 30 chronic pain patients were evaluated (17 patients without hypnosis, 13 patients with hypnosis). The main diagnosis according to ICD-10 was "chronic pain disorder" (F45.41) with a MPSS stage III in all patients. The PDI was significantly improved in the hypnosis group (p = 0.019). The other items all showed a trend towards improvement in the hypnosis group (exception GAD-7) but without statistical significance (p > 0.05). DISCUSSION: In a small patient collective, the present investigation was able to show that the integration of modern hypnotherapy into the treatment of chronic pain patients in an inpatient setting can be another useful therapeutic aspect. In particular, the instructions for learning independently seem to be useful due to the limited in-patient time. More research needs to be carried out to support our initial findings.

Psychological interventions for acute pain after open heart surgery.

BACKGROUND: This is an update of a Cochrane review previously published in 2014. Acute postoperative pain is one of the most disturbing complaints in open heart surgery, and is associated with a risk of negative consequences. Several trials investigated the effects of psychological interventions to reduce acute postoperative pain and improve the course of physical and psychological recovery of participants undergoing open heart surgery. OBJECTIVES: To compare the efficacy of psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention control in adults undergoing open heart surgery for pain, pain medication, psychological distress, mobility, and time to extubation. SEARCH METHODS: For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, and PsycINFO for eligible studies up to February 2017. We used the 'related articles' and 'cited by' options of eligible studies to identify additional relevant studies. We checked lists of references of relevant articles and previous reviews. We searched the ProQuest Dissertations and Theses Full Text Database, ClinicalTrials and the WHO International Clinical Trials Registry Platform to identify any unpublished material or ongoing trials. We also contacted the authors of primary studies to identify any unpublished material. In addition, we wrote to all leading heart centres in Germany, Switzerland, and Austria to check whether they were aware of any ongoing trials. SELECTION CRITERIA: Randomised controlled trials comparing psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention in adults undergoing open heart surgery. DATA COLLECTION AND ANALYSIS: Two review authors (SZ and SK) independently assessed trials for eligibility, estimated the risk of bias and extracted all data. We calculated effect sizes for each comparison (Hedges' g) and meta-analysed data using a random-effects model. We assessed the evidence using GRADE and created 'Summary of findings' tables. MAIN RESULTS: We added six studies to this update. Overall, we included 23 studies (2669 participants).For the majority of outcomes (two-thirds), we could not perform a meta-analysis since outcomes were not measured, or data were provided by one trial only.No study reported data on the number of participants with pain intensity reduction of at least 50% from baseline. Only one study reported data on the number of participants below 30/100 mm on the Visual Analogue Scale (VAS) in pain intensity (very low-quality evidence). Psychological interventions did not reduce pain intensity in the short-term interval (g 0.39, 95% CI -0.18 to 0.96, 2 studies, 104 participants, low-quality evidence), medium-term interval (g -0.02, 95% CI -0.24 to 0.20, 4 studies, 413 participants, moderate-quality evidence) or in the long-term interval (g 0.05, 95% CI -0.20 to 0.30, 2 studies, 200 participants, moderate-quality evidence).No study reported data on median time to re-medication or on number of participants re-medicated. Only two studies provided data on postoperative analgesic use in the short-term interval, showing that psychological interventions did not reduce the use of analgesic medication (g 1.18, 95% CI -2.03 to 4.39, 2 studies, 104 participants, low-quality evidence). Studies revealed that psychological interventions reduced mental distress in the medium-term (g 0.37, 95% CI 0.13 to 0.60, 13 studies, 1388 participants, moderate-quality evidence) and likewise in the long-term interval (g 0.32, 95% CI 0.10 to 0.53, 14 studies, 1586 participants, moderate-quality evidence). Psychological interventions did not improve mobility in the medium-term interval (g 0.23, 95% CI -0.22 to 0.67, 3 studies, 444 participants, low-quality evidence), nor in the long-term interval (g 0.09, 95% CI -0.10 to 0.28, 4 studies, 458 participants, moderate-quality evidence). Only two studies reported data on time to extubation, indicating that psychological interventions reduced the time to extubation (g 0.56, 95% CI 0.08 to 1.03, 2 studies, 154 participants, low-quality evidence).Overall, the very low to moderate quality of the body of evidence on the efficacy of psychological interventions for acute pain after open heart surgery cannot be regarded as sufficient to draw robust conclusions.Most 'Risk of bias' assessments were low or unclear. We judged selection bias (random sequence generation) and attrition bias to be mostly low risk for included studies. However, we judged the risk of selection bias (allocation concealment), performance bias, detection bias and reporting bias to be mostly unclear. AUTHORS' CONCLUSIONS: In line with the conclusions of our previous review, there is a lack of evidence to support or refute psychological interventions in order to reduce postoperative pain in participants undergoing open heart surgery. We found moderate-quality evidence that psychological interventions reduced mental distress in participants undergoing open heart surgery. Given the small numbers of studies, it is not possible to draw robust conclusions on the efficacy of psychological interventions on outcomes such as analgesic use, mobility, and time to extubation respectively on adverse events or harms of psychological interventions.

Doctors as street-level bureaucrats in a rural hospital in South Africa.

INTRODUCTION: In the perspectives of implementation of policy, the top-down and bottom-up perspectives of policy-making dominate the discourse. However, service delivery and therefore the experience of the policy by the citizen ultimately depend on the civil servant at the front line to implement the policy. Lipsky named this street-level bureaucracy, which has been used to understand professionals working in the public sector throughout the world. The public sector in South Africa has undergone a number of changes in the transition to a democratic state, post 1994. This needs to be understood in public administration developments throughout the world. At the time of the study, the public sector was characterized by considerable inefficiencies and system failures as well as inequitable distribution of resources. The context of the study was a rural hospital serving a population of approximately 150 000. RESULTS: An insider-ethnography over a period of 13 months explored the challenges of being a professional within the public sector in a rural hospital in South Africa. Data collection included participant observation, field notes of events and meetings, and documentation review supplemented with in-depth interviews of doctors working at a rural hospital. Street-level bureaucracy was used as a framework to understand the challenges of being a professional and civil servant in the public sector. RESULTS: The context of a resource-constrained setting was seen as a major limitation to delivering a quality service. Yet considerable evidence pointed to doctors (both individually and collectively) being active in managing the services in the context and aiming to achieve optimal health service coverage for the population. In the daily routine of the work, doctors often advocated for patients and went beyond the narrow definitions of the guidelines. They compensated for failing systems, beyond a local interpretation of policy. However, doctors also at times used their discretion negatively, to avoid work or to contribute to the inefficiencies of healthcare delivery. CONCLUSIONS: While appearing to be in conflict, the merging of the roles of the health professional and the bureaucrat is required to be able to function effectively within the healthcare system. Being a doctor and being a civil servant are synergistic in daily work, and as a result it is difficult to neatly differentiate professional and civil servant roles in decision-making. It is in the discretion of both roles that considerable flexibility within the roles is possible. Such freedom to act is critical for being able to find local solutions and thereby improve healthcare services. The findings resonate strongly with studies from other parts of the world and offer a window into making sense of the local decision making of doctors. Street-level bureaucracy remains an important lens to view the work of healthcare professionals in the public sector. In the tension between the top-down policy-making and the bottom-up pressure, street-level bureaucracy acts as an important terrain for improving the implementation of services and therefore advocacy and health system improvement.

[Interdisciplinary consensus statement on alternative airway management with supraglottic airway devices in pediatric emergency medicine: Laryngeal mask is state of the art]. / Interdisziplinär konsentierte Stellungnahme zum Atemwegsmanagement mit supraglottischen Atemwegshilfen in der Kindernotfallmedizin: Larynxmaske ist State-of-the-art.

BACKGROUND: Airway management with supraglottic airway devices (SGA) in life-threatening emergencies involving children is becoming increasingly more important. The laryngeal mask (LM) and the laryngeal tube (LT) are devices commonly used for this purpose. This article presents a literature review and consensus statement by various societies on the use of SGA in pediatric emergency medicine. MATERIAL AND METHODS: Literature search in the database PubMed and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine levels of evidence. RESULTS: The evidence for successful application of the various types of LM is significantly higher than for LT application. Reports of smaller series of successful applications of LT are currently limited to selected research groups and centers. Insufficient evidence currently exists for the successful application of the LT especially for children below 10 kg body weight and, therefore, its routine use cannot currently be recommended. SGAs used for emergencies should have a possibility for gastric drainage. DISCUSSION: Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children, currently only the LM can be recommended for alternative (i.e. non-intubation) airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1.5, 2, 2.5, 3, 4 and 5) for prehospital and in-hospital emergency use and all users should be regularly trained in its application.

[Role of Institutional Review Boards for multi-centre studies in national health services research - a cross-sectional study of the effort to obtain secondary ethical approvals for the DACAPO study]. / Die Rolle von Ethikkommissionen für die nationale Versorgungsforschung - eine Querschnittsstudie des Aufwandes zur Erlangung von Sekundärvoten anhand der DACAPO-Studie.

BACKGROUND: Health services research (HSR) is of fundamental importance for the continuous improvement of preventive, diagnostic or therapeutic measures. The conduct of multi-centre HSR studies requires that ethical approval by Institutional review boards (IRB's) is obtained. We documented the effort, the complexity and the man power necessary to obtain secondary ethical approval for a national HSR in Germany ("Surviving the Acute Respiratory Distress Syndrome" [DACAPO-study]). METHODS: Having obtained a primary ethical approval by the IRB of Regensburg University, the time, correspondence, necessity for amendments, corrections, or additional costs by 34 IRB's for 64 participating study centers was documented. RESULTS: The complete obtainment was found to be time consuming and associated with a high workload and man power. A time span of seven month was needed to receive votes from all IRB's. The median time span was 25,5 days (25 %/75 % percentile 13 and 42 days, respectively). Requirements in terms of corrections or amendments were inhomogeneous and frequent changes were necessary. There were additional fees for secondary votes of 4328,40 €. Total costs for the study center Regensburg were 21.193,40 € (2,6 % of the grant volume). CONCLUSION: Obtaining all ethical approvals for a multi-centre observational HSR study in Germany is complex and time consuming. Various and inhomogeneous formalities may delay the plan and realization of HSR. A Homogenization and simplification of the procedure of ethics votes should be discussed.

[The premedication visit--suggestions for a patient-friendly design]. / Das Prämedikationsgespräch--Anregungen zu einer patientenfreundlichen Gestaltung.

The premedication visit is often a difficult situation for the anaesthetist. On the one hand the patient needs to be informed in detail, but on the other he must not be alienated unnecessarily. Furthermore, a hospital stay represents an exceptional situation for the patient in which he behaves differently than in everyday life and shows a limited ability to process information. Following certain communication strategies allows to convey information to the patient in a comprehensible manner and to describe his individual anaesthesiological risk without needlessly creating fear.

The effect of nutrients on carbon and nitrogen fixation by the UCYN-A-haptophyte symbiosis.

Symbiotic relationships between phytoplankton and N2-fixing microorganisms play a crucial role in marine ecosystems. The abundant and widespread unicellular cyanobacteria group A (UCYN-A) has recently been found to live symbiotically with a haptophyte. Here, we investigated the effect of nitrogen (N), phosphorus (P), iron (Fe) and Saharan dust additions on nitrogen (N2) fixation and primary production by the UCYN-A-haptophyte association in the subtropical eastern North Atlantic Ocean using nifH expression analysis and stable isotope incubations combined with single-cell measurements. N2 fixation by UCYN-A was stimulated by the addition of Fe and Saharan dust, although this was not reflected in the nifH expression. CO2 fixation by the haptophyte was stimulated by the addition of ammonium nitrate as well as Fe and Saharan dust. Intriguingly, the single-cell analysis using nanometer scale secondary ion mass spectrometry indicates that the increased CO2 fixation by the haptophyte in treatments without added fixed N is likely an indirect result of the positive effect of Fe and/or P on UCYN-A N2 fixation and the transfer of N2-derived N to the haptophyte. Our results reveal a direct linkage between the marine carbon and nitrogen cycles that is fuelled by the atmospheric deposition of dust. The comparison of single-cell rates suggests a tight coupling of nitrogen and carbon transfer that stays balanced even under changing nutrient regimes. However, it appears that the transfer of carbon from the haptophyte to UCYN-A requires a transfer of nitrogen from UCYN-A. This tight coupling indicates an obligate symbiosis of this globally important diazotrophic association.

Anaesthetic management of cytoreductive surgery followed by hyperthermic intrathoracic chemotherapy perfusion.

BACKGROUND: Macroscopic cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion (HITHOC) is a new multimodal approach for selected patients with primary and secondary pleural tumors, which may provide the patient with better local tumor control and increased overall survival rate. METHODS: We present a single-center study including 20 patients undergoing cytoreductive surgery and HITHOC between September 2008 and April 2013 at the University Medical Center Regensburg, Germany. Objective of the study was to describe the perioperative, anaesthetic management with special respect to pain and complication management. RESULTS: Anaesthesia during this procedure is characterized by increased intrathoracic airway and central venous pressure, hemodynamic alterations and the risk of systemic hypo- and hyperthermia. Securing an adequate intravascular volume is one of the primary goals to prevent decreased cardiac output as well as pulmonary edema. Transfusion of packed red blood cells (PRBC) was necessary in seven of 20 (35%) patients. Only two patients (10%) showed an impairment of coagulation in postoperative laboratory analysis. Perioperative forced diuresis is recommended to prevent postoperative renal insufficiency. Supplementary thoracic epidural analgesia in 13 patients (65%) showed a significant reduction of post-operative pain compared with peroral administration of opioid and non-opioid analgesics. CONCLUSION: This article summarizes important experiences of the anaesthesiological and intensive care management in patients undergoing HITHOC.

Psychological interventions for acute pain after open heart surgery.

BACKGROUND: Acute postoperative pain is one of the most disturbing complaints in open heart surgery, and is associated with a risk of negative consequences. Several trials investigated the effects of psychological interventions to reduce acute postoperative pain and improve the course of physical and psychological recovery of participants undergoing open heart surgery. OBJECTIVES: To compare the efficacy of psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention in adults undergoing open heart surgery on pain, pain medication, mental distress, mobility, and time to extubation. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8), MEDLINE (1946 to September 2013), EMBASE (1980 to September 2013), Web of Science (all years to September 2013), and PsycINFO (all years to September 2013) for eligible studies. We used the 'related articles' and 'cited by' options of eligible studies to identify additional relevant studies. We also checked lists of references of relevant articles and previous reviews. We also searched the ProQuest Dissertations and Theses Full Text Database (all years to September 2013) and contacted the authors of primary studies to identify any unpublished material. SELECTION CRITERIA: Randomised controlled trials comparing psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention in adults undergoing open heart surgery. DATA COLLECTION AND ANALYSIS: Two review authors (SK and JR) independently assessed trials for eligibility, estimated the risk of bias and extracted all data. We calculated effect sizes for each comparison (Hedges' g) and meta-analysed data using a random-effects model. MAIN RESULTS: Nineteen trials were included (2164 participants).No study reported data on the number of participants with pain intensity reduction of at least 50% from baseline. Only one study reported data on the number of participants below 30/100 mm on the Visual Analogue Scale (VAS) in pain intensity. Psychological interventions have no beneficial effects in reducing pain intensity measured with continuous scales in the medium-term interval (g -0.02, 95% CI -0.24 to 0.20, 4 studies, 413 participants, moderate quality evidence) nor in the long-term interval (g 0.12, 95% CI -0.09 to 0.33, 3 studies, 280 participants, low quality evidence).No study reported data on median time to remedication or on number of participants remedicated. Only one study provided data on postoperative analgesic use. Studies reporting data on mental distress in the medium-term interval revealed a small beneficial effect of psychological interventions (g 0.36, 95% CI 0.10 to 0.62, 12 studies, 1144 participants, low quality evidence). Likewise, a small beneficial effect of psychological interventions on mental distress was obtained in the long-term interval (g 0.28, 95% CI 0.05 to 0.51, 11 studies, 1320 participants, low quality evidence). There were no beneficial effects of psychological interventions on mobility in the medium-term interval (g 0.23, 95% CI -0.22 to 0.67, 3 studies, 444 participants, low quality evidence) nor in the long-term interval (g 0.29, 95% CI -0.14 to 0.71, 4 studies, 423 participants, low quality evidence). Only one study reported data on time to extubation. AUTHORS' CONCLUSIONS: For the majority of outcomes (two-thirds) we could not perform a meta-analysis since outcomes were not measured, or data were provided by one trial only. Psychological interventions have no beneficial effects on reducing postoperative pain intensity or enhancing mobility. There is low quality evidence that psychological interventions reduce postoperative mental distress. Due to limitations in methodological quality, a small number of studies, and large heterogeneity, we rated the quality of the body of evidence as low. Future trials should measure crucial outcomes (e.g. number of participants with pain intensity reduction of at least 50% from baseline) and should focus to enhance the quality of the body of evidence in general. Altogether, the current evidence does not clearly support the use of psychological interventions to reduce pain in participants undergoing open heart surgery.

[Botulinum toxin injections for chronic migraine in adolescents - an early therapeutic option in the transition from neuropaediatrics to neurology]. / Botulinumtoxin-Injektionen bei chronischer Migräne im Jugendalter - eine frühzeitige Therapieoption in der Transition von der Neuropädiatrie zur Neurologie.

BACKGROUND: The prevalence of chronic headaches in children and adolescents is up to 2 % resulting in the beginning of the later typical headache careers of adults. The therapy for chronic migraine with botulinum toxin is now established in adults. However, there is only limited experience in the use of botulinum toxin in paediatric patients. METHODS: 10 patients aged 13 - 17 years who suffered from chronic migraine according to the IHS criteria were injected at 31 specific injection points of the head and neck muscles with a total amount of 150 IE of botulinum toxin A (Botox®) according to the approved scheme. The number of headache days per month over the following 9 months was recorded and side effects were retrospectively determined. RESULTS: The responder rate (that is reduction of headache days per month more than 50 %) was 7/10 at three months after the injection. On average the number of headache days per month was reduced from 19.2 days to a minimum of 10.1 days. After three to six months the number of headache days increased again in all responders. Slight local side effects such as redness or temporary pain were observed in all patients, but severe side effects such as infections, fever, ptosis or allergic reactions did not occur. DISCUSSION: This small case series shows that the therapy for chronic migraine with botulinum toxin A can also be effective and safe in adolescents. As many adolescents still suffer from headaches later as adults a link between neuropaediatricians and neurologists is justifiable. An early botulinum toxin therapy followed by the transition of the adolescents would be helpful.

Comparable light stimulation of organic nutrient uptake by SAR11 and Prochlorococcus in the North Atlantic subtropical gyre.

Subtropical oceanic gyres are the most extensive biomes on Earth where SAR11 and Prochlorococcus bacterioplankton numerically dominate the surface waters depleted in inorganic macronutrients as well as in dissolved organic matter. In such nutrient poor conditions bacterioplankton could become photoheterotrophic, that is, potentially enhance uptake of scarce organic molecules using the available solar radiation to energise appropriate transport systems. Here, we assessed the photoheterotrophy of the key microbial taxa in the North Atlantic oligotrophic gyre and adjacent regions using (33)P-ATP, (3)H-ATP and (35)S-methionine tracers. Light-stimulated uptake of these substrates was assessed in two dominant bacterioplankton groups discriminated by flow cytometric sorting of tracer-labelled cells and identified using catalysed reporter deposition fluorescence in situ hybridisation. One group of cells, encompassing 48% of all bacterioplankton, were identified as members of the SAR11 clade, whereas the other group (24% of all bacterioplankton) was Prochlorococcus. When exposed to light, SAR11 cells took 31% more ATP and 32% more methionine, whereas the Prochlorococcus cells took 33% more ATP and 34% more methionine. Other bacterioplankton did not demonstrate light stimulation. Thus, the SAR11 and Prochlorococcus groups, with distinctly different light-harvesting mechanisms, used light equally to enhance, by approximately one-third, the uptake of different types of organic molecules. Our findings indicate the significance of light-driven uptake of essential organic nutrients by the dominant bacterioplankton groups in the surface waters of one of the less productive, vast regions of the world's oceans-the oligotrophic North Atlantic subtropical gyre.

The toxicity of local anesthetics: the place of ropivacaine and levobupivacaine.

PURPOSE OF REVIEW: Ropivacaine and levobupivacaine were developed after evidence of bupivacaine-related severe toxicity. Despite a comparable analgesic profile, quantitative differences become evident with regard to their specific rate of systemic toxicity. The present article provides a concise review of the toxic potencies of levobupivacaine and ropivacaine. RECENT FINDINGS: As lipophilicity is known to be a major determinant in local anesthetic toxicity, the clinical safety profile of ropivacaine seems to be more favorable than that of levobupivacaine. Experimental studies and case reports confirm this hypothesis, showing that ropivacaine is characterized by fewer (cardio) toxic effects and, most probably, a greater margin of safety. Both agents also may dose dependently damage neurons and skeletal muscle tissue at the injection site. Although their specific rate of neurotoxicity appears to be rather low, levobupivacaine is characterized by an outstanding myotoxic potential. SUMMARY: Compared with bupivacaine, both agents may be considered as 'more well tolerated' but not as 'totally well tolerated', as they are still capable of inducing systemic and local toxicity. However, ropivacaine seems to have the greatest margin of safety of all long-acting local anesthetics at present.

The main components of St John's Wort inhibit low-density lipoprotein atherogenic modification: a beneficial "side effect" of an OTC antidepressant drug?

Hypericin and pseudohypericin are polycyclic-phenolic structurally related compounds found in Hypericum perforatum L. (St John's wort). As hypericin has been found to bind to LDL one may assume that it can act as antioxidant of LDL lipid oxidation, a property which is of prophylactic/therapeutic interest regarding atherogenesis as LDL oxidation may play a pivotal role in the onset of atherosclerosis. Therefore, in the present paper hypericin, pseudohypericin and hyperforin, an other structurally unrelated constituent in St John's wort were tested in their ability to inhibit LDL oxidation. LDL was isolated by ultracentrifugation and oxidation was initiated either by transition metal ions (copper), tyrosyl radical (myeloperoxidase/hydrogen peroxide/tyrosine) or by endothelial cells (HUVEC). LDL modification was monitored by conjugated diene and malondialdehyde formation. The data show that all compounds (hypericin, pseudohypericin and hyperforin) at doses as low as 2.5 micromol/l are potent antioxidants in the LDL oxidation systems used. The results indicate that the derivatives found in Hypericum perforatum have possible antiatherogenic potential.

Local anesthetic myotoxicity.

Skeletal muscle toxicity is a rare and uncommon side effect of local anesthetic drugs. Intramuscular injections of these agents regularly result in reversible myonecrosis. The extent of muscle damage is dose dependent and worsens with serial or continuous administration. All local anesthetic agents that have been examined are myotoxic, whereby procaine produces the least and bupivacaine the most severe muscle injury.The histologic pattern and the time course of skeletal muscle injury appear rather uniform: hypercontracted myofibrils become evident directly after injection, followed by lytic degeneration of striated muscle sarcoplasmic reticulum, and by myocyte edema and necrosis over the next 1 to 2 days. Myoblasts, basal laminae, and connective tissue elements remain intact in most cases, which permits muscular regeneration within 3 to 4 weeks. Subcellular pathomechanisms of local anesthetic myotoxicity are still not understood in detail. Increased intracellular Ca2+ levels appear to be the most important element in myocyte injury; since denervation, inhibition of sarcolemmal Na+ channels, and direct toxic effects on myofibrils have been excluded as sites of action. In this respect, the quantitative impact of further mitochondria-mediated pathways--at least in bupivacaine toxicity--is still to be established. Although experimental myotoxic effects are impressively intense and reproducible, only a few case reports of myotoxic complications in patients after local anesthetic administrations have been published. In particular, the occurrence of clinically relevant myopathy and myonecrosis has been described after continuous peripheral blocks, infiltration of wound margins, trigger point injections, and peri- and retrobulbar blocks.

[Retrospective analysis of ruthenium-106 brachytherapy for small and medium-sized malignant melanoma of the posterior choroid]. / Retrospektive Analyse der Ruthenium-106-Brachytherapie bei kleinen bis mittelgrossen malignen Melanomen der posterioren Aderhaut.

BACKGROUND: Transpupillary thermotherapy is a new and most promising treatment modality for up to medium-sized choroidal melanoma at the posterior pole. We analysed the results of conventional ruthenium-106 brachytherapy in these special tumour subgroup. PATIENTS AND METHODS: Results of ruthenium-106 brachytherapy (radioactive dose to the tumour apex 150 Gy) in a series of 52 eyes with primary malignant choroidal melanoma (posterior to the equator, thickness