[Complementary methods in the treatment of complex regional pain syndrome]

BACKGROUND

Complex regional pain syndrome (CRPS) affects 10-15% of patients following injuries (fractures, surgery) to the outer extremities and people after a stroke. The affected area hurts, is inflamed and lacks strength, while mobility and sensitivity are restricted. Complementary medicine as part of integrative medicine offers additional effective treatment options.

RESEARCH QUESTION

Complementary therapies that extend the guideline recommendations, demonstrate clinical evidence and/or are plausible are presented.

RESULTS

Mind-body medicine procedures (mindfulness, relaxation, yoga, Qi Gong, etc.) support the patient's self-efficacy and stimulate the vagus nerve as well as promoting the reduction of pain, depression and anxiety and improving quality of life. Phytotherapeutics such as turmeric or stinging nettle have an anti-inflammatory effect. Water treatments reduce pain, and acupuncture and neural therapy can be tried.

CONCLUSIONS

Integrative, complementary medical therapy options support the CRPS patient in coping with their disease and the related pain. These options can play an important role in the multimodal, interdisciplinary treatment of this disease.

[Herbal medicines for psychiatric disorders]

BACKGROUND

In Germany herbal medicines are traditionally frequently used. They represent an important therapeutic option, especially in self-medication.

METHODS

Current systematic review articles and meta-analyses were evaluated and summarized with respect to the evidence of phytotherapeutic drugs for selected psychiatric indications.

RESULTS

Apart from the use of St. John's wort for depression, no other herb has so far shown convincing evidence.

CONCLUSION

Due to the promising effects and the low side effect potential within the existing studies, further randomized controlled trials (e. g. for Passiflora incarnata, Rhodiola rosea and Lavendula officinalis) are definitely indicated.

Efficacy, acceptability and safety of cognitive behavioural therapies in fibromyalgia syndrome - A systematic review and meta-analysis of randomized controlled trials

This updated systematic review aimed at evaluating the efficacy, acceptability and safety of cognitive behavioural therapies (CBTs) in fibromyalgia syndrome (FMS). Clinicaltrials.gov, Cochrane Library, MEDLINE, PsycINFO and SCOPUS were searched from September 2013 to May 2017. Randomized controlled trials (RCTs) comparing CBTs with controls were analysed. Primary outcomes were ≥50% pain relief, ≥20% improvement of health-related quality of life (HRQoL), negative mood, fatigue, disability, acceptability and safety at end of therapy and at 6 months follow-up. Effects were summarized by a random effects model using risk differences (RD) or standardized mean differences (SMD) with 95% confidence intervals (CI). 29 RCTs with 2509 subjects were included. CBTs were superior to controls (waiting list, attention control, treatment as usual, other active non-pharmacological therapies) in pain relief of 50% or greater (RD 0.05 [95% CI 0.02-0.07] (high-quality evidence), improvement of HRQoL of 20% or greater (RD 0.13 [95% CI 0.00-0.26], (moderate quality evidence), and in reducing negative mood (SMD -0.43 [95% CI -0.62 to -0.24]) (high-quality evidence), disability (SMD -0.30 [95% CI -0.52 to -0.08]) (high-quality evidence) and fatigue (SMD - 0-27 [95% CI -0.50 to -0.03]) (high-quality evidence). There were no statistically significant differences between CBTs and controls in acceptability and safety (high-quality evidence). The update did not change the major findings of the previous review. CBTs provided a clinically relevant benefit over control interventions in reducing some key symptoms of FMS and disability at the end of treatment.

SIGNIFICANCE

This updated systematic review with meta-analysis on cognitive behavioural therapies (CBTs) including acceptance-based CBTs endorse the efficacy and tolerability of CBTs in reducing key symptoms and disability in FMS in the short- and long-term if compared to waiting list, treatment as usual, attention controls and active non-pharmacological therapies. CBTs did not differ in efficacy except superiority for coping with pain and tolerability from recommended drug therapy (pregabalin and/or duloxetine).

[Opioids in chronic low back pain. A systematic review and meta-analysis of efficacy, tolerability and safety in randomized placebo-controlled studies of at least 4 weeks duration]

BACKGROUND

The efficacy and safety of opioid therapy in chronic low back pain (CLBP) is under debate. We updated a recent systematic review on the efficacy and safety of opioids in CLBP.

METHODS

We screened MEDLINE, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL) up until October 2013, as well as reference sections of original studies and systematic reviews of randomized controlled trials (RCTs) of opioids in CLBP. We included double-blind randomized placebo-controlled studies of at least 4 weeks duration. Using a random effects model, absolute risk differences (RD) were calculated for categorical data and standardized mean differences (SMD) for continuous variables.

RESULTS

We included 12 RCTs with 17 treatment arms and 4375 participants. Median study duration was 12 (4-16) weeks. Of the 17 treatment arms, seven (41.2 %) used oxycodone; four (23.6 %) tramadol; buprenorphine and oxymorphone were each used in two (11.8 %) and hydromorphone and tapentadol each in one (5.8 %). The results for studies with parallel/cross-over design were as follows (with 95 % confidence interval, CI): opioids were superior to placebo in reducing pain intensity (SMD - 0.29 [- 0.37, - 0.21], p < 0.0001; six studies with 2896 participants). Opioids were superior to placebo in 50 % pain reduction (RD 0.05 [0.01, 0.10], p = 0.01; two studies with 1492 participants; number needed to benefit (NNTB) 19 [95 % CI 10-107]). Opioids were not superior to placebo in reports of much or very much improved pain (RD 0.16 [- 0.01, 0.34], p = 0.07; two studies with 1153 participants). Opioids were superior to placebo in improving physical functioning (SMD - 0.22 [- 0.31, - 0.12], p < 0.0001; four studies with 1895 participants). Patients dropped out less frequently with opioids than with placebo due to lack of efficacy (RD - 0.10 [- 0.16, - 0.04], p = 0.001; five studies with 3168 participants; NNTB 10 [8-13]). Patients dropped out more frequently with opioids than with placebo due to adverse events (RD 0.12 [0.05, 0.19], p = 0.0007; six studies with 2910 participants; number needed to harm (NNTH) 7 [95 % CI 6-8]). There was no significant difference between opioids and placebo in terms of the frequency of serious adverse events or deaths.

CONCLUSION

Opioids were superior to placebo in terms of efficacy and inferior in terms of tolerability. Opioids and placebo did not differ in terms of safety during the study period. The conclusion on the safety of opioids compared to placebo is limited by the low number of serious adverse events and deaths. Short-term and intermediate-term opioid therapy may be considered in selected CLBP patients. The English full-text version of this article is freely available at SpringerLink (under "Supplemental").

[Methodology of the development of the updated LONTS guidelines for long-term administration of opioids in noncancer pain]

BACKGROUND

The update of the German S3 guidelines on long-term opioid therapy of chronic noncancer pain (CNCP), the"LONTS" (AWMF registration number 145/003) was scheduled for May 2014.

METHODS

The guidelines were developed by 25 scientific societies and two patient self-help organizations under the coordination of the German Pain Society and the Association of the Scientific Medical Societies in Germany (AWMF).

RESULTS

A systematic literature search was performed in the CENTRAL, MEDLINE and Scopus databases from October 2008 to October 2013. Meta-analyses of randomized controlled trials (RCT) of opioids in CNPC of study duration ≥ 4 weeks were conducted. Levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine version 2009 classification system. The formulation and strength of recommendations was established in a multistep formalized consensus procedure, in accordance with AWFM rules and standards. The guidelines were reviewed by three scientific societies not involved in their development and were approved by the executive boards of the societies that were engaged in development of the guidelines.

CONCLUSION

The guidelines will be published in several forms: complete and short scientific versions, as well as clinical practice and patient versions.

Systematic review of complementary and alternative medicine treatments in inflammatory bowel diseases

OBJECTIVE

We performed a systematic review for Complementary and Alternative Medicine [CAM] as defined by the National Institute of Health in Inflammatory Bowel Disease [IBD], ie Crohn's disease [CD] and ulcerative colitis [UC], with the exception of dietary and nutritional supplements, and manipulative therapies.

METHODS

A computerized search of databases [Cochrane Library, Pubmed/Medline, PsychINFO, and Scopus] through March 2014 was performed. We screened the reference sections of original studies and systematic reviews in English language for CAM in IBD, CD and UC. Randomized controlled trials [RCT] and controlled trials [CT] were referred and assessed using the Cochrane risk of bias tool.

RESULTS

A total of: 26 RCT and 3 CT for herbal medicine, eg aloe-vera gel, andrographis paniculata, artemisia absinthium, barley foodstuff, boswellia serrata, cannabis, curcumin, evening primrose oil, Myrrhinil intest®, plantago ovata, silymarin, sophora, tormentil, wheatgrass-juice and wormwood; 1 RCT for trichuris suis ovata; 7 RCT for mind/body interventions such as lifestyle modification, hypnotherapy, relaxation training and mindfulness; and 2 RCT in acupuncture; were found. Risk of bias was quite heterogeneous. Best evidence was found for herbal therapy, ie plantago ovata and curcumin in UC maintenance therapy, wormwood in CD, mind/body therapy and self-intervention in UC, and acupuncture in UC and CD.

CONCLUSIONS

Complementary and alternative therapies might be effective for the treatment of inflammatory bowel diseases; however, given the low number of trials and the heterogeneous methodological quality of trials, further in-depth research is necessary.

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.

The Combined Expression Pattern of BMP2, LTBP4, and DERL1 Discriminates Malignant From Benign Canine Mammary Tumors

Several markers of malignancy have been proposed for canine mammary tumors on the mRNA and protein levels. However, their association with tumor malignancy applies only for mean values of large groups of tumors, but no single marker identified to date can be used to reliably predict malignancy for individual tumors. A quantitative real-time reverse transcription polymerase chain reaction array was established to quantify the expression levels of 49 genes relevant to carcinogenesis in laser-microdissected tumor cells of 10 benign and 13 metastatic canine mammary tumors. Analysis of variance and discriminant analysis were used to identify relevant gene expression patterns that differentiate adenomas from metastatic carcinomas and their lymph node metastases. Seventeen genes with significant ( P < .05) differences in gene expression levels between benign and malignant tumors were identified—including ERBB1, SLIT2, progesterone receptor, MIG6, SATB1, and SMAD6—but correct classification of each tumor as benign or malignant was impossible on the basis of any of these genes alone. However, the combined expression patterns of BMP2, LTBP4, and DERL1 (Derlin-1) correctly classified each individual tumor as benign or malignant. This pilot study identified a complex mRNA expression pattern of 3 genes that was able to identify malignancy in laser-microdissected tumor cells for each individual tumor, instead of group means as used in previous studies.

[Case payments in hospital psychiatry in the USA. The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)]

OBJECTIVE

In Germany the introduction of a prospective payment system (PPS) is intended for inpatients hospitalised in psychiatric facilities. We investigate the various elements of the Prospective Payment System for Inpatient Psychiatric Facilities (IFP PPS) which was established in the USA in 2005 with respect to their potential to be incorporated into a german PPS.

RESULTS

The most important elements of IFP PPS (impact of diagnosis, comorbidity, patient age, per diem adjustment for length of stay, various other adjustment factors like facility characteristics and geographical factors) are presented. The IFP PPS was especially designed for the requirements of psychiatric inpatient facilities in the USA. Complexity of the individual elements of the PPS appears to be manageable. However, various elements, e. g. the facility based adjustments including wage index or rural location and cost of living adjustments will not be applicable to countries other than the US. The 15 diagnosis related groups of the IFP PPS system refer to ICD-9 which is less differentiated than the ICD-10 which is in use in Germany, thus these psychiatric DRG will not be compatible under conditions of a german PPS. The per diem adjustment for length of stay is the predominating element of the IFP PPS, relation to effort/performance is insufficiently represented.

CONCLUSION

Some elements of the IFP PPS may be applicable to a german prospective payment system for psychiatric inpatient facilities, especially with respect to the rules for per diem adjustment for length of stay and for handling of cases with frequent discharge and readmission of patients. Altogether a stronger representation of elements of performance of inpatient facilities seems to be desirable.

A study of decision making among U.S. psychiatric nurses

The purpose of this study was to describe psychiatric nurses' decision making and to test a Finnish instrument. A 56-item survey was mailed to 351 psychiatric nurses with a return rate of 48%. A varimax factor analysis showed 5 factors (intuitive, self-confidence, interpretive, collected information, and analytic processing) with alphas ranging from .71 to .85. Results indicate U.S. psychiatric nurses extensively use intuitive interpretive decision making and cultural bias needs to be considered when using a foreign instrument. Further research is needed to refine this instrument and describe psychiatric nurses' decision making.

Decision making of psychiatric nurses in Finland, Northern Ireland, and the United States

The purpose of this study was to describe the decision-making process of 339 psychiatric nurses in Finland, Northern Ireland, and the United States and to discuss any differences observed among nurses in these countries. The instrument used in the study was a 56-item, Likert-type questionnaire tested in several previous studies that have confirmed its validity and reliability. Three different models of decision making were identified on the basis of factor analysis. Overall, it may be concluded that the decision-making process of psychiatric nurses is broadly based, but it varies between countries. Nurses from Northern Ireland used only analytical decision-making models; nurses from Finland made decisions strongly favored analytical decision-making models but also used some intuitive models; and American nurses used intuitive decision-making and analytical-processing models.

Effects of carbamazepine and valproate on haloperidol plasma levels and on psychopathologic outcome in schizophrenic patients

The objective of this study was to compare the effects of carbamazepine (CBZ) and valproate (VPA) cotreatment on the plasma levels of haloperidol and on the psychopathologic outcome in schizophrenic disorders. In this controlled clinical trial, 27 patients with an ICD-10 diagnosis of schizophrenia (N = 24) or schizoaffective disorder (N = 3) were randomly assigned to receive 4 weeks of treatment with either haloperidol alone, haloperidol with CBZ, or haloperidol with VPA. Whereas the haloperidol dose remained stable, the antiepileptic drug doses were adjusted to achieve therapeutic plasma levels. Clinical state was rated by the Positive subscale of the Positive and Negative Syndrome Scale and the Inpatient Multidimensional Psychiatric Scale. The use of CBZ was associated with significantly lower haloperidol plasma levels and with a worse clinical outcome compared with antipsychotic monotherapy. VPA had no significant effect on either plasma levels or on psychopathology. Our results suggest that comedication with haloperidol and CBZ is associated with a high risk for treatment failure. This might be a result of a pharmacokinetic interaction on the hepatic level. The concomitant use of VPA with neuroleptic therapy is not impaired by clinically significant drug interactions, but it is not associated with a better outcome under our conditions.

[Filmless documentation and image distribution to referring physicians exemplified by a radiologic community practice]

In healthcare, cost effectiveness as well as the quality of examinations and procedures are subjected to quickly increasing expectations and demands: we like to demonstrate how the resulting challenges and problems can be met with implementation of modern information technology. Analysing the respective demands (pattern of quantities) and choosing the adequate technical solution/technical approach, we found filmless reading and the usage of digital image distribution to communicate with referring physicians to be cost effective as well as of higher quality. Special attention should be paid to the rigorous maintenance of data security and access. Today's information technology allows individual adjustment to the respective size and requirements of a radiological department or practice for filmless reading and digital image distribution. Working with the systems as a matter of routine and using all of the expanding technological possibilities, an important improvement of service and quality can be achieved. Amortisation will be obtained despite high investments, due to the subsequent savings in personal- and enterprise costs.

Dipole Moment Function of LiF and LiCl Obtained from the Herman-Wallis Analysis: A Comparative Study with the MBER Data

FTIR absorption spectra of the fundamental bands of LiF and LiCl were measured with an apodized resolution of 0.01 cm-1. The Herman-Wallis analysis of these spectra led to the determination of the ratio of the dipole derivative to the permanent dipole moment, [µe/(dµ/dr)ere], for each molecule. The vibrational dependence of the dipole moment for each molecule has been already reported and these data were reanalyzed to determine the dipole moment function independently. The results from the Herman-Wallis analysis were compared with these results, and good agreement was found. This demonstrates that the Herman-Wallis analysis can produce reliable relative values of dipole moment functions. Copyright 1999 Academic Press.

[Adjuvant treatment of schizophrenic illness with carbamazepine]

Very few controlled clinical trials have been assessing the interaction of antipsychotics and antiepileptics. However, schizophrenic patients frequently receive a combination therapy consisting of haloperidol and carbamazepine. The data for this treatment strategy are contradictory and may depend on the initial plasma concentration of the antipsychotic. There is convincing evidence that after addition of carbamazepine the plasma concentration of neuroleptics drops due to hepatic enzyme induction. In this study, we treated 18 schizophrenic patients either with haloperidol alone or in combination with carbamazepine. The use of carbamazepine was associated with a dramatic fall in haloperidol plasma levels and a worse clinical outcome compared to the monotherapy group. These results, together with a review of the literature, lead us to the conclusion that there are no obvious advantages of carbamazepine co-medication in schizophrenia compared to an optimized neuroleptic monotherapy.

Motility disorders of the esophagus: diagnosis with barium-rice administration

PURPOSE

To evaluate the role of barium-rice administration for a standardized diagnosis of dysphagia and esophageal motility disorders.

MATERIALS AND METHODS

Sixty healthy volunteers and 218 patients with various esophageal disorders (achalasia, scleroderma and other connective tissue diseases, neurologic diseases, esophagitis and others) were examined both by a conventional barium study and by a barium-rice study. The barium-rice meal consisted of barium sulfate and boiled rice, mixed half and half. The time required for esophageal clearance of one sip was measured.

RESULTS

Normal esophageal transit time in healthy controls was between 5 and 15 s for both methods. In patients, the conventional barium study revealed a prolonged transit time in only 16.5% (36 of the 218 cases). The barium-rice study was abnormal in 51.8% (113 of 218 cases), independent of the underlying disease. The barium-rice study was pathological in 77 of those 182 patients (42.3%) who had normal barium transit time. In 24 patients the radiologic results was confirmed by endoscopy and manometric measurements.

CONCLUSIONS

Esophageal motility abnormalities are detected by a barium-rice study with a high sensitivity. With this simple and low-cost method, quantitative and reproducible results can be obtained. Barium-rice administration is a suitable tool for screening and follow-up of patients with dysphagia and esophageal motility disorders.

[Motility disorders of the esophagus--their diagnosis with a rice-barium meal]

The purpose of this study was to evaluate the role of a "barium-rice" study for diagnosis of dysphagia and oesophageal motility disorders.

MATERIAL AND METHODS

203 patients with oesophageal motility disorders of various aetiologies were examined by both conventional barium study and a "barium-rice" study. During the latter, oesophageal clearance of a defined mixture of barium sulfate and boiled rice was measured.

RESULTS

The conventional barium study revealed prolonged transit time in only 15.8% (32 of 203 cases), whereas barium-rice study was pathological in 50.8% (103 to 203 cases). In 71 of 171 patients (41.5%) with a normal barium study, barium-rice passage was prolonged. In 23 patients, radiological results were confirmed by manometric measurements.

CONCLUSION

Oesophageal motility disorders are detected by a barium-rice study with high sensitivity independent of the underlying disease. The barium-rice study offers a simple diagnostic tool revealing quantitative and reliable results. The barium-rice study is a suitable method for screening and follow-up of patients with dysphagia and oesophageal motility disorders.

[A short infusion or a bolus injection of contrast medium in i.v. urography. Comparative density measurements in the kidney pelvic-caliceal system using sequential computed tomography]

The rate of contrast injection during i.v. urography may vary considerably (bolus injection or drip infusion). The effect of 5 rates of injection (6, 12, 18, 36 and 72 ml/min) on the contrast density in the renal collecting system was examined over a period of 30 minutes. Measurements showed an inter-individual difference of more than 200% in each group. The intra-individual variations for different rates of injection were very slight; individual concentration in the kidney for a given dose depends only slightly on the rate of injection. There is no statistically significant improvement in contrast values as a result of a bolus injection. The reduced incidence of side effects justifies the use of bolus injections but pressure injections are unnecessary from a diagnostic point view.

Confidence Builders: A Self-Esteem Group at an Inpatient Psychiatric Hospital

1. Many people with mental illness experience low self-esteem. They tend to minimize their own positive attributes, strengths, and abilities, making it difficult to accept positive feedback. 2. As an alternative to the one-to-one relationship, the Self-Esteem Group provides a situation in which self-esteem can be increased through constructive social interactions, trust, and support from group members. 3. Structured exercises, which encourage sharing and development of positive aspects of self, were completed by group members during each session. These exercises made it easier for group members to focus ideas, feelings, and experiences related to the topic for discussion.

[Lymphographic findings in AIDS patients]

The lymphographic findings in 20 patients with AIDS-most in clinical stage IV-can be divided into four categories. In six there were no specific changes and in a further six the storage pattern was that of sinus histiocytosis. One patient showed transition to malignant lymphoma and another patient had atypical mycobacterial infection of the retroperitoneal lymph nodes. Six patients showed a lymphographic pattern of scarring. The results of this study show that lymphography is a sensitive method that can provide important additional information.

[Retractile mesenteritis. Diagnostic and therapeutic aspects]

An 18-year-old boy, who had severe abdominal pain for 18 months associated with marked weight loss, was found to have a stenosed ileal sling on double-contrast radiology of the small intestine. At operation a plate-like tumour was extending from the pancreas to the aortic bifurcation. Histological examination of removed tissue revealed retractile mesenteritis (mesenteric panniculitis; liposclerotic mesenteritis). The symptoms regressed and the patient again gained weight under immunotherapy with 1 mg/kg of prednisone and 2 mg/kg of cyclophosphamide daily. Subsequently, under prednisone alone, there was a recurrence, which responded within five weeks to daily 60 mg prednisone and 125 mg cyclophosphamide. The patient remains symptom-free on 125 mg cyclophosphamide and 10 mg prednisone daily.

[Extracorporeal shockwave lithotripsy of gallstones: how many patients are suitable for it?]

The proportion of patients with gallbladder stones suitable for extracorporeal shockwave lithotripsy (ESWL) was analysed prospectively in 200 patients aged 17-76 years (62 males, 138 females) with symptomatic cholecystolithiasis. Criteria for inclusion were clinical symptoms, solitary stones (diameter 10-30 mm) or up to three stones with comparable total volume, contractile gallbladder, no calcification of stones, normal biliary tract anatomy. To check these criteria a step-by-step diagnostic procedure was instituted which consisted of history, ultrasonography with contractility test, abdominal X-ray film, computed tomography measurement of stone density, and endoscopic retrograde cholangiography. Only 19 patients fulfilled the criteria. The others had to be excluded because of history (35), stone size or number (73), impaired gallbladder contractility (27), calcified stone (30), pigment content (12), and/or biliary tract anatomy. Thus only a surprisingly small percentage (about 10%) of patients with symptomatic gallbladder stones is suitable for ESWL.

[Anaesthesia for the severe burn patient (author's transl)]

By means of medical records, anaesthesia protocols and autopsy reports on 59 severely burnt patients of all age and risk groups, the three anaesthetic procedures mainly used in this group of patients-NLA, inhalation narcosis with halothane and Ketamine mono-anaesthesia-were retrospectively compared with regard to intra-operative complications and mortality. All the patients were in the initial phase of the treatment of burns, and had to undergo a variety of surgical interventions; these included changes of dressing, tracheotomy, necrotomy and skin grafts. Special pathophysiological problems of burns with particular consideration of the cardiocascular system, the lungs, the kidneys, and the electrolyte and acid-base balance are pointed out. Attention is drawn to the decisive importance of "preanaesthetic management" and to the specific technical problems of anaesthesia in patients suffering from burns. Each of the anaesthetic procedures discussed proved to be fundamentally suitable for the anaesthesia of persons suffering from very severe burns. Each of the anaesthetic procedures discussed proved to be fundamentally suitable for the anaesthesia of persons suffering from very severe burns. It should be left to the individual to decide which procedure in his experience should be preferred for a particular case.

[Unusual defective antibody reaction after polio vaccination (author's transl)]

Over several years we have determined the titers of the neutralizing antibodies against the three types of polio virus in 147 adult females working in hospitals or laboratories. Through administration of a trivalent oral vaccine we attempted to boost the vaccination and supplement the missing antibodies. A strong antibody reaction against all three types of polio virus could only be obtained usually after an additional parenteral injection of inactivated serum. Four cases are described in detail as rare occurrences (2.7 percent of those investigated). For some unknown reason, the desired antibody formation could not be obtained in these subjects in spite of repeated administration of both types of vaccine.