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In the weaning of patients from mechanical ventilation by gradually reducing pressure support ventilation (PSV), an automated computerized system recently proved to be superior to traditional physician-directed weaning. The aim of this study was to replicate these findings when weaning a broad surgical intensive care unit (ICU) patient population off the ventilator. Sixty patients requiring mechanical ventilation over 24 h were randomized to either automated (n = 30) or physician-directed (n = 30) weaning. The primary endpoint was duration of weaning. Secondary endpoints were duration of mechanical ventilation, length of ICU stay, reintubation rates, and workload for staff. Weaning duration did not differ significantly between the computer-driven group and the physician-directed group (0.64 vs. 2.33 d, 95%CI: -0.10 to 2.15, p = 0.167). No significant differences were detected for any secondary endpoint except the workload for PSV settings, which was lower in the computer-driven weaning group (0.0 vs. 0.15 settings/h, p

Die Radiofrequenzablation (RFA) stellt eine neue Methode zur lokalen Destruktion von Lebertumoren dar. Indikationsstellung und Durchfuhrung sind gegenwartig nicht ausreichend validiert. Zur Erfassung des aktuellen Standes der RFA in Deutschland wurden 2026 Kliniken mittels standardisiertem Fragebogen befragt. Bei einer Rucklaufquote von 17,5% setzten 58 Abteilungen die RFA zum Befragungszeitpunkt ein und behandelten ca. 1700 Patienten. 25,9% sahen eine Indikation bereits bei potenziell kurativ resezierbaren Tumoren, 22,4% auch bei erwarteter inkompletter Ablation zur Tumormassenreduktion. 75% kombinieren Resektion und RFA zur Erzielung einer „R-0-Situation“. Die maximale Tumorgrose zur vollstandigen Ablation wird mit 3–11 cm angegeben. Als Kontraindikationen wurden am haufigsten Tumorgrose, Tumoranzahl, kritische Tumorlokalisationen und Einschrankungen der Leberfunktion genannt. Die Umfrage dokumentiert eine landesweit erhebliche Diskrepanz bei Indikation, Durchfuhrung und Ergebnissen der RFA in der Behandlung von Lebertumoren. Fehlende Standards und eine Uberschatzung der methodischen Moglichkeiten konnen zu einem unkritischen Einsatz, Abweichung von Standardtherapien oder unbefriedigenden Ergebnissen fuhren.

Economic aspects have gained increasing importance in recent years. The operating room (OR) is the most cost-intensive sector and determines the turnover process of a surgical patient within the hospital. Thus, optimisation of workflow processes is of particular interest for health care providers. If the results of surgery are viewed as a product, everything associated with surgery can be evaluated analogously to a manufacturing process. All steps involved in producing the end-result can and should be analysed with the goal of producing an efficient, economical and quality product. The leadership that physicians can provide to manage this process is important and leads to the introduction of a specialised "OR manager". This position must have the authority to issue directives to all other members of the OR team. An OR management subordinates directly to the administration of the hospital. By integrating and improving management of various elements of the surgical process, health care institutions are able to rationally trim costs while maintaining high-quality services. This paper gives a short introduction into the difficulties of organising an OR. Some suggestions are made to overcome common shortcomings in the daily practise. A proposal for an "OR statute" is presented that should be a basis for discussion within the OR team. It must be modified according to individual needs and prerequisites in every hospital. The single best opportunity for dramatic improvement in effective resource use in surgical services lies in the perioperative process. The management strategy must focus on process measurement using information technology and feed-back implementing modern quality management tools.However, no short-term effects can be expected from these changes. Improvements take about a year and continuous feed-back of all measures must accompany the reorganisation process.

We report on our experiences with internal hemipelvectomy followed by an implantation of a endoprosthetic pelvic replacement (EPR) performed in 15 patients over a period of 15 years. Our primary aim was to determine the indications for this procedure because of its high rate of complications. Due to the malignant character of the disease and the biomechanical stress on the anatomical region, the demands on the surgeon are high. The most important factor is a sufficiently wide resection of the primary tumour because most are chondrosarcomata which do not respond to other therapies. In addition, the malignant character of the tumour has the greatest influence on the long-term results. Internal hemipelvectomy and endoprosthetic pelvic replacement are accompanied by a high rate of operative and postoperative complications. Nevertheless, nearly full anatomical and functional reconstruction can be obtained provided a medium level of function is accepted. Follow-up results of the remaining six still living patients were evaluated by means of three different scoring systems. All patients had only a medium score but emphasised subjective acceptance of the endoprosthetic pelvic replacement even when removal was necessary later on. Because of the lower functional outcome of alternative operative procedures such as pseudarthroses and arthrodeses and problems with the replantation of autoclaved autografts or implantation of an allograft, internal hemipelvectomy combined with endoprosthetic pelvic replacement is the treatment of choice for these specific acetabular lesions, provided a complete resection is feasible. Otherwise, an external hemipelvectomy is necessary because even alternative limb-salvaging procedures must incorporate the same complete resection of the tumour. In cases of metastatic lesions, internal hemipelvectomy and endoprosthetic pelvic replacement are indicated relatively because of the systemic character of the disease. The procedure should be considered only when resection of a solitary metastasis enables a cure and/ or prolongation of ilfe with an improved quality of life.

The peritoneal resident cell population is influenced by various inflammatory and immunogenic stimuli. The influence of intraperitoneal application of polyethyleneterephthalate (PET) (group A) and ultra-high-molecular-weight polyethylene (UHMW-PE) (group B) powders on peritoneal cell count and macrophage activity was investigated. Powders were tested to mimic wear particles from solid implant devices as these particles often cause chronic granulomatous inflammation. The results were compared with the inflammatory response following an abdominal midline incision (group C) and untreated animals (group D). On days 1, 7, 14 and 30 peritoneal cells were quantified and the number of active macrophages was assessed. Groups A and C mice showed a significant loss of macrophages in the peritoneal lavage at day 1 but this returned to normal values (group D) on day 7. In contrast, group B animals remained at low peritoneal cell counts but showed the highest number of active macrophages. Only in this latter group was adhesion formation and granulomatous clustering of polymer powder observed. Applying the parameters macrophage count and the number of active macrophages it can be concluded that PET elicits a weaker inflammatory reaction than UHMW-PE in mice peritoneal cavity. Thus this animal model may be used as a screening test for biomedical materials, especially their wear products.

Unter den eitrigen Osteomyelitiden bzw. Arthritiden stellt die bakterielle Sakroiliitis eine grose Seltenheit dar. Ihre operative Therapie ist nach erfolgloser konservativer Behandlung, bei Abszesbildung, septischen Zustanden sowie Vorliegen von neurologischen Ausfallen indiziert. Zwischen 1983 und 1990 wurden 9 Patienten nach diesen Kriterien operativ mit Ausraumung des entzundlichen Bereichs, primarer Arthrodese des Sakroiliakalgelenks mittels autologem Knochenspan, adjuvanter Antibiotikatherapie sowie postoperativer Immobilisation behandelt. Eine Nachuntersuchung, durchschnittlich 47 Monate postoperativ, ergab in 6 von 8 Fallen gute funktionelle und rontgenologische Ergebnisse, 2 Patienten klagten uber geringe Restbeschwerden. Bei keinem der Nachuntersuchten kam es zu einem Rezidiv, ein Patient war postoperativ an den Folgen einer langfristigen, bereits praoperativ bestehenden Sepsis verstorben. Nach diesen Ergebnissen sollte die operative Behandlung der bakteriellen Sakroiliitis rechtzeitig erwogen werden, da dann die Operation mit einer geringen Komplikationsrate verbunden ist und nur eines geringen operationstechnischen Aufwands bedarf.

Das Bruchverhalten von 25 frischen isolierten Leichenwirbelkorpern unterschiedlicher Hohe wurde im statischen Kompressionsversuch analysiert und mit den computertomographisch ermittelten Absorptionswerten verglichen.

In the case of surgically dressed necroses of the hip condyle and coxarthroses a condition was found after fracture of the pelvis or after dislocation of the hip joint in 7.2% of the cases. In 13.2% of the cases a trauma was found anamnestically. It was subdivided into fractures of the acetabulum, fractures of the pelvic girdle, dislocations, and fractures of the pelvic brim on the basis of the system of Judet and Engler as well as Feldkamp. Fractures of the pelvic brim through muscular traction, traction of the ligament, and direct trauma were discussed. The most frequent delayed consequences arising after dislocations of the hip joint and fractures of the acetabulum are: necroses of the head of the femur, coxarthroses, pseudarthroses, and myositis ossificans. The pathogenesis of the delayed injuries resulted from: capsular and vascular lesions, damage to cartilage with fractures in the spongiosa region, incongruence of the surface of the joint, insufficiency of the static structure of the pelvic ring, deposit of calcium salt outside the bone. In some cases the progress of the necrosis could be arrested by means of osteotomy and spongiosa filling. The rate of necrosis increases in proportion to the period between the time of occurrence of the accident and reposition (limit of 6 h). Even though about half the pelvic girdle fractures show good results with conservative treatment, in the case of fractures of the acetabulum a reconstruction as far as possible continuous and without stages is to be aimed at. In many cases the development of a myositis ossificans cannot be prevented.

A case of a combined neurofibroma-granular cell tumor is presented. The tumor had developed in the left middle cranial fossa after an intracranial trigeminal nerve operation 23 years before. It had displaced and infiltrated the temporal lobe and expanded probably via the fissura orbitalis into the orbit. The thickened optic nerve revealed a marked widening of the subdural fissure by typical granular cells. The cufflike tumor cell aggregation in the subdural fissure had compressed the optic fascicle, thereby inducing a demyelinisation and axonal degeneration. A reactive gliosis in the optic fascicle masks the typical pattern of the optic nerve atrophy. The gangliocytes of the third retinal neuron are atrophic and replaced by reactively proliferated fibrillary astrocytes. A short review of the literature and theories concerning histogenesis of the granular cell tumor (neurogenic or mesoderma) is given. An intermediary type of neurofibromatous and granular cells which we found motivates us to agree with a mesodermal origin.

The allochromatic behaviour of nerve cell nucleoli in the Luxol-fast-blue-method (blue nucleoli) in cases of raised brain pressure is probably due to a lactacidotic pH-shift basing on cerebral hypoxia. In 109 out of 134 cases with blue nucleoli signs of cerebral hypertension could be observed. The IEP of nerve cell nucleoli was determined in the nuclei pontis. Clinical and pathophysiological data were evaluated.

In a comparative study the value of castless immobilisation methods for stabilising the lateral ankle instability was examined. For this the dimension of the lateral talar tilt as a sign for chronic lateral ankle instability in 32 sportsmen with chronic ankle instability was checked initially. Afterwards the reduction of this instability due to the application of the tape-bandage and the "ankle-brace" was tested under the same standardised conditions. In regard to the reduction of the lateral talar tilt a reduction of this instability of the ankle joint is possible significantly. But compared to the normal talar tilt showing a stable ankle joint, it is not possible to reach this in all cases of ankle instability. So for treatment of the lateral ligament rupture it is necessary to use the usual cast for stabilising the joint after ligament suture before reduction of the time of immobilisation is possible. The use in cases of chronic instability or as a precaution method is not restricted when a sufficient active stabilisation is possible.

Three cases of myxomatous meningiomas with unusually abundant myxopoiesis are reported. Histochemical and staining methods are applied to characterize the mucous substances. They are identified as a complex of neutral and acid mucopolysaccharides with a protein component. Histochemical and histological findings are correlated. The question is discussed whether an excessive myxopoiesis of meningioma cells represents regressive changes or specialized cellular activity.