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Fragestellung: Stammnervenverletzungen der oberen Extremitäten sind oft schwere und langwierige Verletzungen. Eine frühzeitige und präzise Diagnostik ist daher zur Therapieplanung entscheidend. Zusätzlich erscheint die Anwendung von bildgebenden Methoden auch im Verlaufsmonitoring [zum vollständigen Text gelangen Sie über die oben angegebene URL]

Fragestellung: Stammnervenverletzungen der oberen Extremitäten sind oft schwere und langwierige Verletzungen. Eine frühzeitige und präzise Diagnostik ist daher zur Therapieplanung entscheidend. Zusätzlich erscheint die Anwendung von bildgebenden Methoden auch im Verlaufsmonitoring [zum vollständigen Text gelangen Sie über die oben angegebene URL]

Fragestellung: Die Weiterbildungsordnungen der Plastischen Chirurgie und der Handchirurgie verlangen die Beherrschung mikrochirurgischer Techniken. Standards wie diese Fähigkeiten erlangt werden sollen sind jedoch noch nicht festgelegt, so dass jede Klinik im Idealfall ein eigenes mikrochirurgisches[zum vollständigen Text gelangen Sie über die oben angegebene URL], 59. Kongress der Deutschen Gesellschaft für Handchirurgie

Fragestellung: Gegenstand der Untersuchung war die plastisch-chirurgische Therapiestrategie bei freier Gewebetransplantation zum Unterschenkel und Fuß bei Eingefäß-Situation. Methoden: Eingeschlossen wurden alle Patienten, bei denen zwischen Mai 2013 und Dezember 2017 aufgrund eines[zum vollständigen Text gelangen Sie über die oben angegebene URL], 49. Jahrestagung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC), 23. Jahrestagung der Vereinigung der Deutschen Ästhetisch-Plastischen Chirurgen (VDÄPC)

Haemorrhagic disorders must be excluded prior to any operation or other invasive procedure that has the potential to involve serious bleeding. When assessing the individual risk of bleeding, screening tests of hemostasis must be combined with the patient's clinical history and symptoms, and any history of bleeding must be explored under direct medical supervision using a standardized questionnaire. However, this bleeding history is neither very specific, nor is it particularly sensitive. Screening tests that have been found to be useful include platelet count, activated partial thrombo plastin time (aPTT), prothrombin time (PT) and clottable fibrinogen. No reliable, sensitive and specific screening test is however available today to screen for platelet dysfunction or von Willebrand disease. A specialized coagulation laboratory should be involved when the bleeding history or laboratory screening indicate a potential haemorrhagic disorder.

Argatroban is a direct, selective and reversible active site thrombin inhibitor derived from L-arginine. It is a representative of a new class of antithrombotic drugs which offer inhibition of clot-bound as well as fluid-phase thrombin. Argatroban is characterised by favourable pharmacokinetics (beta-elimination half-time approximately 40-50 min) undergoing hepatic metabolism and mainly biliary excretion. Renal impairment will not result in altered or delayed elimination. For many years, argatroban has been used in Japan and in the United States and is approved by the FDA for anticoagulation in patients with heparin-induced thrombocytopenia (HIT type II). The ease of monitoring with the activated partial thromboplastin time, lack of induction of antibodies and adequate safety in renal failure patients, make this drug a favourable mode therapy in comparison with other anticoagulants such as lepirudin or heparinoids. Since June 2005 argatroban has been approved in Germany for the treatment of patients with HIT type II. The main characteristics of the drug with special considerations for anaesthesiologists and intensive care physicians are presented in this review.

Die amerikanischen Industriegewerkschaften des Dachverbandes CIO orientierten sich in dem beschriebenen Zeitraum (1935-1955) oft an der Außenpolitik der Administration, formulierten aber stets klar ihr aufgeklärtes Eigeninteresse im Rahmen des rapiden nationalen und internationalen Wandels dieser Zeit. Das ist das Hauptergebnis des Autors. Er stellt sich damit gegen die revisionistischen Studien der 60er, 70er und 80er Jahre, die der CIO-Führung stets ein opportunistisches Verhältnis zur Roosevelt- und besonders zur Truman-Administration unterstellen. Die Führung des CIO versuchte in den Jahren vor und während des Zweiten Weltkrieges stets, die Durchsetzung von Arbeitnehmerrechten mit den Erfordernissen der Kriegsrüstung zu verknüpfen und konnte dabei einige Erfolge erzielen. Die im Wagner Act formulierten Arbeitnehmerrechte wurden in dieser Zeit durchgesetzt, verteidigt und mit gesellschaftlicher Legitimität versehen. Der Autor belegt in seiner Studie, daß nicht ein reflexhafter Antikommunismus der New Dealer in den Gewerkschaften, sondern eine sklavenhafte Moskau-Hörigkeit des linken, von Kommunisten und der CPUSA dominierten Flügels der CIO-Gewerkschaften zur Diskreditierung radikal-sozialistischer und kommunistischer Perspektiven und zur Ausgrenzung kommunistischer Gewerkschaften im Zuge des beginnenden Kalten Krieges geführt haben. Der Angriff der Kommunisten auf die Strategie der Einbindung in die New Deal Koalition (sie manifestiert sich in der Unterstützung des aussichtslosen linken Präsidentschaftskandidaten Henry Wallace) macht nach dem Zweiten Weltkrieg die Konfrontation zwischen dem rechten und dem linken Lager unausweichlich. Gleichzeitig waren die amerikanischen Arbeitnehmer mehrheitlich nicht an sozialistischen und kommunistischen Perspektiven interessiert. Sie wollten Teilhabe und Chancengerechtigkeit im amerikanischen Gesellschaftssystem. Nach dem Zweiten Weltkrieg beteiligten sich die CIO-Gewerkschaften am demokratischen Aufbau insbesondere in Westeuropa und bildeten mit dem labor attache program ein eigenes diplomatisches Korps, das auch tatsächlich in die amerikanische Außenpolitik integriert und vom State Department finanziert wurde. Sie engagierten sich auch in einem weiten internationalen Geflecht demokratischer Gewerkschaften. Die Würdigung der Herausbildung einer eigenen, sub-staatlichen gewerkschaftlichen Außenpolitik ist ein weiteres wichtiges Ergebnis der vorliegenden Studie., The CIO unions in the years between 1935 and 1955 oftentimes followed the lines of the administrations' foreign policy but did so with a decided and frank formulation of their enlightened self-interest. This is the main result of the author's research. Other than the revisionist studies of the 60s, 70s and 80s, he stresses the positive results of the CIO's involvement in and reaction to the rapid and deep national and international change in the New Deal era and it's immediate aftermath. Revisitionist studies of labor politics usually state or imply a basic opportunism of the CIO leadership towards the Roosevelt and Truman administrations. The author argues that the CIO leadership and a majoritiy of CIO unions did their best to link the necessities of wartime mobiliziation to the strengthening of worker's rights - oftentimes, though by no means always - with success. The provisions of the Wagner Act were applied and defended in the years before and during World War II. The author argues that the slavelike adherence of the left wing within the CIO to the twists and turns of Stalinist policy (especially in the aftermath of the Hitler-Stalin Pact) led to the expulsion of those unions during the first years of the Cold War - and not an unfounded, unjustified anticommunism, as the revisionists imply. It also led to the discreditation of any socialist and communist perspectives - had there ever been such in the United States. The CIO left wing was indeed dominated in large parts by the CPUSA, a known fact in the CIO. American workers in their majority were not interested in socialist or communist perspectives. They were interested in participation and opportunity. The communist's assault on the CIO's integration in the New Deal Coalition (manifest in their support for the leftwinger Henry Wallace in the presidential campaign of 1948) made a showdown between left and right wing inevitable. CIO unions actively participated in the democratic reconstruction of Western Europe - especially in their own diplomatic program: the labor attache program. It was an integral part of the government's diplomatic corps and funded by the State Department. CIO unions also interacted with a large number of democratic unions in all parts of the world. The recognization of a sub-state-level, non-government foreign involvement, an independent, though integrated foreign policy of the CIO is another important result of this study.

Melagatran is a direct inhibitor of thrombin and-like its oral prodrug ximelagatran-a newly developed dipetide with high antithrombotic efficacy. They present a linear dose-response, a short plasma half-life and the therapeutic range may be advantageous compared with classic anticoagulants such as heparins or vitamin K antagonists. The results of clinical studies for prevention and treatment of thromboembolic complications are encouraging. The use of melagatran and ximelagatran will gain significance in the perioperative management, thus being of particular importance for anaesthesiology and critical care medicine in the near future.

Salicylates increase the risk of hemorrhage. An ischemic brain infarct has not previously been described following intoxication with salicylates. Case report. A 58-year-old comatose patient was admitted with symptoms of a basilar artery thrombosis. A diagnostic angiography was impossible because laboratory results showed a prothrombin time (Quick) of 9% and a toxic salicylate level of 528 mg/l. During the next few days CCT and MRI scans revealed ischemic infarctions within the brain stem. Discussion. Salicylates can induce hemorrhage both by inhibiting platelet aggregation and - especially in higher doses - by vitamin K antagonism, leading to severe coagulopathy. The occurrence of an ischemic infarction, as presented in this case report, can be explained by a reduction of the vitamin K-dependent protein C level.

Dextrans are known to inhibit platelet aggregation. However, conflicting results have been reported with hydroxyethyl starch (HES), usually administered as a single dose. To clarify this, we studied the effects of HES on platelet number, aggregation and volume during the course of long-term hemodilution therapy. Twelve patients with disturbances of cerebrovascular perfusion were randomized and divided into two groups of 6 patients each. One group was treated with 10% HES 200/0.62, the other with 6% HES 200/0.62. The patients in group 1 received a loading dose of 500 ml, followed by 500 ml daily for 10 days. Group 2 patients were infused a loading dose of 500 ml, followed by 1000 ml on days 1 to 4 and 500 ml on days 5 to 10. 10% HES had a larger volume effect. The hematocrit was lowered by 19.0%, whereas 6% HES caused a decrease of only 15.6%. 10% HES lowered the platelet number significantly (p0.05) by 5.8%, 6% HES did not lower the platelet number significantly. Platelet volume decreased significantly during therapy (p0.05) in both groups. 10% HES reduced the platelet volume by 13.9%, the reduction with 6% HES was 9.0%. Under therapy with 10% HES, platelet aggregation declined slightly, but significantly (p0.05), whilst no effect was seen with 6% HES. During long-term hemodilution therapy with HES, the initial decrease in platelet number, which is due to dilution, is quickly compensated. The continuous decline in mean platelet volume during therapy is probably due to colloid-osmotic shrinkage. Since there is a positive correlation between platelet size and function, the slight inhibition of platelet aggregation caused by 10% HES is possibly due to the observed decline in platelet volume.

To prevent dangers to health resulting from the application of drugs, the legislator requires the central registration and evaluation of all drug risks, especially of side effects and reciprocal effects. Since 1988 pharmaceutical enterprises have had to denominate a qualified person ('Stufenplanbeauftragter') who is responsible for the fulfilment of obligatory reporting. In case of complaints or side effects he has to take suitable measures according to a special plan ('Stufenplan').The basis of this survey are the legal requirements for drugs ('Arzneimittelgesetz') and supplementary regulations which define the duties of the 'Stufenplanbeauftragter'.Blood components are subject to the legal requirements ('Arzneimittelgesetz') without reservations. Therefore the corresponding regulations have to be applied without modification in institutes for transfusion medicine. In this article the tasks of the 'Stufenplanbeauftragter' are summarized and practical experience of a university institute for transfusion medicine is presented.In connection with the transmission of viral infectious diseases it became evident that the 'Stufenplanbeauftragter' is very important for the initiation of effective measures in case of serious side effects. The security of blood components could be improved by the realization of the corresponding legal requirements in the institutes for transfusion medicine.

Investigation of the influence of C2/C6 occupation ratio of 2 different 6% hydroxyethyl starch (HES) solutions on elimination kinetics and blood fluidity.A single-blinded, prospective randomised cross-over study.Haemostasiological-angiologic outpatient department of the university of Homburg.6 voluntary apparently healthy subjects.A 500 ml infusion of 2 different HES solutions (6% HES 200/0.5 or 6% HES 200/0.62, respectively) was given intravenously within 1 h. A wash-out phase of 3 months was kept between both infusions. The concentration and distribution of the molecular weight of the intravasal HES molecules up until 24 h after the infusion as well as the blood fluidity before and after the infusion were measured.Besides the molecular substitution (MS), which is different for the 2 employed HES solutions, the occupation ratio of the C2 respectively C6 (C2/C6 occupation ratio) of the glucose ring influences the breakdown of the HES molecules. This influences the blood fluidity. While the decrease in haematocrit 1 h after the end of the infusion is comparable, the decrease in the haematocrit in the case of high C2/C6 occupation ratio and a high MS is maintained for a longer period of time. The increase in plasma viscosity in the case of high C2/C6 occupation ratio and high MS is more marked.The infusion of HES 200/0.62 leads to a significantly longer prevalence in comparison to HES 200/0.5, in combination with clearly larger degradation products in the plasma; this fact causes a more marked dilutional effect, but also a more marked increase in the plasma viscosity up to 24 h after the end of infusion. In the discussion on haemodilution therapy in patients with arterial occlusive disease the employment of HES which induces an increase in plasma viscosity is thought to be a disadvantage.

The goal of the study is to test and control the quality of a special leap-frog technique which enables saving heterologous blood.In a randomized double-blind placebo-controlled study homologous blood was taken in 40 out of 100 patients with coronary heart disease before aortocoronary bypass operation. The leap-frog technique was used. Within 8 weeks 3-4 erythrocyte concentrates and 0.9-1.2 liters plasma were sampled. The volume (verum: HES 200/0.5 10%; placebo: 0.9% NaCl solution) substituted corresponding to the volume of blood donated. Each patient received 200 mg Fe2+/day p.o.Clinically, only patients treated with HES in stage of autologous blood sampling benefited significantly. Two patients showed adverse effects. The peri- and postoperative course was comparable. In the NaCl group one of the patients received homologous erythrocyte concentrates. None of the patients died pre-, peri- or post-operatively.40% of the cardiosurgical patients could be considered for autologous blood donation. Isovolemic hemodilution with HES 200/0.5 10% was a suitable and safe measure in preoperative blood sampling. Physical exercise should be performed before and after autologous blood donation. A reduced exercise tolerance suggests that autologous blood donation should be stopped.

Clinically, only patients treated with HES in stage of autologous blood sampling benefited significantly. Two patients showed adverse effects. The peri- and postoperative course was comparable. In the NaCl group one of the patients received homologous erythrocyte concentrates. None of the patients died pre-, peri- or postoperatively. 40% of the cardiosurgical patients could be considered for autologous blood donation. Isovolemic hemodilution with HES 200/0.5 10% was a suitable and safe measure in preoperative blood sampling. Physical exercise test should be performed before and after autologous blood donation. A reduced exercise tolerance suggests to stop autologous blood donation.

The platelet reactivity was measured before and 1 h after thrombapheresis in n = 54 donors. On average, apheresis did not significantly influence the platelet reactivity. Still in 10% of the donors a marked increase in platelet reactivity was seen.

When no specific factor concentrate is available fresh-frozen plasma (FFP) is indicated in the treatment of clinically relevant hemorrhagic diathesis. These disorders include congenital factor V and XI deficiencies, multiple factor defects, as disseminated intravascular coagulation and severe liver disease, and patients receiving massive transfusions, when bleeding occurs and severe abnormalities on coagulation testing are evident. FFP is beneficial when used with plasma exchange in thrombotic thrombocytopenic purpura and related disorders. Various virucidal treatments including solvent-detergent (SD), photoactivated dyes (methylene blue) or pasteurization have been evolved to improve virus safety of human plasma. More extensive studies to demonstrate efficient virus inactivation in plasma have been performed with SD compared to other methods. On the other hand, the use of single-donor FFP in methylene blue treatment is possibly superior to pooled plasma which is processed according to the SD procedure. Pasteurization enables the inactivation not only of lipid-enveloped but also of non-lipid-enveloped viruses. Virucidal treatment of plasma may cause alterations in clotting factors, fibrinolysis and protease inhibitors; however, the currently achieved recovery of procoagulant activities is approximately comparable with that found in untreated FFP. The toxicity of virucidal additives is reported to be negligible since manufacturing includes a removal procedure (SD) or comparably low amounts (methylene blue) are used in inactivation treatment.

Quality controls of autologous blood collections in critically ill patients comprise the control of blood products, blood collection, and of the patients themselves. The control of products is defined in European guidelines, the AMG (law governing the manufacture and prescription of medicine) and GMP regulations. The products are described in the monograph of the Federal Health Office. The quality control of blood collection in patients with a critical vascular disease is important since vagotonic or hypertensive crises may occur frequently (in 10-15% of cardiosurgical patients). The quality control of the critically ill patients themselves is important in order to be able to balance benefits against risks. A phlebotomy of 500 ml may lead to a considerable deterioration of the clinical condition. The clinical condition can be controlled by simple exercise tests prior to and after the blood collection (bicycle ergometer, treadmill or climbing stairs). In our own investigations only about 25% of cardiosurgical patients (40% of patients with aortocoronary venous bypass) received autohemotherapy, and 20% of them showed a clinical deterioration during the phase of blood collection. Other problematic patients are those suffering from a tumor. A clear clinical benefit of autohemotherapy in these patients has not been demonstrated up to now; nevertheless, when a curative therapy is possible, they should be treated with autohemotherapy.

Desmopressin (DDAVP) is an effective tool for increasing factor VIII (FVIII)/von Willebrand factor (vWF) in normal subjects and in patients with haemophilia A and von Willebrand's disease. There are a few studies utilizing DDAVP to increase the FVIII/vWF yield in plasmapheresis donors. In these studies, DDAVP was given either by intranasal administration or intravenous infusion. The aim of our pilot study was to investigate the subcutaneous (s.c.) injection of DDAVP in combination with double bag plasmapheresis. 8 donors with blood group A and 5 with O were given 0.4 micrograms/kg body weight DDAVP as a s.c. injection 30 min prior to the first donation. FVIII increased 3.7 and ristocetin cofactor 2.5 the initial value in the donors. In the plasma bags, a 3 (1st bag) and 3.5 (2nd bag) fold higher FVIII level was found, when compared with baseline levels. There was only a mild decrease of blood pressure, and serious adverse effects were not observed. Our data suggest that s.c. DDAVP may be more effective and especially suited for increasing FVIII/vWF yield in plasmapheresis donors.

Prothrombin complex concentrates (PCC) are frequently used for the treatment of acquired coagulation factor deficiencies. However, a major problem when using these preparations is their thrombogenic potential. Thus, the potency and tests for thrombogenicity were studied prospectively in 7 different PCC's. Human albumine and a factor IX concentrate served as controls. The potency of coagulation factors and inhibitors varied considerably, especially for proteins S and C. Two preparations exhibited high amidolytic activities in vitro. These activities could be quenched in part by the addition of hirudin or antithrombin III. Additionally, these two preparations caused more severe cardiopulmonary reactions in rabbits and an increase of fibrin split products. We conclude that the use of these preparations in patients, in whom an acquired protein C or S defect, or a hypercoagulable state, can be suspected, cannot be recommended.

Recombinant human erythropoietin (rh-EPO) has been shown to be effective in the treatment of renal anemia. Additionally, rh-EPO improves the hemostatic defect of uremia. On the other hand, a hypertensinogen effect and an increased risk for thrombosis have been reported in hemodialysis (HD) patients with rh-EPO. 20 HD patients in Homburg were recruited for a multicenter, placebo-controlled study (MF 3981), aiming to assess the risk of rh-EPO. Initially, 10 patients received rh-EPO at a dose of 3 x 80 U/kg body weight and week which was subsequently adjusted according to the hematocrit. After 6 months, the patients receiving placebo were changed to rh-EPO therapy. Clinical and laboratory data were obtained before, as well as 1, 3, 6 and 12 months after beginning of the study. Erythrocyte counts increased significantly in the rh-EPO group. Also, an increase of platelet count, fibrinogen and plasma viscosity was observed during rh-EPO. Tissue type plasminogen activator and plasminogen activator inhibitor as well as von-Willebrand-factor remained unchanged, although a shortening of the bleeding time was observed. Blood pressure and arterial blood flow were not influenced by rh-EPO.

Heparin exerts its anticoagulant function by accelerating the inhibitory effect of antithrombin III. Low molecular weight heparin (LMWH), which is derived from unfractionated heparin (UFH), exhibits marked anti-Xa activity and minor thrombin inhibition. It has an elevated bioavailability and longer half-life as to the anti-Xa clearance when compared to UFH. Platelet, endothelial and fibrinolytic effects are also involved in antithrombotic action. Clinical trials have shown that LMWH compared to UFH is an equivalent and even advantageous method of antithrombotic prophylaxis in surgical patients and has also a minor risk of bleeding.

A 7-year-old boy with severe hemophilia B suffered an intraspinal extradural hemorrhage without preceding trauma. Since the age of 3 years the patient is HIV-1 positive. The actual hemorrhage caused a strong pain in the thoracolumbar area without signs of spinal cord compression. It was diagnosed by CT-scan. By early high dose factor-IX substitution the hemorrhage was stopped and no neurological complications occurred. The further substitution regime is described.