[Diagnostics and surgical treatment of painful neuromas]. / Diagnostik und chirurgische Therapie schmerzhafter Neurome.

BACKGROUND: Painful neuromas that often develop after peripheral nerve injury require adequate diagnosis and treatment because of the suffering they cause. The scientific basis for the development of painful neuromas has not yet been sufficiently investigated. In addition to conservative procedures, a larger number of surgical techniques are available for treatment of painful neuromas. OBJECTIVE: A review of the basic principles, diagnostic and treatment options for painful neuromas. MATERIAL AND METHODS: Presentation of the scientific basis regarding the development of painful neuromas. Illustration and discussion of the most common diagnostic and treatment procedures. RESULTS: The scientific basis regarding the development of painful neuromas after peripheral nerve injury has not yet been adequately developed. In order to be able to make a correct diagnosis, the use of standardized diagnostic criteria and adequate imaging techniques are recommended. In the sense of a paradigm shift, the use of the formerly neuroma-bearing nerve for reinnervation of target organs is to be preferred over mere burying in adjacent tissue. CONCLUSION: In addition to standardized diagnostics the management of painful neuromas often requires a surgical intervention after all conservative therapeutic measures have been exhausted. As an alternative to restoring the continuity of the injured nerve, targeted reinnervation of electively denervated target organs by the formerly neuroma-bearing nerve is preferable over other techniques.

Stabilization and operation of a Kerr-cat qubit.

Quantum superpositions of macroscopically distinct classical states-so-called Schrödinger cat states-are a resource for quantum metrology, quantum communication and quantum computation. In particular, the superpositions of two opposite-phase coherent states in an oscillator encode a qubit protected against phase-flip errors1,2. However, several challenges have to be overcome for this concept to become a practical way to encode and manipulate error-protected quantum information. The protection must be maintained by stabilizing these highly excited states and, at the same time, the system has to be compatible with fast gates on the encoded qubit and a quantum non-demolition readout of the encoded information. Here we experimentally demonstrate a method for the generation and stabilization of Schrödinger cat states based on the interplay between Kerr nonlinearity and single-mode squeezing1,3 in a superconducting microwave resonator4. We show an increase in the transverse relaxation time of the stabilized, error-protected qubit of more than one order of magnitude compared with the single-photon Fock-state encoding. We perform all single-qubit gate operations on timescales more than sixty times faster than the shortest coherence time and demonstrate single-shot readout of the protected qubit under stabilization. Our results showcase the combination of fast quantum control and robustness against errors, which is intrinsic to stabilized macroscopic states, as well as the potential of of these states as resources in quantum information processing5-8.

[Surgical anatomy of the maxillary sinus]. / Chirurgische Anatomie der Kieferhöhle.

BACKGROUND: Improved understanding of the microanatomy of the paranasal sinuses, including its individual variations, makes a substantial contribution to current progress in endonasal endoscopic microsurgery. Microanatomy of the sinuses is an active field of present scientific investitations. MATERIALS AND METHODS: A comprehensive review on microanatomy of the maxillary sinus is presented from the perspective of contemporary endonasal endoscopic microsurgery. RESULTS: The range of variation of the individual microanatomy of all sections of the maxillary sinus is presented, in particular to minimize secondary sugical tissue trauma, to avoid complications (e.g. on orbital tissues) and as a basis for the prelacrimal access to the maxillary sinus. CONCLUSION: Improved understanding of the range of microanatomical variations reduced the burden on the patient while opimizing the effectiveness of the necessary surgical manipulations.

Extended evaluation of the efficacy of a proactive forced oscillation technique-based auto-CPAP algorithm.

PURPOSE: Previous studies revealed substantially varying therapy efficacy of automatic continuous positive airway pressure (APAP) devices in the treatment of obstructive sleep apnea (OSA). We evaluated the efficacy of a new APAP device using the forced oscillation technique (FOT) to evaluate upper airway obstruction during apneas and flow contour analyses during hypopneas. METHODS: Forty-six initially diagnosed OSA patients were included and the pressure range was set from 5 to 20 hPa. Therapy efficacy was assessed based on the reduction of apnea-hypopnea index (AHI), improvement of objective sleep quality parameters, and the appropriateness of the device's pressure regulation. RESULTS: AHI and arousal index significantly decreased during APAP therapy (median [interquartile range]: AHI 36 [23-55] vs. 2 [1-6]/h, arousal index 30 [22-45] vs. 15 [10-19]/h, both p < 0.001). The amount of slow wave sleep (SWS) and rapid-eye-movement (REM) sleep significantly increased (SWS 20 [14-29] vs. 29 [19-34]%, REM 16 [11-21] vs. 24 [14-30]%, both p < 0.01). Most residual respiratory events during therapy were of central etiology and attributable to five patients, who presented with treatment-emergent central sleep apnea. The device's pressure regulation abolished most obstructive respiratory events (n = 6.7 residual obstructive events per patient). Of central respiratory events, 534/646 (83%) did not lead to pressure increases. CONCLUSION: This pilot study provides a proof of concept that the APAP device combining FOT and evaluation of flow contour allows for the suppression of obstructive events without relevant false reactions.

Gated Conditional Displacement Readout of Superconducting Qubits.

We have realized a new interaction between superconducting qubits and a readout cavity that results in the displacement of a coherent state in the cavity, conditioned on the state of the qubit. This conditional state, when it reaches the cavity-following, phase-sensitive amplifier, matches its measured observable, namely, the in phase quadrature. In a setup where several qubits are coupled to the same readout resonator, we show it is possible to measure the state of a target qubit with minimal dephasing of the other qubits. Our results suggest novel directions for faster readout of superconducting qubits and implementations of bosonic quantum error-correcting codes.

A Comparison between 6-point Dixon MRI and MR Spectroscopy to Quantify Muscle Fat in the Thigh of Subjects with Sarcopenia.

BACKGROUND: Changes in muscle fat composition as for example observed in sarcopenia, affect physical performance and muscular function, like strength and power. OBJECTIVES: The purpose of this study was to compare 6-point Dixon magnetic resonance imaging and multi-echo magnetic resonance spectroscopy sequences to quantify muscle fat. Setting, participants and measurements: Two groups were recruited (G1: 23 healthy young men (28 ± 4 years), G2: 56 men with sarcopenia (80 ± 5 years)). Proton density fat fraction was measured with a 6-point product and a 6-point prototype Dixon sequence in the left thigh muscle and with a high-speed multi-echo T2*-corrected H1 magnetic resonance spectroscopy sequence within the semitendinosus muscle of the left thigh. To evaluate the comparability among the different methods, Bland-Altman and linear regression analyses of the proton density fat fraction results were performed. RESULTS: Mean differences ± 1.96 * standard deviation between spectroscopy and 6pt Dixon sequences were 1.9 ± 3.3% and 1.5 ± 3.6% for the product and prototype sequences, respectively. High correlations were measured between the proton density fat fraction results of the 6-point Dixon sequences and spectroscopy (R = 0.95 for the product sequence and R = 0.97 for the prototype sequence). CONCLUSIONS: Dixon imaging and spectroscopy sequences show comparable accuracy for fat measurements in the thigh. Spectroscopy is a local measurement, whereas Dixon sequences provide maps of the fat distribution. The high correlations of the 6-point Dixon sequences with spectroscopy support their clinical use. They provide higher spatial resolution than spectroscopy, but are not suitable for a more complicated spectral analysis to separate extra- and intramyocellular lipids.

Endovascular Treatment of Dural Arteriovenous Fistulas of the Anterior or Posterior Condylar Vein : A Cadaveric and Clinical Study and Literature Review.

Dural arteriovenous fistulas (DAVF) involving the anterior and posterior condylar vein at the skull base are rare but important to recognize. Due to the highly variable anatomy of the venous system of the skull base, detailed anatomical knowledge is essential for correct diagnosis and appropriate treatment of these lesions. In this report we review the normal anatomy of the condylar veins and describe rare and, to our knowledge, not previously reported anatomical variants. We also highlight the treatment modalities for these lesions with focus on the endovascular transvenous occlusion based on four consecutive cases from our center.

[Recognizing rare cardiac diseases by electrocardiogram]. / Seltene Herzerkrankungen am Elektrokardiogramm erkennen.

A number of rare cardiac diseases can be recognized by electrocardiogram (ECG). This article illustrates the clinical importance of ECG as a key diagnostic tool to detect Wolff-Parkinson-White syndrome and channelopathies, which are frequently diagnosed late after one or more affected family members have become victims of sudden cardiac death. These channelopathies include long QT syndrome, short QT syndrome, Brugada syndrome, and catecholaminergic polymorphic ventricular tachycardia. In addition, typical ECG findings are frequently present in patients with idiopathic ventricular tachycardia, arrhythmogenic right ventricular dysplasia, digitalis intoxication, hyperkalemia, acute cor pulmonale due to pulmonary embolism, as well as severe left ventricular hypertrophy as in hypertrophic cardiomyopathy.

Anatomy of the sphenopalatine artery and its implications for transnasal neurosurgery.

BACKGROUND: The knowledge of sinonasal vasculature is inevitable in transnasal neurosurgery. We performed an anatomical study on the sphenopalatine artery from the perspective of skull base procedures. METHODOLOGY: To analyse the anatomical landmarks of the sphenopalatine artery, arterial skull corrosion casts (26 head halves) underwent endoscopic transnasal phantom surgery. Furthermore, we performed microsurgical dissection on formaldehyde-fixated cadavers with arterial perfusion (14 head halves) as well as studied Cone Beam CT-scans of anonymised patients and cadavers (115 head sides). RESULTS: In our cadaveric material, the sphenopalatine foramen is located at the transition of the superior and middle nasal meatus (95.0%) or in the superior nasal meatus (5.0%). It is the main entry point of the branches of the sphenopalatine artery into the nasal cavity. In most cadaveric cases (25.0%), at this level there are 2 branches superiorly and 1 vessel inferiorly to the ethmoid crest. An average of 2.4 vessels leave the sphenopalatine foramen superiorly to the ethmoid crest, 97.8% of them belong to the sphenopalatine arterys posterior septal branches. An average of 2.1 branches leave the sphenopalatine foramen inferiorly to the ethmoid crest; all of them belong to the posterior lateral nasal branches. There are no cases with a single artery at the plane of the sphenopalatine foramen. We describe a triangular bony structure bordering the sphenopalatine foramen anteriorly which is built up by the palatine and ethmoid bone as well as the maxilla. According to the radiographic studies, this triangular prominence is surrounded superiorly by a posterior ethmoid cell (57.4%), the sphenoid sinus (41.7%) or the orbit (0.9%) with a varying contribution of the superior nasal meatus; inferolaterally by the maxillary sinus (98.3%) or the pterygopalatine and infratemporal fossa (1.7%) and inferomedially by the middle nasal meatus. The medial vertex of the bony triangle corresponds to the ethmoid crest of the palatine bone. In transnasal endoscopic surgery, the posterior lateral nasal branches of the sphenopalatine artery appear at the triangle's inferomedial edge, the posterior septal branches emerge at its superior edge. CONCLUSIONS: The triangular bony structure is a landmark to find and differentiate the posterior lateral nasal and posterior septal branches of the sphenopalatine artery and to identify the sphenoid sinus.

Nerve ultrasound as follow-up tool in treated multifocal motor neuropathy.

BACKGROUND AND PURPOSE: High-resolution ultrasound is a valuable tool in supporting the diagnosis of multifocal motor neuropathy (MMN) but longitudinal data under therapy are lacking. METHODS: The change in peripheral nerve ultrasound pattern in patients with MMN was assessed over time. Patients with MMN received a thorough initial examination and follow-up over a period of 6-12 months using high-resolution ultrasound of the cervical roots and the nerves of the arms and legs, nerve conduction studies, Medical Research Council Sum Score (MRCSS) and Rotterdam Inflammatory Neuropathy Cause and Treatment Group (INCAT) score to evaluate changes under treatment. The Ultrasound Pattern Sum Score (UPSS) was used as standardized peripheral nerve ultrasound protocol. RESULTS: Seventeen patients with MMN received initial examinations of whom 12 were successfully followed up. All patients with MMN showed at least localized but often multifocal peripheral nerve enlargement. An enlarged overall cross-sectional area as well as enlarged single fascicles (>3 mm²) in clinically and electrophysiologically affected (>90%) and unaffected (>70%) nerves were found. The UPSS did not correlate with clinical disability at both visits. However, the change in clinical disability (evaluated as difference in MRCSS) and the change in UPSS correlated significantly inversely (P = 0.004). CONCLUSIONS: High-resolution sonography of peripheral nerves revealed multifocal nerve enlargement in MMN. Distinct enlargement patterns may support the diagnosis. Ultrasound findings did not correlate well with clinical severity or electrophysiological findings at initial presentation. As changes in UPSS correlated significantly with the clinical course in terms of muscle strength (MRCSS), sonographic assessment may represent a useful tool for therapeutic monitoring.

[Diagnostic nerve ultrasonography]. / Diagnostische Nervensonographie.

CLINICAL/METHODICAL ISSUE: For the diagnostics of nerve lesions an imaging method is necessary to visualize peripheral nerves and their surrounding structures for an etiological classification. STANDARD RADIOLOGICAL METHODS: Clinical neurological and electrophysiological investigations provide functional information about nerve lesions. The information provided by a standard magnetic resonance imaging (MRI) examination is inadequate for peripheral nerve diagnostics; however, MRI neurography is suitable but on the other hand a resource and time-consuming method. METHODICAL INNOVATIONS: Using ultrasonography for peripheral nerve diagnostics. PERFORMANCE: With ultrasonography reliable diagnostics of entrapment neuropathies and traumatic nerve lesions are possible. The use of ultrasonography for neuropathies shows that a differentiation between different forms is possible. ACHIEVEMENTS: Nerve ultrasonography is an established diagnostic tool. In addition to the clinical examination and clinical electrophysiology, structural information can be obtained, which results in a clear improvement in the diagnostics. Ultrasonography has become an integral part of the diagnostic work-up of peripheral nerve lesions in neurophysiological departments. PRACTICAL RECOMMENDATIONS: Nerve ultrasonography is recommended for the diagnostic work-up of peripheral nerve lesions in addition to clinical and electrophysiological investigations. It should be used in the clinical work-up of entrapment neuropathies, traumatic nerve lesions and spacy-occupying lesions of nerves.

Genetic ablation of the p66Shc adaptor protein reverses cognitive deficits and improves mitochondrial function in an APP transgenic mouse model of Alzheimer's disease.

The mammalian ShcA adaptor protein p66Shc is a key regulator of mitochondrial reactive oxygen species (ROS) production and has previously been shown to mediate amyloid ß (Aß)-peptide-induced cytotoxicity in vitro. Moreover, p66Shc is involved in mammalian longevity and lifespan determination as revealed in the p66Shc knockout mice, which are characterized by a 30% prolonged lifespan, lower ROS levels and protection from age-related impairment of physical and cognitive performance. In this study, we hypothesized a role for p66Shc in Aß-induced toxicity in vivo and investigated the effects of genetic p66Shc deletion in the PSAPP transgenic mice, an established Alzheimer's disease mouse model of ß-amyloidosis. p66Shc-ablated PSAPP mice were characterized by an improved survival and a complete rescue of Aß-induced cognitive deficits at the age of 15 months. Importantly, these beneficial effects on survival and cognitive performance were independent of Aß levels and amyloid plaque deposition, but were associated with improved brain mitochondrial respiration, a reversal of mitochondrial complex I dysfunction, restored adenosine triphosphate production and reduced ROS levels. The results of this study support a role for p66Shc in Aß-related mitochondrial dysfunction and oxidative damage in vivo, and suggest that p66Shc ablation may be a promising novel therapeutic strategy against Aß-induced toxicity and cognitive impairment.

Double-lumen tubes and auto-PEEP during one-lung ventilation.

BACKGROUND: Double-lumen tubes (DLT) are routinely used to enable one-lung-ventilation (OLV) during thoracic anaesthesia. The flow-dependent resistance of the DLT's bronchial limb may be high as a result of its narrow inner diameter and length, and thus potentially contribute to an unintended increase in positive end-expiratory pressure (auto-PEEP). We therefore studied the impact of adult sized DLTs on the dynamic auto-PEEP during OLV. METHODS: In this prospective clinical study, dynamic auto-PEEP was determined in 72 patients undergoing thoracic surgery, with right- and left-sided DLTs of various sizes. During OLV, air trapping was provoked by increasing inspiration to expiration ratio from 1:2 to 2:1 (five steps). Based on measured flow rate, airway pressure (Paw) and bronchial pressure (Pbronch), the pressure gradient across the DLT (ΔPDLT) and the total auto-PEEP in the respiratory system (i.e. the lungs, the DLT and the ventilator circuit) were determined. Subsequently the DLT's share in total auto-PEEP was calculated. RESULTS: ΔPDLT was 2.3 (0.7) cm H2O over the entire breathing cycle. At the shortest expiratory time the mean total auto-PEEP was 2.9 (1.5) cm H2O (range 0-5.9 cm H2O). The DLT caused 27 to 31% of the total auto-PEEP. Size and side of the DLT's bronchial limb did not impact auto-PEEP significantly. CONCLUSIONS: Although the DLT contributes to the overall auto-PEEP, its contribution is small and independent of size and side of the DLT's bronchial limb. The choice of DLT does not influence the risk of auto-PEEP during OLV to a clinically relevant extent. CLINICAL TRIAL REGISTRATION: DRKS00005648.

Synaptic dysfunction, memory deficits and hippocampal atrophy due to ablation of mitochondrial fission in adult forebrain neurons.

Well-balanced mitochondrial fission and fusion processes are essential for nervous system development. Loss of function of the main mitochondrial fission mediator, dynamin-related protein 1 (Drp1), is lethal early during embryonic development or around birth, but the role of mitochondrial fission in adult neurons remains unclear. Here we show that inducible Drp1 ablation in neurons of the adult mouse forebrain results in progressive, neuronal subtype-specific alterations of mitochondrial morphology in the hippocampus that are marginally responsive to antioxidant treatment. Furthermore, DRP1 loss affects synaptic transmission and memory function. Although these changes culminate in hippocampal atrophy, they are not sufficient to cause neuronal cell death within 10 weeks of genetic Drp1 ablation. Collectively, our in vivo observations clarify the role of mitochondrial fission in neurons, demonstrating that Drp1 ablation in adult forebrain neurons compromises critical neuronal functions without causing overt neurodegeneration.

Quantifying the sensitivity of G. oxydans ATCC 621H and DSM 3504 to osmotic stress triggered by soluble buffers.

In Gluconobacter oxydans cultivations on glucose, CaCO3 is typically used as pH-buffer. This buffer, however, has disadvantages: suspended CaCO3 particles make the medium turbid, thereby, obstructing analysis of microbial growth via optical density and scattered light. Upon searching for alternative soluble pH-buffers, bacterial growth and productivity was inhibited most probably due to osmotic stress. Thus, this study investigates in detail the osmotic sensitivity of G. oxydans ATCC 621H and DSM 3504 using the Respiratory Activity MOnitoring System. The tested soluble pH-buffers and other salts attained osmolalities of 0.32-1.19 osmol kg(-1). This study shows that G. oxydans ATCC 621H and DSM 3504 respond quite sensitively to increased osmolality in comparison to other microbial strains of industrial interest. Osmolality values of >0.5 osmol kg(-1) should not be exceeded to avoid inhibition of growth and product formation. This osmolality threshold needs to be considered when working with soluble pH-buffers.

Muscle ultrasonography as an additional diagnostic tool for the diagnosis of amyotrophic lateral sclerosis.

OBJECTIVE: We aimed to determine the utility of muscle ultrasonography (MUS) in addition to electromyography (EMG) in the diagnosis of amyotrophic lateral sclerosis (ALS). METHODS: In all, 60 patients with ALS and 20 with other neuromuscular disorders underwent MUS and EMG. In addition, 30 healthy controls underwent only MUS. Occurrence of fasciculations and fibrillations was evaluated. Ultrasonic echogenicity was graded semiquantitatively. RESULTS: The incidence of fasciculations was significantly higher in patients undergoing MUS than in those undergoing EMG (p<0.05), even in muscles of full strength (p<0.001). However, EMG was more sensitive in detecting fibrillations (p<0.05). MUS had an overall higher sensitivity in detecting spontaneous activity in the tongue (p<0.05). Patients with ALS showed significantly increased muscle echo intensity (EI) compared to patients who were initially suspected as having ALS and normal controls (p<0.05), irrespective of the clinical or electrophysiological status. CONCLUSION: Our results showed that the sensitivity and specificity of MUS in diagnosing ALS was almost equivalent to those of EMG, using the Awaji criteria. Combination of MUS and EMG enhances the diagnostic accuracy compared to EMG alone (p<0.05). SIGNIFICANCE: The combination of EMG and MUS can be used to evaluate the lower motor neuron affection by reducing the use of the often painful and uncomfortable EMG examinations but without decreasing the diagnostic sensitivity and specificity.

[Critical illness polyneuropathy and critical illness myopathy]. / Critical-Illness-Polyneuropathie und Critical-Illness-Myopathie.

Critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are frequent complications in critically ill patients and both are associated with sepsis, systemic inflammatory response syndrome (SIRS) and multiorgan failure. Major signs are muscle weakness and problems of weaning from the ventilator. Both CIP and CIM lead to elongated times of ventilation, elongated hospital stay, elongated times of rehabilitation and increased mortality. Electrophysiological measurements help to detect CIP and CIM early in the course of the disease. State of the art sepsis therapy is the major target to prevent the development of CIP and CIM. Although no specific therapy of CIP and CIM has been established in the past, the diagnosis generally improves the therapeutic management (weaning from the ventilator, early physiotherapy, etc.). This review provides an overview of clinical and diagnostic features of CIP and CIM and summarizes current pathophysiological and therapeutic concepts.

The breast care nurse: the care specialist in breast centres.

BACKGROUND: In Europe, breast cancer is the most common form of cancer in women; 26.5 per cent of all new malignant diseases and 17.5 per cent of all cancer deaths are due to this type of cancer. In Germany, approximately every tenth woman is diagnosed with breast cancer during her lifetime. OBJECTIVE: In order to increase the quality of life of breast cancer patients, the European Society of Mastology (EUSOMA) requires the availability of, and an integration of qualified and specialized care into the interdisciplinary team. Thus, in Germany, a new type of job profile for 'breast nurse' as a qualified care specialist has to be established and has to be oriented towards the international standards of a breast care nurse (BCN). METHODS: The Charité's Academy of Health--in cooperation with the Interdisciplinary Breast Centre of the Charité--has offered a career advisory service curriculum for the BCN since 2006 in accordance with the EUSOMA guidelines. RESULTS: In three courses, 45 BCNs have been trained. In the first refresher seminar in May 2009, the BCNs were given an opportunity to exchange with fellow BCNs their experiences. CONCLUSION: We were able to set up a new curriculum to train nurses as BCNs as to improve the quality of care for breast cancer patients and to orientate the training towards the international standards of a BCN qualification.

Reducing chimera formation during PCR amplification to ensure accurate genotyping.

Measurements of population diversity are fundamental to the reconstruction of the evolutionary and epidemiological history of organisms. Commonly used protocols to measure population diversity using the polymerase chain reaction (PCR) are prone to the introduction of artificial chimeras. These are often difficult to detect and can confound the correct interpretation of results due to the false generation of recombinants when the underlying DNA sample contains multiple distinct templates. This study presents a standardised procedure to suppress the formation of artificial chimeras during PCR amplification. The solution is based on the accurate determination of the efficiency and end point of the log-linear phase of a PCR. This procedure will facilitate the generation of data sets that more accurately reflect the underlying population diversity rather than artifacts introduced by the process itself.

[Amyotrophic lateral sclerosis: management of bulbar symptoms]. / Amyotrophe Lateralsklerose: Symptomatische Therapie bulbärer Symptome.

Symptomatic treatment of amyotrophic lateral sclerosis (ALS) is relevant in preventing complications and improving quality of life as long as curative therapies are still out of sight. About one third of ALS patients show disabling problems associated with dysarthria, dysphagia, sialorrhea, and a pseudobulbar affective disorder already in the early stages of ALS. A multidisciplinary approach is the cornerstone of symptomatic treatment of bulbar and pseudobulbar ALS features. Except for riluzole randomized controlled trials are lacking. Here, we review the current views with regard to epidemiology, pathophysiology, diagnosis, and practical aspects of treating bulbar and pseudobulbar symptoms.