The effects of sugammadex vs. neostigmine on postoperative respiratory complications and advanced healthcare utilisation: a multicentre retrospective cohort study.

Reversing neuromuscular blockade with sugammadex can eliminate residual paralysis, which has been associated with postoperative respiratory complications. There are equivocal data on whether sugammadex reduces these when compared with neostigmine. We investigated the association of the choice of reversal drug with postoperative respiratory complications and advanced healthcare utilisation. We included adult patients who underwent surgery and received general anaesthesia with sugammadex or neostigmine reversal at two academic healthcare networks between January 2016 and June 2021. The primary outcome was postoperative respiratory complications, defined as post-extubation oxygen saturation < 90%, respiratory failure requiring non-invasive ventilation, or tracheal re-intubation within 7 days. Our main secondary outcome was advanced healthcare utilisation, a composite outcome including: 7-day unplanned intensive care unit admission; 30-day hospital readmission; or non-home discharge. In total, 5746 (6.9%) of 83,250 included patients experienced postoperative respiratory complications. This was not associated with the reversal drug (adjusted OR (95%CI) 1.01 (0.94-1.08); p = 0.76). After excluding patients admitted from skilled nursing facilities, 8372 (10.5%) patients required advanced healthcare utilisation, which was not associated with the choice of reversal (adjusted OR (95%CI) 0.95 (0.89-1.01); p = 0.11). Equivalence testing supported an equivalent effect size of sugammadex and neostigmine on both outcomes, and neostigmine was non-inferior to sugammadex with regard to postoperative respiratory complications or advanced healthcare utilisation. Finally, there was no association between the reversal drug and major adverse cardiovascular events (adjusted OR 1.07 (0.94-1.21); p = 0.32). Compared with neostigmine, reversal of neuromuscular blockade with sugammadex was not associated with a reduction in postoperative respiratory complications or post-procedural advanced healthcare utilisation.

Serum anti-GM2 and anti-GalNAc-GD1a IgG antibodies are biomarkers for acute canine polyradiculoneuritis.

OBJECTIVES: A previous single-country pilot study indicated serum anti-GM2 and anti-GA1 anti-glycolipid antibodies as potential biomarkers for acute canine polyradiculoneuritis. This study aims to validate these findings in a large geographically heterogenous cohort. MATERIALS AND METHODS: Sera from 175 dogs clinically diagnosed with acute canine polyradiculoneuritis, 112 dogs with other peripheral nerve, cranial nerve or neuromuscular disorders and 226 neurologically normal dogs were screened for anti-glycolipid antibodies against 11 common glycolipid targets to determine the immunoglobulin G anti-glycolipid antibodies with the highest combined sensitivity and specificity for acute canine polyradiculoneuritis. RESULTS: Anti-GM2 anti-glycolipid antibodies reached the highest combined sensitivity and specificity (sensitivity: 65.1%, 95% confidence interval 57.6 to 72.2%; specificity: 90.2%, 95% confidence interval 83.1 to 95.0%), followed by anti-GalNAc-GD1a anti-glycolipid antibodies (sensitivity: 61.7%, 95% confidence interval 54.1 to 68.9%; specificity: 89.3%, 95% confidence interval 82.0 to 94.3%) and these anti-glycolipid antibodies were frequently present concomitantly. Anti-GA1 anti-glycolipid antibodies were detected in both acute canine polyradiculoneuritis and control animals. Both for anti-GM2 and anti-GalNAc-GD1a anti-glycolipid antibodies, sex was found a significantly associated factor with a female to male odds ratio of 2.55 (1.27 to 5.31) and 3.00 (1.22 to 7.89), respectively. Anti-GalNAc-GD1a anti-glycolipid antibodies were more commonly observed in dogs unable to walk (OR 4.56, 1.56 to 14.87). CLINICAL SIGNIFICANCE: Anti-GM2 and anti-GalNAc-GD1a immunoglobulin G anti-glycolipid antibodies represent serum biomarkers for acute canine polyradiculoneuritis.

Does the identification of seniors at risk (ISAR) score effectively select geriatric patients on emergency admission?

The number of older patients admitted to emergency departments (ED) increases continuously. The Identification of Seniors at Risk (ISAR) score is currently recommended to screen patients in German ED, but its appropriateness is being criticized. ISAR scores and clinical characteristics from 98 emergency admissions (EA), 80 from acute geriatrics (AG) and 89 from a geriatric rehabilitation (GR) unit were compared retrospectively. No significant differences were found between groups, being the ISAR score positive in 87.7% of EA, 94.9% of AG and 94.4% of GR cases. None of positively identified geriatric patients in the EA was transferred to the geriatric ward of competence. EA patients showed significantly higher number of functional impairments (p = 0.001) and higher BI score (p < 0.0001) compared to AG and GR groups. A higher ISAR score threshold and additional functional information might be needed to better select patients in need of prompt treatment by a geriatric team.

Do independent geriatric outpatients with nocturnal polyuria profit from desmopressin?

OBJECTIVE: To compare the efficacy of desmopressin and placebo in independent geriatric outpatients with nocturnal polyuria (NP). METHODS: A prospective, randomized, single-center, national, double blind, placebo-controlled, fixed-dose, parallel group comparative trial was carried out. The study included 110 geriatric outpatients, 55 patients per treatment group using desmopressin acetate nasal spray (strength: 0.1 mg/ml) once daily of 10 µg/spray blast or placebo. MEASUREMENT: The NP positive geriatric outpatients with >33% nocturnal urine output volume, antidiuretic hormone (ADH) positive or negative were treated over 10 days with intranasal spray in the evening time (7 p.m.), drug or placebo. On day 1 voiding frequency, voiding volumes day and night, serum osmolarity and arginine-vasopressin (AVP) were measured at 7 p.m. On days 2, 5 and 10 creatinine, blood urea nitrogen (bun), blood count and C­reactive protein (CrP), vena cava diameter and bioimpedance were measured and a structured interview was implemented (voiding frequency, sleeping behavior and subjective and cognitive behavior). RESULTS: The NP patients showed a mean night voiding volume of 50.60%, 39.21% (n = 102) showed a low AVP level at baseline with no correlation to sodium concentration or voiding frequencies. The primary efficacy criterion, a decrease of the nocturnal voiding frequency during the course of the clinical trial as change from baseline at day 10 (visit 4) was 50% versus 41.40% in the verum versus placebo group, respectively but the differences were not significant. The U­test showed superiority of AVP-positive NP patients to a positive reaction on desmopressin. Sleeping time hours increased in both groups without significant differences. CONCLUSION: In this 10-day clinical trial desmopressin was not proven to be therapeutically superior to placebo with respect to micturition frequency or sleeping hours. Independent geriatric outpatients with decreased ADH levels seemed to respond and benefit from active treatment with desmopressin. The unexpected results in the placebo group may be due to the effect of intensive outpatient care and information on NP outpatients with normal AVP levels.

Dysregulated autophagy in restrictive cardiomyopathy due to Pro209Leu mutation in BAG3.

Myofibrillary myopathies (MFM) are hereditary myopathies histologically characterized by degeneration of myofibrils and aggregation of proteins in striated muscle. Cardiomyopathy is common in MFM but the pathophysiological mechanisms are not well understood. The BAG3-Pro209Leu mutation is associated with early onset MFM and severe restrictive cardiomyopathy (RCM), often necessitating heart transplantation during childhood. We report on a young male patient with a BAG3-Pro209Leu mutation who underwent heart transplantation at eight years of age. Detailed morphological analyses of the explanted heart tissue showed intracytoplasmic inclusions, aggregation of BAG3 and desmin, disintegration of myofibers and Z-disk alterations. The presence of undegraded autophagosomes, seen by electron microscopy, as well as increased levels of p62, LC3-I and WIPI1, detected by immunohistochemistry and western blot analyses, indicated a dysregulation of autophagy. Parkin and PINK1, proteins involved in mitophagy, were slightly increased whereas mitochondrial OXPHOS activities were not altered. These findings indicate that altered autophagy plays a role in the pathogenesis and rapid progression of RCM in MFM caused by the BAG3-Pro209Leu mutation, which could have implications for future therapeutic strategies.

Chemo-Enzymatic Epoxidation of Lallemantia IbericaSeed Oil: Process Development and Economic-Ecological Evaluation.

The chemo-enzymatic epoxidation of Lallemantia iberica seed oil (LISO), a novel plant oil characterized by its exceptional high content of alpha-linolenic acid (> 60%), was developed using an immobilized lipase from Pseudozyma antarctica and hydrogen peroxide as oxidant. A statistical approach was used to study the effect of enzyme amount, temperature, time, and solvent amount on the oxirane oxygen content obtained during epoxidation. An oxirane oxygen content of 8.6 ± 0.2% corresponding to a yield of 82% was obtained under optimized conditions that were identified to be at an enzyme load of 8.2 g/mol of double bonds, a solvent amount of 56.4 wt.%, a temperature of 33 °C, and an incubation time of 17 h. In addition, the experimental investigation was combined with a techno-economic and ecological assessment gaining detailed information regarding cost structure and environmental impact for the chemo-enzymatic epoxidation of the novel plant oil.

[Magnetic resonance imaging features of a caudal cruciate ligament rupture associated with a suspected bone bruise lesion in a dog]. / Magnetresonanztomographische Befunde einer isolierten Ruptur des kaudalen Kreuzbandes mit "Bone-Bruise"-Läsion bei einem Hund.

In this case study we describe a surgically confirmed caudal cruciate ligament rupture in a 10-year-old Border Collie. Magnetic resonance imaging (MRI) demonstrated a complete rupture of the caudal cruciate ligament, a suspected bone bruise lesion on the proximolateral tibia and a muscle strain injury of the M. flexor digitorum lateralis. In human medicine, bone bruise lesions in MRI have been described as "footprint injuries" and can thereby explain the mechanism of trauma in ligament injuries. The combination of the MRI findings in this case can help to understand how the rarely diagnosed isolated rupture of the caudal cruciate ligament occurred in this dog.

A family of secreted pathogenesis-related proteins in Candida albicans.

Analysing culture supernatants of yeast and hyphal cells of Candida albicans, we found two close homologues of pathogenesis-related (PR-) 1 proteins, Rbe1p and Rbt4p, in the secretome. Due to sequence homology, three additional, yet not characterized open reading frames, ORF19.6200, ORF19.2787 and ORF19.2336, together with RBE1 and RBT4 were assigned to a novel family of CaPRY proteins. In a Δrbe1/Δrbt4 deletion strain, genome-wide transcriptional analysis revealed differential transcription of only a limited set of genes implicated in virulence and oxidative stress response. Single deletion of RBE1 or RBT4 in a clinical C. albicans isolate resulted in a moderate but significant attenuation in virulence in a mouse model for disseminated candidiasis. However, a synergistic effect was observed in a Δrbe1/Δrbt4 double deletion strain, where virulence was strongly affected. Remarkably, transcription of RBT4 and RBE1 was each upregulated in blastospores of Δrbe1 or hyphae of Δrbt4 deletion strains respectively, indicating functional complementation thereby compensating a potential virulence defect in the single deletion strains. Furthermore, the double deletion strain showed increased sensitivity to attack by polymorphonuclear leucocytes. Therefore, the crucial contribution of both C. albicans pathogenesis-related proteins to virulence might be vested in protection against phagocyte attack.

[Rehabilitation following total knee replacement. Conservative orthopedics and sport science]. / Anschlussheilbehandlung nach Knietotalendoprothesenimplantation. Konservative Orthopädie und Sportwissenschaft.

Total knee replacement (TKR) is a highly standardized procedure. However; many patients are not satisfied with the functional results. Surgery focuses initially on restoration of joint function. Based on the ICF classification (WHO) rehabilitation adds individual and social perspectives. The focus is not limited to body functions but includes abilities and participation. After surgery the patient suffers from pain, swelling, restricted blood circulation and a dramatic impairment of motor function. To prepare patients for activities of daily living it is important to analyze and understand the demands after TKR. Key qualities are the range of motion of the knee joint, functional joint stability, postural stability and muscle coordination. The paper describes a comprehensive rehabilitation protocol which is mainly based on the concept of functional training which consists of purposeful training preparing patients for activities of daily living and participation. It attempts to focus on multijoint movement as much as possible using closed chain muscle action (leg press, indoor cycling, gait training) and on sensorimotor training. A second focus is on postural stability (balance training). For clinical evaluation standardized scores are widely used (e.g. knee society score, HSS score). These scores were adapted for evaluation of the rehabilitation process (e.g. Staffelstein score, EVA-Reha score). However; these are not specific enough to analyze the effects of sensorimotor training and balance training. More detailed assessments should be used to evaluate the benefits of functional based rehabilitation concepts.

[Psychosomatic aspects in orthopedics]. / Psychosomatische Aspekte in der Orthopädie.

Psychosomatic disease patterns are a common differential diagnosis for orthopedic symptoms. Furthermore, mental factors, such as the method of disease processing or mental comorbidities, such as depression or somatization disorders have a great influence on the chronification of orthopedic complaints and the outcome following orthopedic interventions. The aim of this article is to present the psychosomatic pathomechanisms and disease patterns relevant for orthopedics and to derive recommendations for physician-patient communication, diagnostics, therapy and assessment.

[Involuntary patient admission and treatment against patient's will by emergency physicians]. / Zwangseinweisung und Zwangsbehandlung bei psychiatrischen Patienten als notärztliche Aufgabe.

INTRODUCTION: The treatment of acutely ill patients who presumably lack the insight or judgement to determine their need for medical treatment, is a difficult challenge for emergency physicians. We have carried out a study to assess the frequency and relevance of involuntary treatment and procedures in medical emergency services. METHODS: Retrospective chart analysis for a 1-year period was performed for all treatment protocols of a medical emergency service unit and for all court-ordered treatments of a guardianship court. Cases of involuntary treatment by emergency physicians were identified and analysed. RESULTS: In 10.4% of all emergency calls analysed a relevant and acute psychiatric condition was found. In 0.3% of the cases or 4.8% of the psychiatric cases, involuntary inpatient commitment was chosen by the emergency physician. DISCUSSION: Involuntary inpatient commitment by emergency physicians was only necessary in relatively few cases. Nevertheless, in order to be able to correctly consider treatment and management options, emergency physicians should be aware of the basic conditions for treatment without a patient's consent.

Posttraumatic anterior-inferior instability of the shoulder: arthroscopic findings and clinical correlations.

INTRODUCTION: The main purpose of our study was to evaluate intra-articular lesions in glenohumeral-instability with arthroscopy and correlate them with clinical findings as well as history of instability. MATERIAL AND METHODS: In this prospective multi-centre study, we evaluated arthroscopic findings in 303 patients with posttraumatic anterior-inferior instability of the shoulder. The study cohort was divided into 2 groups: patients with a history of one dislocation (Group 1, n=61, 20.1%) and patients with a history of more than one dislocation (Group 2, n=242, 79.9%). RESULTS: In Group 1, 37 patients had an IGHL-lesion, 31 a MGHL-lesion and 41 a Hill-Sachs lesion. In Group 2, 182 patients had an IGHL-lesion, 172 a MGHL-lesion and 203 a Hill-Sachs lesion. The percentage of lesions in Group 2 (IGHL-75.2%, MGHL-71.1%, Hill-Sachs-83.9%) was significantly higher than in Group 1 (IGHL-60.7%, MGHL-50.8%, Hill-Sachs-67.2%, P=0.0233, P=0.0026, and P=0.0033, respectively). Within Group 2 we found significantly more Hill-Sachs-lesions with a history of an increasing number of recurrences (P=0.0436). We also found an increase of IGHL- and MGHL-lesions with an increasing number of recurrences, but this difference was not significant. The distribution of lesion types of the anterior labrum-ligament complex showed no significant difference between the two groups, apart from a higher incidence of ALPSA-lesions within Group 2 (34.7% versus 18.0% in Group 1). The results of this study show that recurrences after primary posttraumatic anterior-inferior shoulder dislocation cause increasing ligamental damage as well as increasing Hill-Sachs lesions within the gleno-humeral joint. CONCLUSION: Thus we conclude that early surgical stabilization after posttraumatic anterior-inferior shoulder dislocation is necessary to prevent increasing damage within the shoulder joint.

Identification and characterization of Cor33p, a novel protein implicated in tolerance towards oxidative stress in Candida albicans.

We applied two-dimensional gel electrophoresis to identify downstream effectors of CPH1 and EFG1 under hypha-inducing conditions in Candida albicans. Among the proteins that were expressed in wild-type cells but were strongly downregulated in a cph1Delta/efg1Delta double mutant in alpha-minimal essential medium at 37 degrees C, we could identify not-yet-characterized proteins, including Cor33-1p and Cor33-2p. The two proteins are almost identical (97% identity) and represent products of allelic isoforms of the same gene. Cor33p is highly similar to Cip1p from Candida sp. but lacks any significant homology to proteins from Saccharomyces cerevisiae. Strikingly, both proteins share homology with phenylcoumaran benzylic ether reductases and isoflavone reductases from plants. For other hypha-inducing media, like yeast-peptone-dextrose (YPD) plus serum at 37 degrees C, we could not detect any transcription for COR33 in wild-type cells, indicating that Cor33p is not hypha specific. In contrast, we found a strong induction for COR33 when cells were treated with 5 mM hydrogen peroxide. However, under oxidative conditions, transcription of COR33 was not dependent on EFG1, indicating that other regulatory factors are involved. In fact, upregulation depends on CAP1 at least, as transcript levels were clearly reduced in a Deltacap1 mutant strain under oxidative conditions. Unlike in wild-type cells, transcription of COR33 in a tsa1Delta mutant can be induced by treatment with 0.1 mM hydrogen peroxide. This suggests a functional link between COR33 and thiol-specific antioxidant-like proteins that are important in the oxidative-stress response in yeasts. Concordantly, cor33Delta deletion mutants show retarded growth on YPD plates supplemented with hydrogen peroxide, indicating that COR33 in general is implicated in conferring tolerance toward oxidative stress on Candida albicans.

Primary stability of various forms of osteosynthesis in the treatment of fractures of the proximal tibia.

The treatment of fractures of the proximal tibia is complex and makes great demands on the implants used. Our study aimed to identify what levels of primary stability could be achieved with various forms of osteosynthesis in the treatment of diaphyseal fractures of the proximal tibia. Pairs of human tibiae were investigated. An unstable fracture was simulated by creating a defect at the metaphyseal-diaphyseal junction. Six implants were tested in a uniaxial testing device (Instron) using the quasi-static and displacement-controlled modes and the force-displacement curve was recorded. The movements of each fragment and of the implant were recorded video-optically (MacReflex, Qualysis). Axial deviations were evaluated at 300 N. The results show that the nailing systems tolerated the highest forces. The lowest axial deviations in varus and valgus were also found for the nailing systems; the highest axial deviations were recorded for the buttress plate and the less invasive stabilising system (LISS). In terms of rotational displacement the LISS was better than the buttress plate. In summary, it was found that higher loads were better tolerated by centrally placed load carriers than by eccentrically placed ones. In the case of the latter, it appears advantageous to use additive procedures for medial buttressing in the early phase.

[Imaging and preoperative planning of osteotomy of tibial head osteotomy]. / Bildgebung und präoperative Planung der Tibiakopfosteotomie.

Valgus-producing osteotomy of the proximal tibia is a well-established treatment for medial femorotibial osteoarthritis in the varus knee. The ideal patient is active, under 55 years of age, has a stable varus deformity of less than 10 degrees, a good bone stock, and an osteoarthritis stage that is restricted to the medial compartment of the knee. Coventry reported a failure rate in proximal tibial osteotomy to be significantly higher when the postoperative alignment was less than 8 degrees of anatomical valgus. Hernigou noted better clinical long-term results in cases with a precise correction of malalignment. There are different preoperative planning methods varying between simple estimates of correction angles and specific radiographic planning tools. The reproducibility of operative outcome with regard to a predictable anatomic alignment and functional recovery must have high priority. This chapter deals with different preoperative planning methods to improve the reliability of surgical results after tibial osteotomy.

[Stability, bone healing and loss of correction after valgus realignment of the tibial head. A roentgen stereometry analysis]. / Stabilität, Knochenheilung und Korrrekturverlust nach valgisierender Tibiakopfumstellung. Eine Röntgenstereometrieanalyse.

In high tibial closing-wedge osteotomies (HTO), closure of an osteotomy gap after resection of a bony wedge can be associated with a fissure of the medial cortex of the tibial head (MCT). The effect of a broken MCT on the recurrence of varus deformity is disputed. In this study, serial roentgen stereometric analysis (RSA) was used to determine the fixation stability of a rigid internal "L" plate after HTO. Full weight lower limb radiographs were used to determine the sagittal alignment in patients with varying degrees of varus malalignment and correction over time. Forty-two patients with varus gonarthrosis stage I-III (Ahlback) were treated with HTO and internal fixation with an L-shaped rigid plate. Patients were followed by serial RSA, conventional radiographs, and clinical evaluation (Hospital of Special Surgery score) over a 12-month period. In 19 of 42 successive patients, an average wedge size of 6.9 degrees was resected leaving the MCT intact (group 1). In 23 of 42 of patients, the MCT was unintentionally fissured during surgery when an average 10.3 degrees -wedge was resected (group 2). In group 2, RSA revealed a fivefold increase in lateral displacement of the distal tibial segment within 3 weeks after HTO. Twelve weeks after HTO, translations between tibial segments were below the accuracy of the RSA setup in the majority of patients. Group 1 patients demonstrated a higher initial fixation stability, less occurrence of varus deformity, and a higher HSS score compared to patients with larger wedge sizes and frequent fracture of the MCT (group 2). Before bone healing is achieved, the integrity of the MCT plays a crucial role for the clinical and radiological outcome after HTO.