50,916 research outputs found
Sicherheit und Monitoring der patientenkontrollierten intravenösen Analgesie. Anwendungspraxis in deutschen Krankenhäusern
No full textCurrent practice of acute pain management in children - a national follow-up survey in Germany
No full textOBJECTIVES
This study aimed to summarize the current standard practices for acute pain management in children in Germany and the implementation of these procedures. The last survey on acute pain management in children was performed in 1999, highlighting the need for an up to date review.
METHODS
A questionnaire was mailed to German departments of anesthesiology (n = 885), asking for structures and processes of acute pain management in children. Results were compared between hospitals with and without an acute pain service and with and without a pediatric department.
RESULTS
Of the 407 responding hospitals (response rate of 46%), 342 treated children younger than 14 years. These were considered for analysis. Of the 342 hospitals, 42% contained either a general pediatric department or a department of pediatric surgery, and the majority of the responding hospitals had an acute pain service (83%). Pain intensities were measured at least once per shift in 40% of the institutions, and at least once or twice a day in 27%. Of the institutions, 31% did not document pain scores regularly, without any difference between hospitals with or without a pediatric department. Standard operating procedures for acute pain management existed in 68% of the hospitals, with large differences in content and length. Opioids were administered to children in 85% of the hospitals. Nonopioid analgesics were the first choice baseline analgesics in most hospitals. Peripheral regional and epidural analgesia were performed in children in 18% and 8% of the hospitals, respectively (21%/16% with a paediatric department, 16%/1% without; P < 0.001).
CONCLUSION
Current practice of pediatric pain management varied widely and the recommendations of guidelines, like regular pain management, were frequently not met. However, improvements could be observed since 1999, for example, an increase in regular pain measurements (4% vs 67%). Furthermore, pain management in hospitals running a pediatric department had a higher degree of organization, and more sophisticated analgesic techniques
Kritische Ereignisse in der Akutschmerztherapie – eine Risikoanalyse von CIRS-Meldungen
No full textBACKGROUND: Areas of activity with many intersections pose an increased risk for errors and critical incidents. Therefore, procedures for acute pain therapy are potentially associated with an increased risk for adverse patient outcomes. OBJECTIVE: The aim was to identify and grade the risk of critical incidents in the context of acute pain management. MATERIAL AND METHODS: The register of the nationwide reporting system critical incident reporting system of the Professional Association of German Anesthesiologists, the German Society for Anesthesiology and Intensive Care Medicine and the Medical Center for Quality in Medicine (CIRSmedical Anesthesiology) was screened for incidents concerning pain management. Out of 5365 cases reported nationwide up to 24 March 2020, 508 reports with the selection criterion “pain” could be identified and reviewed and 281 reports (55%) were included in a systematic analysis. RESULTS: Of the 281 reports most came from anesthesiology departments (94%; 3% from surgery departments and 3% from other departments). The reported cases occurred most frequently on normal wards but a relevant proportion of the reports concerned intermediate and intensive care units or areas covered by a pain service (PS). Based on the description of the incident in the report, an involvement of the PS could be assumed for 42% of the cases. In terms of time, most of the events could be assigned to normal working hours (90%) and working days (84%; weekends 16%). The analyzed reports related to parenteral administration of analgesics (40%) and central (40%) or peripheral regional anesthesia procedures (23%) and 13% of the reports related to patient-controlled intravenous analgesia (PCIA; multiple answers possible). Most of the events were caused by technical errors, communication deficits and deviations from routine protocols. A relevant number of the cases were based on mix-ups in the administration route, the dosage, or the active agent. About one third of the sources of error were of an organizational nature, 59% of the cases posed a possible vital risk and in 16% of cases patients had vital complications. The risk grading by risk matrix resulted in an extremely high risk in 7%, a high risk in 62%, a moderate risk in 25% and a low risk in 6% of the cases. Comparing risk assessment of events with involvement of different analgesic methods, multiple medication, combination of analgesic methods or involvement of PS showed no significant differences. Likewise, no differences could be identified between the risk assessments of events at different superordinate cause levels. If more than one overriding cause of error had an impact, initially no higher risk profile was found. CONCLUSION: Incidents in the context of acute pain management can pose high risks for patients. Incidents or near-incidents are mostly related to mistakes and lack of skills of the staff, often due to time pressure and workload as well as to inadequate organization
GnRH-II receptor-like antigenicity in human placenta and in cancers of the human reproductive organs
No full textWe have recently demonstrated that the antiproliferative activity of GnRH-II on human endometrial and ovarian cancer cell lines is not mediated through the GnRH-I receptor. A functional receptor for human GnRH-II has not yet been identified. In this study, we have generated a polyclonal antiserum to the putative human GnRH-II receptor using a peptide (YSPTMLTEVPPC) corresponding to the third extracellular domain coupled to keyhole limpet haemocyanin via the Cys residue. A database search showed no identical peptide sequences in any other human gene. To avoid cross-reactions against two similar amino acid sequences the antiserum was pre-absorbed using these peptides. Immune histological sections of human placenta and human endometrial, ovarian and prostate cancers using rabbit anti-human GnRH-II receptor antiserum showed GnRH-II receptor-like staining. Western blot analysis of cell membrane preparations of human endometrial and ovarian cancer cell lines yielded a band at approximately 43 kDa whereas Western blot analysis of cell membrane preparations of ovaries obtained from the marmoset monkey (Callithrix jacchus) yielded a band at approximately 54 kDa. To identify the GnRH-II receptor-like antigen we used the photo-affinity labelling technique. Photochemical reaction of I-125-labelled (4-azidobenzoyl)-N-hydroxysuccinimide-[D-LyS(6)]-GnRH-II (10(-9) M) with cell membrane preparations of human endometrial and ovarian cancer cells yielded a band at approximately 43kDa. In competition experiments, the GnRH-I agonist Triptorelin (10(-7) M) showed a weak decrease of I-125-labelled (4-azidobenzoyl)-N-hydroxysuccinimide-[D-LyS6]-GnRH-II binding to its binding site. The GnRH-I antagonist Cetrorelix (10(-7) M) showed a clearly stronger decrease, whereas GnRH-II agonist [D-Lys(6)]-GnRH-II (10(-7) M) was the most potent competitor. Western blot analysis of the same gel using rabbit anti-human GnRH-II receptor antiserum identified this band as GnRH-II receptor-like antigen
Truth-Revealing Mechanisms for Courts
No full textIn trials witnesses often slant their testimony in order to advance their own interests. To obtain truthful testimony, the law relies on cross-examination under threat of prosecution for perjury. We show that perjury law is an imperfect truth-revealing mechanism. More importantly, we develop a perfect truth-revealing mechanism. Under this mechanism the witness is sanctioned if a court eventually finds that the testimony was incorrect; the court need not determine that testimony was dishonest. We explain how truth-revealing mechanisms could combat distortions of observations by factual witnesses and exaggerations by experts, including "junk science."
Speculu[m] exemploru[m] ex diuersis libris in vnu[m] laboriose collectu[m].
No full textEerste blad (blanco) ontbreektThe author is probably Johannes Busch (CIBN)Titel uit incipit. Drukker en datum uit colofonBMC: Catalogue of books printed in the XVth century now in the British Museum I 226bGesamtkatalog der Wiegendrucke ; M42951Machiels, J. Catalogus van de boeken gedrukt vóór 1600 ; S 488Polain, M.-L. Catalogue des livres imprimé au 15e siècle ... ; 3574Europeana-GoogleBook
Actions of gonadotropin-releasing hormone analogues in pituitary gonadotrophs and their modulation by ovarian steroids
No full textRecently, GnRH antagonists (GnRHant) like cetrorelix and ganirelix have been introduced in protocols of controlled ovarian hyperstimulation for assisted reproductive techniques to prevent premature luteinizing hormone (LH) surges. Here we tested, whether the actions of cetrorelix and the GnRH agonist (GnRHag) triptorelin in gonadotrophs are dependent on the steroid milieu. Furthermore, we characterized the actions of cetrorefix and triptorelin on LH secretion and the total LH pool. Female rat pituitary cells were treated either with 0.1 nM triptorelin for 1, 2, 4 and 6 days or for 1, 3, 5 and 6 h or with 1, 10 or 100 nM cetrorelix for 1, 2, 3 and 5 h or for 10 min. Cells were stimulated for 3 h with different concentrations of GnRH (10 pM-1 mu M). For analysis of the total LH pool, which is composed of stored and released LH, cells were lysed with 0.1% Triton X-100 at -80 degrees C overnight. To test, whether the steroid milieu affects the actions of cetrorelix and triptorelin, cells were incubated for 52 h with 1 nM estradiol (E) alone or with combinations of 100 nM progesterone (P) for 4 or 52 h, respectively. Cells were then treated with 0.1 nM triptorelin for 9 h or I nM cetrorelix for 3 h and stimulated for 3 h with different concentrations of GnRH (10 pM-1 mu M). The suppressive effect of triptorelin on LH secretion was fully accomplished after 3 h of treatment, for cetrorelix only 10 min were sufficient. The concentration of cetrorelix must be at least equimolar to GnRH to block LH secretion. Cetrorelix shifted the EC50s of the GnRH dose-response curve to the right. Triptorelin suppressed total LH significantly (from 137 to 36 ng/ml) after 1 h in a time-dependent manner. In contrast, only high concentrations of cetrorelix increased total LH. In steroid treated cells the suppressive effects of triptorelin were more distinct. One nanomolar cetrorelix suppressed GnRH-stimulated LH secretion of cells not treated with steroids from 10.1 to 3.5 ng/ml. In cells, additionally treated with estradiol alone or estradiol and short-term progesterone, LH levels were higher (from 3.5 to 5.4 or 4.5 ng/ml, respectively). In cells co-treated with estradiol and progesterone for 52 h LH secretion was only suppressed from 10.1 to 9.5 ng/ml. Steroid treatments diminished the suppressive effect of cetrorelix on LH secretion. In conclusion, the depletion of the total LH pool contributes to the desensitizing effect of triptorelin. The actions of cetrorelix and triptorelin are dependent on the steroid milieu. (c) 2006 Elsevier Ltd. All rights reserved
Process control in acute pain management. An analysis of the degree of organization of applied standard protocols
No full textThe aim of this study was to analyze the degree of organization of different standard protocols for acute pain management, as well as the derivation and definition of typical but structurally different models. A total of 85 hospitals provided their written standardized protocols for analysis. Protocols for defined target processes from 76 hospitals and another protocol used by more than one hospital were included into the analysis. The suggested courses of action were theoretically simulated to identify and characterize process types in a multistage evaluation process. The analysis included 148 standards. Four differentiated process types were defined ("standardized order", "analgesic ladder", "algorithm", "therapy path"), each with an increasing level of organization. These four types had the following distribution: 27 % (n = 40) "standardized order", 47 % (n = 70) "analgesic ladder", 22 % (n = 33) "algorithm", 4 % (n = 5) "therapy path". Models with a higher degree of organization included more control elements, such as action and intervention triggers or safety and supervisory elements, and were also associated with a formally better access to medication. For models with a lower degree of organization, immediate courses of action were more dependent on individual decisions. Although not quantifiable, this was particularly evident when simulating downstream courses of action. Interfaces between areas of hospital activity and a cross-departmental-boundary validity were only considered in a fraction of the protocols. Concepts from clinics with a certificate in (acute) pain management were more strongly process-oriented. For children, there were proportionately more simple concepts with a lower degree of organization and less controlling elements. This is the first analysis of a large sample of standardized protocols for acute pain management focusing on the degree of organization and the possible influence on courses of action. The analysis shows how different the structures and presumably the practical objectives of the various concepts are. The analyzed protocols with a lower degree of organization can manage only the assignment of a particular medication to the corresponding patient group, with a presumably high requirement for considerable implicit knowledge of the responsible employees. Accordingly, a requirement for such protocols should be that they not only describe the preferred standard therapy, but also define the interactions between the staff members involved. It remains questionable whether a protocol with a low level of organization and a comparably high requirement for implicit knowledge and individual action-also from nonmedical personnel-is able to ensure efficient pain therapy, particularly in view changing staff and dynamic responses to changing pain situations
Prediction of postoperative opioid analgesia using clinical-experimental parameters and electroencephalography
No full textBACKGROUND: Opioids are often used for pain treatment, but the response is often insufficient and dependent on e.g. the pain condition, genetic factors and drug class. Thus, there is an urgent need to identify biomarkers to enable selection of the appropriate drug for the individual patient, a concept known as personalized medicine. Quantitative sensory testing (QST) and clinical parameters can provide some guidance for response, but better and more objective biomarkers are urgently warranted. Electroencephalography (EEG) may be suitable since it assesses the central nervous system where opioids mediate their effects.METHODS: Clinical parameters, QST and EEG (during rest and tonic pain) was recorded from patients the day prior to total hip replacement surgery. Postoperative pain treatment was performed using oxycodone and piritramide as patient-controlled analgesia. Patients were stratified into responders and non-responders based on pain ratings 24 h post-surgery. Parameters were analysed using conventional group-wise statistical methods. Furthermore, EEG was analysed by machine learning to predict individual response.RESULTS: Eighty-one patients were included, of which 51 responded to postoperative opioid treatment (30 non-responders). Conventional statistics showed that more severe pre-existing chronic pain was prevalent among non-responders to opioid treatment (p = 0.04). Preoperative EEG analysis was able to predict responders with an accuracy of 65% (p = 0.009), but only during tonic pain.CONCLUSIONS: Chronic pain grade before surgery is associated with the outcome of postoperative pain treatment. Furthermore, EEG shows potential as an objective biomarker and might be used to predict postoperative opioid analgesia.SIGNIFICANCE: The current clinical study demonstrates the viability of EEG as a biomarker and with results consistent with previous experimental results. The combined method of machine learning and electroencephalography offers promising results for future developments of personalized pain treatment.</p
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