Influence of Long-Lasting Static Stretching Intervention on Functional and Morphological Parameters in the Plantar Flexors: A Randomized Controlled Trial

ABSTRACT

Warneke, K, Keiner, M, Wohlann, T, Lohmann, LH, Schmitt, T, Hillebrecht, M, Brinkmann, A, Hein, A, Wirth, K, and Schiemann, S. Influence of long-lasting static stretching intervention on functional and morphological parameters in the plantar flexors: a randomised controlled trial. J Strength Cond Res 37(10): 1993-2001, 2023-Animal studies show that long-lasting stretching training can lead to significant hypertrophy and increases in maximal strength. Accordingly, previous human studies found significant improvements in maximal voluntary contraction (MVC), flexibility, and muscle thickness (MTh) using constant angle long-lasting stretching. It was hypothesized that long-lasting stretching with high intensity will lead to sufficient mechanical tension to induce muscle hypertrophy and maximal strength gains. This study examined muscle cross-sectional area (MCSA) using magnetic resonance imaging (MRI). Therefore, 45 well-trained subjects (f: 17, m: 28, age: 27.7 ± 3.0 years, height: 180.8 ± 4.9 cm, mass: 80.4 ± 7.2 kg) were assigned to an intervention group (IG) that stretched the plantar flexors 6 × 10 minutes per day for 6 weeks or a control group (CG). Data analysis was performed using 2-way ANOVA. There was a significant Time × Group interaction in MVC ( p < 0.001-0.019, ƞ 2 = 0.158-0.223), flexibility ( p < 0.001, ƞ 2 = 0.338-0.446), MTh ( p = 0.002-0.013, ƞ 2 = 0.125-0.172), and MCSA ( p = 0.003-0.014, ƞ 2 = 0.143-0.197). Post hoc analysis showed significant increases in MVC ( d = 0.64-0.76), flexibility ( d = 0.85-1.12), MTh ( d = 0.53-0.6), and MCSA ( d = 0.16-0.3) in IG compared with CG, thus confirming previous results in well-trained subjects. Furthermore, this study improved the quality for the morphological examination by investigating both heads of the gastrocnemius with MRI and sonography. Because stretching can be used passively, an application in rehabilitation settings seems plausible, especially if no commonly used alternatives such as strength training are applicable.

Comparison of the effects of long-lasting static stretching and hypertrophy training on maximal strength, muscle thickness and flexibility in the plantar flexors

Maximal strength measured via maximal voluntary contraction is known as a key factor in competitive sports performance as well as injury risk reduction and rehabilitation. Maximal strength and hypertrophy are commonly trained by performing resistance training programs. However, literature shows that long-term, long-lasting static stretching interventions can also produce significant improvements in maximal voluntary contraction. The aim of this study is to compare increases in maximal voluntary contraction, muscle thickness and flexibility after 6 weeks of stretch training and conventional hypertrophy training. Sixty-nine (69) active participants (f = 30, m = 39; age 27.4 ± 4.4 years, height 175.8 ± 2.1 cm, and weight 79.5 ± 5.9 kg) were divided into three groups: IG1 stretched the plantar flexors continuously for one hour per day, IG2 performed hypertrophy training for the plantar flexors (5 × 10-12 reps, three days per week), while CG did not undergo any intervention. Maximal voluntary contraction, muscle thickness, pennation angle and flexibility were the dependent variables. The results of a series of two-way ANOVAs show significant interaction effects (p < 0.05) for maximal voluntary contraction (ƞ2 = 0.143-0.32, p < 0.006), muscle thickness (ƞ2 = 0.11-0.14, p < 0.021), pennation angle (ƞ2 = 0.002-0.08, p = 0.077-0.625) and flexibility (ƞ2 = 0.089-0.21, p < 0.046) for both the stretch and hypertrophy training group without significant differences (p = 0.37-0.99, d = 0.03-0.4) between both intervention groups. Thus, it can be hypothesized that mechanical tension plays a crucial role in improving maximal voluntary contraction and muscle thickness irrespective whether long-lasting stretching or hypertrophy training is used. Results show that for the calf muscle, the use of long-lasting stretching interventions can be deemed an alternative to conventional resistance training if the aim is to increase maximal voluntary contraction, muscle thickness and flexibility. However, the practical application seems to be strongly limited as a weekly stretching duration of up to 7 h a week is opposed by 3 × 15 min of common resistance training.

A rule-based robotic assistance system providing physical relief for nurses during repositioning tasks at the care bed

In nursing care, physical overload is an important issue that plays a main role in adding to the number of sick days or even causing staff to withdrawal from the profession. In addition to existing physical aids, robotics in particular has the potential to provide general physical relief during extremely stressful care activities provided at the bedside by performing assistance activities. To shed more light on the relief potential offered, we conducted a study involving 12 caregivers who used a lightweight robot attached to a nursing care bed to assist in the repositioning process. We relied on a robot system architecture that enables rule-based movement adjustments in real time using the Robot Operating System and Unity. The study focused on the repositioning of a patient simulator from the supine to the lateral position. The comparison of the measured ground reaction forces and muscle activity data suggests that robotic assistance during the performance of the activity reduces load peaks and generally leads to more attenuated ground reaction force curves, which results overall in a healthier way of working. With robotic assistance, the average back extensor muscle activations were 25.7% lower compared to conventional repositioning. In addition, the measured maximum occurring muscle activations were reduced by 61.2% when the robotic assistance system was deployed.

Influence of Long-Lasting Static Stretching on Maximal Strength, Muscle Thickness and Flexibility

Background: In animal studies long-term stretching interventions up to several hours per day have shown large increases in muscle mass as well as maximal strength. The aim of this study was to investigate the effects of a long-term stretching on maximal strength, muscle cross sectional area (MCSA) and range of motion (ROM) in humans.

Methods: 52 subjects were divided into an Intervention group (IG, n = 27) and a control group (CG, n = 25). IG stretched the plantar flexors for one hour per day for six weeks using an orthosis. Stretching was performed on one leg only to investigate the contralateral force transfer. Maximal isometric strength (MIS) and 1RM were both measured in extended knee joint. Furthermore, we investigated the MCSA of IG in the lateral head of the gastrocnemius (LG) using sonography. Additionally, ROM in the upper ankle was investigated via the functional “knee to wall stretch” test (KtW) and a goniometer device on the orthosis. A two-way ANOVA was performed in data analysis, using the Scheffé Test as post-hoc test.

Results: There were high time-effects (p = 0.003, ƞ² = 0.090) and high interaction-effect (p < 0.001, ƞ²=0.387) for MIS and also high time-effects (p < 0.001, ƞ²=0.193) and interaction-effects (p < 0.001, ƞ²=0,362) for 1RM testing. Furthermore, we measured a significant increase of 15.2% in MCSA of LG with high time-effect (p < 0.001, ƞ²=0.545) and high interaction-effect (p=0.015, ƞ²=0.406). In ROM we found in both tests significant increases up to 27.3% with moderate time-effect (p < 0.001, ƞ²=0.129) and high interaction-effect (p < 0.001, ƞ²=0.199). Additionally, we measured significant contralateral force transfers in maximal strength tests of 11.4% (p < 0.001) in 1RM test and 1.4% (p=0.462) in MIS test. Overall, there we no significant effects in control situations for any parameter (CG and non-intervened leg of IG).

Discussion: We hypothesize stretching-induced muscle damage comparable to effects of mechanical load of strength training, that led to hypertrophy and thus to an increase in maximal strength. Increases in ROM could be attributed to longitudinal hypertrophy effects, e.g., increase in serial sarcomeres. Measured cross-education effects could be explained by central neural adaptations due to stimulation of the stretched muscles.

Providing physical relief for nurses by collaborative robotics

Manual patient handling is one of the most significant challenges leading to musculoskeletal burden among healthcare workers. Traditional working techniques could be enhanced by innovations that can be individually adapted to the physical capacity of nurses. We evaluated the use of a robotic system providing physical relief by collaboratively assisting nurses in manual patient handling tasks. By quantifying kinetic and muscle activity data, it was possible to distinguish two kinds of movement patterns. Highly asymmetric postures and movements corresponded to distinct extremes in lower limb and spine muscle activity data. The use of collaborative robotics significantly reduced maximum force exertion in the caregiving process by up to 51%. Lateral flexion and torsion of the trunk were reduced by up to 54% and 87%, respectively, leading to a significant reduction in mean spine muscle activity of up to 55%. These findings indicate the feasibility of collaborative robot-assisted patient handling and emphasize the need for future individual intervention programs to prevent physical burden in care.

Effect of Long-term Anti-VEGF Treatment on Viability and Function of RPE Cells

Purpose/Aim of the study: Vascular endothelial growth factor (VEGF)-antagonists are given over long time periods in the clinic, but the long-term effects on retinal pigment epithelium (RPE) cells are not fully investigated. This study aims to investigate these effects with two clinical relevant VEGF antagonists, bevacizumab and aflibercept, on the function of primary RPE cells.Materials and Methods: All tests were conducted with primary porcine RPE. Cells were stimulated with bevacizumab or aflibercept (both 250 µg/ml) for 1 day, 7 days or 4 weeks. Cell viability was tested in MTT Assay. Secretion of TGF-ß was tested in ELISA, phagocytosis in a microscopic assay, migration in a scratch assay, and expression of RPE65 in Western blot. Barrier function was tested for bevacizumab in transwell-cultured cells by measuring transepithelial electrical resistance for up to 3 days.Results: Viability was reduced by both antagonists at all time points tested. TGF-ß secretion was not altered by any treatment. Phagocytosis was not significantly reduced by any treatment. Wound healing ability was not significantly altered by any treatment. The expression of RPE65 was reduced by bevacizumab but not aflibercept after 4 weeks. Transepithelial electrical resistance was not altered.Conclusions: Long-term treatment with anti VEGF may affect viability of RPE cells, and treatment with bevacizumab may have effects on RPE function in long-term treatment.

[New antibiotics for severe infections due to multidrug-resistant pathogens : Definitive treatment and escalation]

Multidrug-resistant pathogens often lead to treatment failure of antimicrobial regimens. After a period of imbalance between the occurrence/spread of resistance mechanisms and the development of new substances, some new substances have meanwhile been approved and many more are currently undergoing clinical testing. They are particularly effective against specific resistance mechanisms/pathogens and should be preserved for definitive treatment of an isolated pathogen. In the absence of alternatives reserve antibiotics, such as aztreonam and colistin have experienced a renaissance. They are again used in special infection scenarios and clinically tested in combination with new substances. Despite the introduction and development of new substances the building of resistance will at some time also render these (at least partially) ineffective. Therefore, their implementation must be carried out according to the antibiotic or infectious diseases stewardship.

Effect of long-term inflammation on viability and function of RPE cells

PURPOSE

Degenerative ocular disorders like age-related macular degeneration (AMD) are associated with long-term pro-inflammatory signals on retinal pigment epithelial (RPE) cells. In this study, we investigated the effect of long term treatment of RPE cells with agonists of toll-like receptor (TLR) -3 (Polyinosinic:polycytidylic acid, Poly I:C), TLR-4 (lipopolysaccharide, LPS) and the pro-inflammatory cytokine TNFα.

METHODS

All tests were conducted with primary porcine RPE. Cells were stimulated with Poly I:C (1, 10, 100 μg/ml), LPS (0.1, 1, 10 μg/ml) or TNFα (12.5, 25 or 50 ng/ml) for 1 day, 7 days or 4 weeks. Cell viability tests (MTT) were additionally tested in ARPE-19 cells. Cytokine secretion (IL-6, IL-1β, IL-8, TNFα, TGF-β) was tested in ELISA, phagocytosis in a microscopic assay, and expression of RPE65 in Western blot. Barrier function was tested in transwell-cultured cells by measuring transepithelial resistance for up to 3 days.

RESULTS

LPS and TNFα significantly reduce cell viability after 1 day and 7 days, Poly I:C after 7 days and 4 weeks. LPS, Poly I:C and TNFα significantly induce the secretion of IL-6 and IL-8 at all tested time points. IL-1β is increased by LPS and Poly I:C after 1 day, but not by TNFα. TNFα secretion is increased by Poly I:C and LPS after 1 day but not at later time points. TGF-β secretion is not influenced by any stimulus. Concerning RPE function, LPS decreased phagocytosis after 7 days, while Poly I:C and TNFα showed no effect. RPE65 expression was strongly reduced by TNFα and LPS after 4 weeks. Wound healing capacity was reduced by Poly I:C but induced by LPS after 7 d and 4 w. Barrier function was not affected by Poly I:C or LPS, while TNFα reduced barrier function after 1 h, 4 h and 3 days.

CONCLUSION

Long term pro-inflammatory stimuli reduce RPE viability, barrier properties and cellular function and induce pro-inflammatory cytokines and therefore may contribute directly to atrophic changes in AMD.

Quantification of Lower Limb and Spine Muscle Activity in Manual Patient Handling - A Case Study

Manual patient handling is one of the physiological risk factors in care. The scientific focus so far, has primarily been on the analysis of lumbar compression during manual caregiving in order to improve the transfer facilitation of caregivers through technical systems. Reference is made in this context to the supportive functional role of the muscles of the lower limb. To assess biomechanical data for the quantification of lower limb and spine muscle activity in manual patient handling, an experimental study was conducted. A quantitative basis for the analysis of caregiving processes and its risk factors is established by evaluating caregivers' posture, ground reaction force components, and muscle activities during ergonomic and non-ergonomic manual patient handling in a laboratory setting.

Design of a Supportive Transfer Robot System for Caregivers to Reduce Physical Strain During Nursing Activities

The number of people in need of long-term care is rising and personnel scarcity is already foreseeable. The shortage of caregivers is further increased due to early retirement attributed to the major health burden when working at high speed with heavy lifting. Since nursing staff in many cases work beyond their physical strain limits during routine activities at the bed and existing systems do not counteract the current trend, we investigate with the present work whether the concept of a collaborative robotic support system can contribute to the physical relief of the nursing staff to make it possible to fall below the physical strain limits.

[S2k guidelines of the PEG on calculated parenteral initial treatment of bacterial diseases in adults : Focussed summary and supplementary information on antibiotic treatment of critically ill patients]

In January 2018 the recent revision of the S2k guidelines on calculated parenteral initial treatment of bacterial diseases in adults-update 2018 (Editor: Paul Ehrlich Society for Chemotherapy, PEG) was realized. It is a helpful tool for the complex infectious disease setting in an intensive care unit. The present summary of the guidelines focuses on the topics of anti-infective agents, including new substances, pharmacokinetics and pharmacodynamics as well as on microbiology, resistance development and recommendations for calculated drug therapy in septic patients. As in past revisions the recent resistance situation and results of new clinical studies are considered and anti-infective agents are summarized in a table.

[Adequate anti-infective treatment : Importance of individual dosing and application]

Sepsis-induced changes in pharmacokinetic parameters are a well-known problem in intensive care medicine. Dosing of antibiotics in this setting is therefore challenging. Alterations to the substance-specific kinetics of anti-infective substances have an effect on the distribution and excretion processes in the body. Increased clearance and an increased distribution volume (V_d) and particularly compromized organ function with reduced antibiotic elimination are often encountered in patients with sepsis. Renal replacement treatment, which is frequently used in intensive care medicine, represents a substantial intervention in this system. Current international guidelines recommend individualized dosing strategies and adaptation of doses according to measured serum levels and pharmacokinetic/pharmacodynamic (PK/PD) parameters as concepts to optimize anti-infective therapy in the critically ill. Likewise, the recommendation to adjust the administration form of beta-lactam antibiotics to prolonged or continuous infusion can be found increasingly more often in the literature. This article reviews the background of the individual dosing in intensive care patients and their applicability to the clinical routine.

[Bacterial sepsis : Diagnostics and calculated antibiotic therapy]

The mortality of patients with sepsis and septic shock is still unacceptably high. An effective antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed focus and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account for selection of anti-infection treatment. Many pathophysiological alterations influence the pharmacokinetics of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of beta-lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM but for continuous infusion TDM is basically necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug resistant pathogens (MDR) in the intensive care unit. For effective treatment antibiotic stewardship teams (ABS team) are becoming more established. Interdisciplinary cooperation of the ABS team with infectiologists, microbiologists and clinical pharmacists leads not only to a rational administration of antibiotics but also has a positive influence on the outcome. The gold standards for pathogen detection are still culture-based detection and microbiological resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction (PCR)-based procedures for pathogen identification and resistance determination, are currently only an adjunct to routine sepsis diagnostics due to the limited number of studies, high costs and limited availability. In complicated septic courses with multiple anti-infective treatment or recurrent sepsis, PCR-based procedures can be used in addition to therapy monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation).

Drag-reducing riblets with fouling-release properties: development and testing

The manufacture and preliminary testing of a drag-reducing riblet texture with fouling-control properties is presented. The commercial fouling-release product Intersleek® 1100SR was modified to manufacture riblet-textured coatings with an embossing technology. Hydrodynamic drag measurements in a Taylor-Couette set-up showed that the modified Intersleek® riblets reduced drag by up to 6% compared to a smooth surface. Barnacle settlement assays demonstrated that the riblets did not substantially reduce the ability of Intersleek® 1100SR to prevent fouling by cyprids of Balanus amphitrite. Diatom adhesion tests revealed significantly higher diatom attachment on the riblet surface compared to smooth Intersleek® 1100SR. However, after exposure to flow, the final cell density was similar to the smooth surface. Statically immersed panels in natural seawater showed an increase of biofilm cover due to the riblets. However, the release of semi-natural biofilms grown in a multi-species biofilm culturing reactor was largely unaffected by the presence of a riblet texture.

[Therapeutic drug monitoring and individual dosing of antibiotics during sepsis : Modern or just "trendy"?]

Pharmacokinetic variability of anti-infective drugs due to pathophysiological changes by severe sepsis and septic shock is a well-known problem for critically ill patients resulting in suboptimal serum and most likely tissue concentrations of these agents.To cover a wide range of potential pathogens, high concentrations of broad spectrum anti-infectives have to reach the site of infection. Microbiological susceptibility testing (susceptible, intermediate, resistant) don't take the pharmacokinetic variability into account and are based on data generated by non-critically ill patients. But inter-patient variability in distribution and elimination of anti-infective drugs in ICU patients is extremely high and also highly unpredictable. Drug clearance of mainly renally eliminated drugs and thus the required dose can differ up to 10-fold due to the variability in renal function in patients with severe infections. To assure a timely and adequate anti-infective regime, individual dosing and therapeutic drug monitoring (TDM) seem to be appropriate tools in the setting of pathophysiological changes in pharmacokinetics (PK) and pharmakodynamics (PD) due to severe sepsis. In the case of known minimal inhibitory concentration, PK/PD indices (time or peak concentration dependent activity) and measured serum level can provide an optimal target concentration for the individual drug and patient.Modern anti-infective management for ICU patients includes more than the choice of drug and prompt application. Individual dosing, optimized prolonged infusion time and TDM give way to new and promising opportunities in infection control.

[Quality assurance concepts in intensive care medicine]

Intensive care medicine (ICM) is characterized by a high degree of complexity and requires intense communication and collaboration on interdisciplinary and multiprofessional levels. In order to achieve good quality of care in this environment and to prevent errors, a proactive quality and error management as well as a structured quality assurance system are essential. Since the early 1990s, German intensive care societies have developed concepts for quality management and assurance in ICM. In 2006, intensive care networks were founded in different states to support the implementation of evidence-based knowledge into clinical routine and to improve medical outcome, efficacy, and efficiency in ICM. Current instruments and concepts of quality assurance in German ICM include core intensive care data from the data registry DIVI REVERSI, quality indicators, peer review in intensive care, IQM peer review, and various certification processes. The first version of German ICM quality indicators was published in 2010 by an interdisciplinary and interprofessional expert commission. Key figures, indicators, and national benchmarks are intended to describe the quality of structures, processes, and outcomes in intensive care. Many of the quality assurance tools have proved to be useful in clinical practice, but nationwide implementation still can be improved.

Quantitative CT imaging of the spatio-temporal distribution patterns of vasa vasorum in aortas of apoE-/-/LDL-/- double knockout mice

OBJECTIVE

To investigate the distribution of vasa vasorum (VV) relative to advanced atherosclerotic lesions (calcified, fibrotic or hemorrhaged) along the aortic wall of apoE-/-/LDL-/- mice at the age of 25 and 80 weeks using high-resolution nano-CT.

METHODS

Aortas from male apoE-/-/LDL-/- mice at the age of 25 weeks (n=4) and 80 weeks (n=7) were infused in situ with contrast agent and harvested for scanning with nano-CT. The spatial distribution of vasa vasorum [number and area/cross-section (mm2)] was compared to aortic luminal cross-sectional area and plaque cross-sectional area in the ascending aorta, aortic arch and descending aorta. Results were complemented with co-localized histology.

RESULTS

The number and total luminal cross-sectional area of VV showed a significant decrease in the ascending aorta and aortic arch from 25 to 80 weeks but not in the descending aorta. The number and cross-sectional area of VV showed significant local differences depending on whether it was near a fibrotic, and hemorrhaged or calcified plaque in animals at the age of 80 weeks. Area of VV progressively increased along the aorta from least in the ascending aorta<aortic arch<descending aorta in animals at the age of 80 weeks and is inverse in animals aged 25 weeks.

CONCLUSION

Atherosclerotic lesion type is correlated to the number and cross-sectional area of VV in different aortic segments in apoE-/-/LDL-/- mice. The chronological development of VV along the aorta proceeds distally from the ascending aorta and aortic arch.

[Patient surveys as an element of quality management in outpatient care: development and assessment of a questionnaire]

OBJECTIVE

The present study was designed to develop and assess a questionnaire measuring all relevant quality dimensions of general practice care from the patients' perspective. Furthermore, the study aimed to evaluate the implementation of a patient survey in outpatient care.

METHODS

Based on the Kölner Patientenfragebogen (KPF) and by developing some additional new items, we created the new questionnaire KPF-A (Kölner Patientenfragebogen-ambulant) which covers all relevant aspects of outpatient care. The questionnaire was distributed to the patients of 41 GP's and specialists in ambulatory care from different regions of Germany. N=3188 patients were included in the sample. We used these data to assess some selected psychometric characteristics of the KPF-A. Factor analysis was used to examine the underlying factor structure. A qualitative study was conducted to evaluate the implementation of the patient survey. Therefore, all N=41 doctors involved were asked to complete five open questions concerning their experience.

RESULTS

Most scales of the KPF-A showed good psychometric characteristics in the present study. Factor analysis revealed a two-factors solution for the new items representing the dimensions "professional competence" and "medical equipment". We have not yet been able to find a sound factor solution for those items representing the dimension "Staff and Organisation". The results of the qualitative study revealed a satisfying implementation of the patient survey in daily routine from the doctors' perspective. The length of the questionnaire was criticised by some participants. In the design of the study patients were supposed to fill in the questionnaires after consultation. This turned out to be difficult. We therefore modified the KPF-A so that patients can fill it in either before or after consultation.

Antikörperkontrollierte zytostatische Therapie des malignen Thymoms bei begleitender Myasthenia gravis

In a 46-year-old female patient with malignant thymoma and concomitant myasthenia gravis relapse with gravitational metastases occurred 6 1/2 years after the first operation. Metastases could be removed surgically only partially and were subsequently irradiated with 50 Gy. After 3 1/2 years renewed metastatic growth occurred. Until then the concomitant myasthenia had been stable during treatment with pyridostigmine and azathioprin and intermittent prednisone; acetylcholine receptor antibody titres had remained largely stable. Combined cytostatic treatment with vincristine, cyclophosphamide, prednisone and doxorubicin or cisplatin led to regression of metastases during the observation period of 1 1/2 years and at the same time to stabilisation of the myasthenia. Acetylcholine receptor antibody titres decreased and this was roughly paralleled by clinical improvement. Whereas there is no obvious correlation of antibodies against acetylcholine-receptor protein and tendency of tumour growth there is good agreement with the course of the accompanying myasthenia.

[Management of the operation room in an university hospital]

The heart of any surgical department is the operation room area. Any disturbances in the daily routine will affect the work flow of the whole hospital. As an example the major complaints of a university surgical department regarding workflow and communication are outlined. To solve these problems a team "OR organization" was established, which started the work based on a new developed OR statute. Within a short period the contentment of the employees as well as the workflow improved. But as a matter of fact, even in the following years of central OR management there is still the need to further stabilize the system and carefully improve the controlling system.

An unusual case of early fulminant post-traumatic fat embolism syndrome

A multiple-injured patient developed a very early onset fulminant fat embolism syndrome that was partially masked by haemorrhagic shock. Despite early diagnosis by transoesophageal echocardiography and aggressive symptomatic treatment, there was a rapid evolution to death. Post mortem examination revealed the presence of both pulmonary and systemic fat emboli. This case highlights the ever present risk of masked fat embolism syndrome shortly after trauma.

Laterale Ischiadikusblockaden

In the present study we examined 41 volunteers using magnetic resonance imaging to obtain biometric data of the thigh used for a planned blockade of the sciatic nerve via the lateral approach. At a needle entry point 12 cm proximal to the gap of the knee joint at the posterior border of the M. vastus lateralis, the sciatic nerve lies on average at a depth of 5.2 cm (39% of the femoral diameter at this site) with an angle of 10.9 degrees to the horizontal in a dorsal direction. Here the popliteal artery lies on average at a depth of 6.4 cm (48% of the femoral diameter) with an angle of 4.7 degrees to the horizontal in a ventral direction. At the marked point in the middle between the gap of the knee joint and the trochanter major at the posterior border of the M. vastus lateralis, the sciatic nerve is at an average depth of 6.2 cm (40% of the femoral diameter at this site) with an angle of 8.2 degrees in a dorsal direction. At a marked point 5 cm distal of the trochanter major at the posterior border of the M. vastus lateralis, the sciatic nerve is at a depth of 9.1 cm at a dorsal angle of 15.5 degrees (49% of the femoral diameter). The lateral blockade of the sciatic nerve at different sites of the thigh is a technique which is easy to plan with the presented biometric data. The popliteal artery could be reached only at the distal puncture point using a deep puncture and an angle in the ventral direction.

[Possibilities in improving patients's turn-over coordination in the OR of an University Hospital]

An efficient Operating Room (OR) management might increase the cost-effectiveness of an OR. For this purpose, we have evaluated the coordination and the times of the solitary processes that are involved in the patient turnover. The mean time between skin suture of the preceding patient and incision of the following patient (SI-time) was, depending on the type of operation, between 44 and 78 minutes. Mean empty-room time (ERT) was 7 minutes. SI-times depended on various factors, including the times necessary to discharge the preceding patient from the OR and the times necessary for induction of anesthesia or for preparation of the OR. Altogether, our data provide evidence for the fact, that optimisation of the patients turnover can decrease SI-times between 10-15 minutes. Although this period appears too short to reliably allow an additional scheduled operation during regular working hours, an improved coordination may result in reduced overtimes of the OR-staff and thus should increase staff satisfaction.

[Fatal outcome after multiple trauma. The thoracic injury as the decisive factor]

In patients suffering from multiple injury, chest trauma is often the main cause of fatality. A case report is given and the literature reviewed.A 49 years old motorcyclist hit a car frontally in a road accident. After primary stabilization and first clinical care, he was transferred to our trauma centre because of severe chest injury, suspected pericardial effusion and lesion of the thoracic aorta. Initial diagnostics (plain radiographs, CT scan of thorax, abdominal ultrasound, echocardiography) showed left-sided serial rib fractures, a fracture of the left scapula, a hematopneumothorax left-sided, bilateral lung contusion, a small pneumothorax of the right side, a minimal pericardial effusion and a small splenic hematoma. The patient was treated in the intensive care unit, and the situation was initially stable. After 12 h, respiration deteriorated and a bronchoscopy showed filling of the airways with mucous fluid. The CT scan showed a worsening of the pulmonary damage and increasing pericardial fluid compression. A pericardiotomy was carried out, but the situation remained unstable. The patient was treated with invasive ventilation (PEEP>10, FiO2>0,5). Sudden severe bleeding out of left lower lobe was managed by thoracotomy and lobectomy. The patient remained unstable and died 95 h after the accident. This case shows that the severity of chest trauma does not necessarily correlate with the initial clinical and radiological findings. Even with all diagnostic and therapeutic procedures, a fatal outcome could not be prevented. This demonstrates the role of chest injury as a major and unforeseeable cause of death in multiple trauma patients.

Balanced Scorecard

The change in hospital funding with diagnosis related groups (DRG), medical advances as well as demographic changes will call for new quantitative and qualitative standards imposed on German hospitals. Increasing costs and competition in the health care sector requires new and innovative strategies for resource management. Today's policy is mainly defined by rationing and intensified workload. The introduction of DRGs will presumably further constrict management perspectives on pure financial aspects. However, to ensure future development, compassionate services and continued existence of hospitals, a balance of seemingly conflicting perspectives, such as finance, customer, process, learning and growth are of utmost importance. Herein doctors and nurses in leading positions should play a key role in changing management practice. For several years the balanced scorecard has been successfully used as a strategic management concept in non-profit organizations, even in the health care sector. This concept complies with the multidimensional purposes of hospitals and focuses on policy deployment. Finally it gives the opportunity to involve all employees in the original development, communication and execution of a balanced scorecard approach.

[OR-manager: surgeon or anaesthetist?]

The heart of any surgical department is the operating room (OR) area. Any disturbances in the daily routine will affect the work flow of the whole hospital. On account of its central function, with numerous connections to other departments, the OR is the crystallisation point for deficiencies in various events and processes. As an example, the major complaints made by a surgical department regarding workflow and communication are outlined. To solve these problems, an "OR organization" team was established, which worked on the basis of a newly developed OR statute. Within 1 year the employees were more contentment and the workflow had improved. However, even in the second year of central OR management there is still the need to further stabilize the system as mismanagement still occurs.

Stress response during weaning after cardiac surgery

We compared the effects of weaning using synchronized intermittent mandatory ventilation (SIMV) with the use of biphasic positive airway pressure (BIPAP) on the stress response, oxygen uptake (VO2) and work of breathing (WOB) in 10 patients after aortocoronary bypass surgery. All three ventilatory settings were investigated in each patient, for example, volume-controlled mechanical ventilation immediately before weaning was followed, in randomized order, by both SIMV and BIPAP. In addition to routine monitoring of continuous and respiratory state, we measured VO2, WOB, and pressure-time product (PTP) as well as the plasma concentrations of epinephrine, norepinephrine, ACTH, cortisol, vasopressin, and prolactin. Although respiratory rate (f), WOB and PTP were greater with both SIMV and BIPAP when compared with control, other variables did not change with the ventilatory mode. In conclusion, weaning from mechanical ventilation using partial support modes does not affect the postoperative stress response in patients who have had uncomplicated cardiac surgery.

Does gastric juice pH influence tonometric PCO2 measured by automated air tonometry?

To determine the influence of changes in gastric juice pH due to intravenous administration of pentagastrin and omeprazole on intramucosal regional PCO2 (Pr(CO2)), we investigated 17 healthy human volunteers. Gastric juice pH was obtained from a glass pH electrode for continuous gastric juice pH measurement and Pr(CO2))was measured by using automated air tonometry. After baseline (8:00 A.M.-9:00 A.M.) the subjects received 0.6 microg/kg/h pentagastrin intravenously for 1 h (9:00 A.M.-10:00 A.M., after stimulation 10:00 A.M.-11:00 A.M.) and 40 mg omeprazole intravenously (after omeprazole 11:00 A.M.-3:00 P.M.). Following pentagastrin administration gastric juice pH significantly decreased from 1.2 +/- 0.4 to 0.6 +/- 0.4 (mean +/- SD, p < 0.007, versus baseline), whereas omeprazole transiently increased luminal pH up to 4.4 +/- 1.7 (p < 0.007 versus baseline). These subsequent changes in gastric juice pH were accompanied by a significant increase in Pr(CO2) from 48 +/- 12 to 61 +/- 17 mm Hg (p < 0.007 versus baseline) and a decrease to 44 +/- 5 mm Hg (p < 0.002 versus pentagastrin), respectively. A gastric juice pH > 4 considerably reduces mean gastric Pr(CO2) and interindividual variability. Thus omeprazole may improve the validity of gastric tonometry data.

Gastrointestinal tract resuscitation in critically ill patients

Particular research interest is currently focusing on the resuscitation of the gastrointestinal tract, because the gut is regarded to be both the "canary of the body", i.e. a sentinel organ during situations of compromised oxygen or substrate supply, as well as the "motor of multiple organ failure". Several therapeutic strategies have recently been proposed for the resuscitation of this organ system, aimed primarily at the augmentation of blood flow and oxygenation but also integrating nutritional or metabolic support and antioxidant administration.