Goal-setting and attainment in prolonged disorders of consciousness - development of a structured approach.

Aims: To develop a structured goal-set for use in programs for the assessment and management of prolonged disorders of consciousness (PDOC).Methods: A retrospective analysis of goals from a consecutive cohort of patients (n = 162) admitted to a specialist in-patient PDOC program in the UK from 2007 to 2018. Overall goal attainment was examined with Goal Attainment Scaling (GAS) using the GAS-Light method. Rates of individual goal-setting and achievement were examined for both standardized objectives (n = 2959) and personalized goals (n = 661). Goal statements from the personalized goals were independently reviewed and mapped to the domains of the existing structured objective set to identify any missing goal areas.Results: Mean outcome GAS T-scores were 47.2 (95% CI: 46.7, 47.6) and 47.7 (95% CI: 46.7, 48.8), respectively, for the standardized and personally set goals. These were closely correlated (r = 0.482, p < .001) with no significant difference between them. Analysis of goal achievement within each domain identified goals that were/were not likely to be achieved. An initial structured set of 20 standardized objectives in 12 domains was expanded and re-organized to produce a final-structured goal-set of 36 objectives in 18 domains.Conclusions: Developed through real-life clinical practice, this first published structured goal-set for PDOC programs now requires testing in other services/settings.

The role of microbiota and inflammation in self-judgement and empathy: implications for understanding the brain-gut-microbiome axis in depression.

RATIONALE: The gut-brain axis includes bidirectional communication between intestinal microbiota and the central nervous system. Bifidobacterium and Lactobacillus spp. have been implicated in psychological health, such as depression, through various pathways (e.g. inflammation). Research needs a better understanding of direct and indirect effects through examination of psychological factors that make people susceptible to, or offer protection against, depression. OBJECTIVE: This study investigated the relationships between gut microbiota, inflammation and psychological risk and resilience factors for depression. METHODS: Forty participants (13 m/27 f) recruited from the general population completed self-report questionnaires for depression, self-judgement, over-identification and affective and cognitive empathy. Faecal and blood samples were taken to assay microbiota (Bifidobacterium; Lactobacillus spp.) and pro-inflammatory molecules (C-reactive protein, CRP and interleukin-6, IL-6), respectively. RESULTS: Hierarchical regression analyses (controlling for sex, age and the shared variance of risk and resilience factors) showed that (i) cognitive depression was significantly predicted by negative self-judgement and reduced cognitive empathy; (ii) abundance of Lactobacillus spp. was directly related to positive self-judgement but only indirectly to cognitive depression and lower affective empathy (both through self-judgement); and (iii) CRP was the strongest predictor of reduced cognitive empathy, with suppression effects seen for age (negative) and IL-6 (positive) after controlling for CRP. CONCLUSIONS: Findings suggest that lactobacilli and inflammation may be differentially associated with mood disorder via brain mechanisms underpinning self-judgement and cognitive empathy, respectively. Further trials investigating interventions to increase Lactobacillus spp. in depression would benefit from direct measures of self-judgement and affective empathic distress, whilst those that aim to reduce inflammation should investigate cognitive empathy.

Effects of whole body cryo-chamber therapy on pain in patients with chronic low back pain: a prospective double blind randomised controlled trial.

BACKGROUND: It is believed that treatment with low temperature can reduce pain perception in chronic pain patients, including chronic low back pain patients. AIM: To evaluate the effects of a two-week repeated intervention of -67 °C cryo-chamber in patients with chronic low back pain. DESIGN: A prospective randomized double blind study design. SETTING: Hospital-based outpatients department POPULATION: Outpatients with chronic low back pain. METHODS: Comparing intervention group (-67 °C) with higher temperature (-5 °C) which was supposed as a control group in a cryo-chamber. RESULTS: Similar effectiveness in pain reduction in both intervention and control groups CONCLUSION: Cryochamber therapy with -67 °C is not superior to (sham cryo chamber) with -5 °C. CLINICAL REHABILITATION IMPACT: Cryo chambers therapy show positive effect by improving pain. For the treatment, -5 °C seems to be sufficient for these patients.

[A fully-implantable active hearing device in congenital auricular atresia]. / Vollimplantierbares Hörsystem bei Atresia auris congenita.

Active implantable hearing devices were primarily developed for sensorineural hearing loss. The vibrator coupling mechanisms were oriented towards normal middle ear anatomy and function. The aim of this project was to modify the only fully implantable hearing device with an implantable microphone for application in congenital auricular atresia, Carina™, and to introduce the modified device into the clinic. A special prosthesis was developed for the transducer and its individual coupling achieved by a special cramping system. The system was implanted in 5 patients with congenital auricular atresia. Audiological results were good; with patients' hearing gain exceeding 30 dB HL. Anatomic limits to the system's indications and technical drawbacks are also discussed.

[Semi-implantable transcutaneous bone conduction hearing devices]. / Teilimplantierbare transkutane Knochenleitungshörgeräte.

BACKGROUND: Patients with air-bone gaps or combined hearing loss that cannot be corrected by tympanoplasty can be treated with bone conduction hearing aids. The disadvantages of conventional and percutaneous systems are, on one hand, the obvious external fixation components and on the other hand, the biological and psychosocial problems of open implants. This project was therefore set up to develop a semi-implantable, magnetically anchored transcutaneous bone conduction device, introduce it into clinical application and follow-up the results. PATIENTS AND METHODS: The principle of this bone conduction device is the magnetic coupling of an external vibrator via implanted double magnets. After extensive laboratory tests, this method was introduced into the clinic in 2006. Following the initial pilot study, 184 implantations in 143 patients have been performed in Recklinghausen since 2008. Long-term evaluation of 20 congenital atresia patients treated with these devices was possible. RESULTS: Worldwide, more than 3000 of these devices have been implanted. The operative implantation technique is relatively simple. With the new "upside down technique", bone removal is no longer necessary. The 2.6-mm thin implants are hardly noticeable. The hearing improvement is similar to that of other bone conduction hearing aids. CONCLUSION: This semi-implantable transcutaneous bone conduction hearing device is another option for patients with air-bone gaps, combined hearing loss or single-sided deafness.

[Malformation and plastic surgery in childhood]. / Fehlbildungen und plastische Chirurgie im Kindesalter.

Malformations of the head and neck show a huge variety of -clinical symptoms with functional and esthetic consequences. Often times its rehabilitation requires multi-staged and multi-disciplinary procedures and concepts. They must consider eating, speech, mimic expression, hearing and "esthetics" or at least "normality". A survey of the most common head and neck malformations and their treatment options are presented here.

[Histomorphologic findings in the facial nerve after water-jet dissection of the parotid gland in dogs]. / Einflüsse des Wasserstrahljets auf die Histomorphometrie und Funktion des N. facialis.

BACKGROUND: Initial results on the application of the water-jet in a parotidectomy setting in an animal study demonstrate that there are morphologic changes which do, and some which do not, affect the clinial function of the facial nerve due to the different jet sizes and operating pressures used. In a further study the histomorphometric data of the facial nerve dissected by the water-jet should be evaluated and correlated to the different sizes of jet and operating pressures. MATERIAL AND METHODS: In total, 102 nerves (in 14 beagles) which had been dissected by water-jets of different sizes and operating pressures were evaluated. After an observation period of 21 days, including documentation of the clinical function of the facial nerve, the nerves were dissected. The number of nerve fibers and the diameter of the different nerve fibers were then evaluated. RESULTS: All nerve fibers dissected with jet sizes of 120 and 150 µm showed an identical cumulative frequency of fiber diameters. All nerve fibers dissected with a water-jet of 200 µm showed morphologic and clinical abnormalities and--in terms of nerve fiber diameters--clear differences to the nerve fibers dissected with 120- or 150-µm jets. Altogether, there is a decrease in fiber diameter along the nerve course. CONCLUSION: Our data show a shift of larger diameters of the nerve trunk to smaller diameters in the terminal nerve fibers. This phenomenon has not been described in the literature to date and is probably not due to the water-jet. Additionally, our data show that 22% of the original nerve fiber damaged by the water-jet is sufficient to preserve the nerve's clinical function.

[Histomorphologic findings in the facial nerve after waterjet dissection of the parotid gland. Animal studies in dogs]. / Einfluss des Wasserstrahldissektors auf die Morphologie des N. facialis. Tierexperimentelle Untersuchungen am Hund.

BACKGROUND: The postoperative facial nerve palsy is a complication after parotidectomy which one is afraid of. The waterjet seems to be a surgical technic which allows separating different tissues without destroying important structures like vessels and nerves. MATERIAL AND METHODS: Totally, 106 nerve preparations, done by the waterjet of 14 beagles, were evaluated. According to a defined procedure during parotidectomy by waterjet different cones and pressure were used. After a period time of 21 days the trunk, the frontal branch and both oral branches of the facial nerve of both sides were dissected. The tissue preparation was done using the standard technic for EM-sections. RESULTS: There are mainly changes due to the preparation like the reduction of nerve fibers and fibrosis depending which cones and pressure has been used. CONCLUSION: Therefore neither the size of the jet (120 or 150 µm) nor the operating pressure of 40 to 60 or 80 bar plays an important role for the function of the facial nerve. Damage to the nerve is mainly due to the preparation technic and the application time. Using the 200 µm jet there is regularly facial nerve damage.

[Planning and intraoperative controls in rhinoplasty]. / Planung und intraoperative Kontrollen in der Rhinochirurgie.

We present a technique to quantify computer simulation in rhinoplasty and to make individual templates to be used intraoperatively. With these templates the exact position and shape of the nasal dorsum, tip, columella and anterioar nasal spine can be controlled and adjusted. Due to our experience this techniques contributes to precise surgical outcome and patient's satisfaction.

[Magnetic coupling of partially implantable bone conduction hearing aids without open implants]. / Die magnetische Ankopplung von Knochenleitungshörgeräten ohne offene Implantate - Prinzip und erste Ergebnisse einer neuen Knochenleitungsversorgung.

INTRODUCTION: Patients with air-bone-gaps that cannot be corrected successfully by tympanoplasty or with mixed hearing loss may be treated with bone conducting hearing aids. Their disadvantages are the obvious external fixation components or the biological and psychosocial problems of open implants. PATIENTS AND METHODS: The principle of these new bone conducting hearing aids is the magnetic coupling between implanted and external magnets. Twin-magnets are implanted into shallow bone beds in a one step procedure. The skin above the magnets is thinned out to a thickness of 4-5 mm, which reduces the attenuation to less than 10 dB compared to direct bone stimulation. RESULTS AND DISCUSSION: The holding strength of the external components is equivalent to partially implantable hearing aids and Cochlea implants and the hearing improvement is similar to other bone conducting hearing aids. We have found the comfort and safety of this system is significantly improved compared to conventional or percutaneous bone conducting hearing aids.

[Guideline: Treatment of obstructive sleep apnea in adults]. / Leitlinie: Therapie der obstruktiven Schlafapnoe des Erwachsenen.

The current guideline discusses conservative and surgical therapy of obstructive sleep apnea (OSA) in adults from the perspective of the ear, nose and throat specialist. The revised guideline was commissioned by the German Society of Ear-Nose-Throat, Head-Neck Surgery (DG HNO KHC) and compiled by the DG HNO KHC's Working Group on Sleep Medicine. The guideline was based on a formal consensus procedure according to the guidelines set out by the German Association of Scientific Medical Societies (AWMF) in the form of a"S2e guideline". Research of the literature available on the subject up to and including December 2008 forms the basis for the recommendations. Evaluation of the publications found was made according to the recommendations of the Oxford Centre for Evidence-Based Medicine (OCEBM). This yielded a recommendation grade, whereby grade A represents highly evidence-based studies and grade D those with a low evidence base.

[The effectiveness of an individual mandibular advancement splint (MAS) in subjects with obstructive tongue-base-snoring]. / Effektivität der individuell adjustierbaren Protusionsschiene bei Patienten mit obstruktivem Zungengrundschnarchen.

OBJECTIVE: Besides operation the mandibular advancement splint (MAS) is one of the main options for treatment of snoring. Especially the MAS by Hinz, which exclusively blocks mandibular retrusion, has been established as an effective alternative. The aim of this study is to examine the effectiveness of this MAS and to evaluate the role of obstruction at the level of the tongue base as a successful pretherapeutic predictor by using the sleep nasal endoscopy. SUBJECTS AND METHODS: From August 2001 until August 2006 we have examined over 450 patients with sleep disorders at our hospital. All patients have had an ENT examination, a standardized polysomnography and a sleep nasal endoscopy with therapy simulation. The application of a MAS is indicated if an obstruction at the level of the tongue base is detected and the RDI (respiratory disturbance index) is below 10/h. 10 patients are examined by PSG and partly by sleep nasal endoscopy before and after adjustment of the MAS. The patient group is classified in three velum- (n = 3), isolated tongue base-snorers, five combined tongue base-/velum- and two tongue base-/epiglottis-snorers. RESULTS: The subjective sleep recovery and the snoring-intensity can be improved by the MAS in eight of ten patients. In addition the long-term acceptance of this therapy is very high. CONCLUSIONS: According to our experiences the MAS by Hinz is an effective treatment option for patients with an obstruction level at the tongue base confirmed by sleep nasal endoscopy.