Publications by authors named "Hans Pinnschmidt"

60 Publications

Assessing volume responsiveness using right ventricular dynamic indicators of preload.

J Anesth 2021 May 5. Epub 2021 May 5.

Department of Anesthesiology, Centre for Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.

Purpose: Dynamic indicators of preload currently only do reflect preload requirements of the left ventricle. To date, no dynamic indicators of right ventricular preload have been established. The aim of this study was to calculate dynamic indicators of right ventricular preload and assess their ability to predict ventricular volume responsiveness.

Materials And Methods: The study was designed as experimental trial in 20 anaesthetized pigs. Micro-tip catheters and ultrasonic flow probes were used as experimental reference to enable measurement of right ventricular stroke volume and pulse pressure. Hypovolemia was induced (withdrawal of blood 20 ml/kg) and thereafter three volume-loading steps were performed. ROC analysis was performed to assess the ability of dynamic right ventricular parameters to predict volume response.

Results: ROC analysis revealed an area under the curve (AUC) of 0.82 (CI 95% 0.73-0.89; p < 0.001) for right ventricular stroke volume variation (SVV), an AUC of 0.72 (CI 95% 0.53-0.85; p = 0.02) for pulmonary artery pulse pressure variation (PPV) and an AUC of 0.66 (CI 95% 0.51-0.79; p = 0.04) for pulmonary artery systolic pressure variation (SPV).

Conclusions: In our experimental animal setting, calculating dynamic indicators of right ventricular preload is possible and appears promising in predicting volume responsiveness.
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http://dx.doi.org/10.1007/s00540-021-02937-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096889PMC
May 2021

The use of pulse pressure variation for predicting impairment of microcirculatory blood flow.

Sci Rep 2021 Apr 28;11(1):9215. Epub 2021 Apr 28.

Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.

Dynamic parameters of preload have been widely recommended to guide fluid therapy based on the principle of fluid responsiveness and with regard to cardiac output. An equally important aspect is however to also avoid volume-overload. This accounts particularly when capillary leakage is present and volume-overload will promote impairment of microcirculatory blood flow. The aim of this study was to evaluate, whether an impairment of intestinal microcirculation caused by volume-load potentially can be predicted using pulse pressure variation in an experimental model of ischemia/reperfusion injury. The study was designed as a prospective explorative large animal pilot study. The study was performed in 8 anesthetized domestic pigs (German landrace). Ischemia/reperfusion was induced during aortic surgery. 6 h after ischemia/reperfusion-injury measurements were performed during 4 consecutive volume-loading-steps, each consisting of 6 ml kg bodyweight. Mean microcirculatory blood flow (mean Flux) of the ileum was measured using direct laser-speckle-contrast-imaging. Receiver operating characteristic analysis was performed to determine the ability of pulse pressure variation to predict a decrease in microcirculation. A reduction of ≥ 10% mean Flux was considered a relevant decrease. After ischemia-reperfusion, volume-loading-steps led to a significant increase of cardiac output as well as mean arterial pressure, while pulse pressure variation and mean Flux were significantly reduced (Pairwise comparison ischemia/reperfusion-injury vs. volume loading step no. 4): cardiac output (l min) 1.68 (1.02-2.35) versus 2.84 (2.15-3.53), p = 0.002, mean arterial pressure (mmHg) 29.89 (21.65-38.12) versus 52.34 (43.55-61.14), p < 0.001, pulse pressure variation (%) 24.84 (17.45-32.22) versus 9.59 (1.68-17.49), p = 0.004, mean Flux (p.u.) 414.95 (295.18-534.72) versus 327.21 (206.95-447.48), p = 0.006. Receiver operating characteristic analysis revealed an area under the curve of 0.88 (CI 95% 0.73-1.00; p value < 0.001) for pulse pressure variation for predicting a decrease of microcirculatory blood flow. The results of our study show that pulse pressure variation does have the potential to predict decreases of intestinal microcirculatory blood flow due to volume-load after ischemia/reperfusion-injury. This should encourage further translational research and might help to prevent microcirculatory impairment due to excessive fluid resuscitation and to guide fluid therapy in the future.
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http://dx.doi.org/10.1038/s41598-021-88458-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8080713PMC
April 2021

Intraoperative impaired cerebrovascular autoregulation and delayed neurocognitive recovery after major oncologic surgery: a secondary analysis of pooled data.

J Clin Monit Comput 2021 Apr 15. Epub 2021 Apr 15.

Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.

Cerebral blood flow is tightly regulated by cerebrovascular autoregulation (CVA), and intraoperative impairment of CVA has been linked with perioperative neurocognitive disorders. We aim to assess whether impairment of CVA during major oncologic surgery is associated with delayed neurocognitive recovery (DNCR) postoperatively. We performed a secondary analysis of prospectively collected data. Patients were included if they had undergone complete pre- and postoperative neuropsychological assessments, continuous intraoperative measurement of CVA, and major oncologic surgery for visceral, urological, or gynecological cancer. Intraoperative CVA was measured using the time-correlation method based on near-infrared-spectroscopy, and DNCR was assessed with a neuropsychological test battery. A decline in cognitive function before hospital discharge compared with a preoperative baseline assessment was defined as DNCR. One hundred ninety-five patients were included in the analysis. The median age of the study population was 65 years (IQR: 60-68); 11 patients (5.6%) were female. Forty-one patients (21.0%) fulfilled the criteria for DNCR in the early postoperative period. We found a significant association between impaired intraoperative CVA and DNCR before hospital discharge (OR = 1.042 [95% CI: 1.005; 1.080], p = 0.028). The type of surgery (radical prostatectomy vs. other major oncologic surgery; OR = 0.269 [95% CI: 0.099; 0.728], p = 0.010) and premedication with midazolam (OR = 3.360 [95% CI: 1.039; 10.870], p = 0.043) were significantly associated with the occurrence of DNCR in the early postoperative period. Intraoperative impairment of CVA is associated with postoperative neurocognitive function early after oncologic surgery. Therefore, intraoperative monitoring of CVA may be a target for neuroprotective interventions. The initial studies were retrospectively registered with primary clinical trial registries recognized by the World Health Organization (ClinicalTrials.gov Identifiers: DRKS00010014, 21.03.2016 and NCT04101006, 24.07.2019).
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http://dx.doi.org/10.1007/s10877-021-00706-zDOI Listing
April 2021

Health-related quality of life and self-reported cognitive function in patients with delayed neurocognitive recovery after radical prostatectomy: a prospective follow-up study.

Health Qual Life Outcomes 2021 Feb 25;19(1):64. Epub 2021 Feb 25.

Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.

Background: Delayed neurocognitive recovery (DNCR) is a common and serious complication after radical prostatectomy. We hypothesized that patients with DNCR in the early postoperative period would report reduced health-related quality of life (HRQoL) and more cognitive failures 12 months after surgery, compared with patients without DNCR.

Methods: We performed a 12-month follow-up on 367 patients who had been enrolled in a prospective observational trial to study the incidence of DNCR after radical prostatectomy. Patients were screened for preoperative cognitive impairment and depression. We defined DNCR as a decline in cognitive function between days 3 and 5 after surgery, compared with baseline assessments. We evaluated HRQoL and cognitive failures 12 months after surgery with the 36-item Short Form Health Survey and the Cognitive Failures Questionnaire. General linear models were used to analyze associations of DNCR with HRQoL and cognitive failures.

Results: Delayed neurocognitive recovery in the early postoperative period was significantly associated with self-reported cognitive failures (B for no DNCR =  - 0.411 [95% CI: - 0.798;0.024], p = 0.038), but not with physical (B = 0.082 [95% CI: - 0.021;0.186], p = 0.118) or mental HRQoL (B =  - 0.044 [95% CI: - 0.149;0.062], p = 0.417) 12 months after surgery. Preoperative depression screening scores were significantly associated with self-reported cognitive failures and both physical and mental HRQoL 12 months after surgery.

Conclusions: Delayed neurocognitive recovery in the early period after radical prostatectomy has a long-term impact on patients' daily lives by impairing memory, attention, action, and perception. Therefore, prevention of DNCR must be a priority for physicians and researchers. Consequent preoperative screening for depressive symptoms may facilitate early psycho-oncological intervention to improve postoperative HRQoL. Trials registration DRKS00010014 , date of registration: 21.03.2016, retrospectively registered.
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http://dx.doi.org/10.1186/s12955-021-01705-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908756PMC
February 2021

Virtual reality as a teaching method for resuscitation training in undergraduate first year medical students: a randomized controlled trial.

Scand J Trauma Resusc Emerg Med 2021 Feb 1;29(1):27. Epub 2021 Feb 1.

Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Martini-Str. 52, 20246, Hamburg, Germany.

Background: Virtual reality is an innovative technology for medical education associated with high empirical realism. Therefore, this study compares a conventional cardiopulmonary resuscitation (CPR) training with a Virtual Reality (VR) training aiming to demonstrate: (a) non-inferiority of the VR intervention in respect of no flow time and (b) superiority in respect of subjective learning gain.

Methods: In this controlled randomized study first year, undergraduate students were allocated in the intervention group and the control group. Fifty-six participants were randomized to the intervention group and 104 participants to the control group. The intervention group received an individual 35-min VR Basic Life Support (BLS) course and a basic skill training. The control group took part in a "classic" BLS-course with a seminar and a basic skill training. The groups were compared in respect of no flow time in a final 3-min BLS examination (primary outcome) and their learning gain (secondary outcome) assessed with a comparative self-assessment (CSA) using a questionnaire at the beginning and the end of the course. Data analysis was performed with a general linear fixed effects model.

Results: The no flow time was significantly shorter in the control group (Mean values: control group 82 s vs. intervention group 93 s; p = 0.000). In the CSA participants of the intervention group had a higher learning gain in 6 out of 11 items of the questionnaire (p < 0.05).

Conclusion: A "classic" BLS-course with a seminar and training seems superior to VR in teaching technical skills. However, overall learning gain was higher with VR. Future BLS course-formats should consider the integration of VR technique into the classic CPR training or vice versa, to use the advantage of both teaching techniques.
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http://dx.doi.org/10.1186/s13049-021-00836-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851931PMC
February 2021

Ablation of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy: Treatment Strategy, Characteristics of Consecutive Atrial Tachycardia and Long-Term Outcome.

J Am Heart Assoc 2021 Feb 17;10(3):e017451. Epub 2021 Jan 17.

Department of Cardiology University Heart and Vascular Center HamburgUniversity Medical Center Hamburg-Eppendorf Hamburg Germany.

Background Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and is associated with a deterioration of clinical status. Ablation of symptomatic AF is an established therapy, but in HCM, the characteristics of recurrent atrial arrhythmias and the long-term outcome are uncertain. Methods and Results Sixty-five patients with HCM (aged 64.5±9.9 years, 42 [64.6%] men) underwent AF ablation. The ablation strategy included pulmonary vein isolation in all patients and ablation of complex fractionated atrial electrograms or subsequent atrial tachycardias (AT) if appropriate. Paroxysmal, persistent AF, and a primary AT was present in 13 (20.0%), 51 (78.5%), and 1 (1.5%) patients, respectively. Twenty-five (38.4%) patients developed AT with a total number of 54 ATs. Stable AT was observed in 15 (23.1%) and unstable AT in 10 (15.3%) patients. The mechanism was characterized as a macroreentry in 37 (68.5%), as a localized reentry in 12 (22.2%), a focal mechanism in 1 (1.9%), and not classified in 4 (7.4%) ATs. After 1.9±1.2 ablation procedures and a follow-up of 48.1±32.5 months, freedom of AF/AT recurrences was demonstrated in 60.0% of patients. No recurrences occurred in 84.6% and 52.9% of patients with paroxysmal and persistent AF, respectively (<0.01). Antiarrhythmic drug therapy was maintained in 24 (36.9%) patients. Conclusions AF ablation in patients with HCM is effective for long-term rhythm control, and especially patients with paroxysmal AF undergoing pulmonary vein isolation have a good clinical outcome. ATs after AF ablation are frequently observed in HCM. Freedom of atrial arrhythmia is achieved by persistent AF ablation in a reasonable number of patients even though the use of antiarrhythmic drug therapy remains high.
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http://dx.doi.org/10.1161/JAHA.120.017451DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955439PMC
February 2021

Real-Time Assessment of Spinal Cord Microperfusion in a Porcine Model of Ischemia/Reperfusion.

J Vis Exp 2020 12 10(166). Epub 2020 Dec 10.

Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf.

Spinal cord injury is a devastating complication of aortic repair. Despite developments for the prevention and treatment of spinal cord injury, its incidence is still considerably high and therefore, influences patient outcome. Microcirculation plays a key role in tissue perfusion and oxygen supply and is often dissociated from macrohemodynamics. Thus, direct evaluation of spinal cord microcirculation is essential for the development of microcirculation-targeted therapies and the evaluation of existing approaches in regard to spinal cord microcirculation. However, most of the methods do not provide real-time assessment of spinal cord microcirculation. The aim of this study is to describe a standardized protocol for real-time spinal cord microcirculatory evaluation using laser-Doppler needle probes directly inserted in the spinal cord. We used a porcine model of ischemia/reperfusion to induce deterioration of the spinal cord microcirculation. In addition, a fluorescent microsphere injection technique was used. Initially, animals were anesthetized and mechanically ventilated. Thereafter, laser-Doppler needle probe insertion was performed, followed by the placement of cerebrospinal fluid drainage. A median sternotomy was performed for exposure of the descending aorta to perform aortic cross-clamping. Ischemia/reperfusion was induced by supra-celiac aortic cross-clamping for a total of 48 min, followed by reperfusion and hemodynamic stabilization. Laser-Doppler Flux was performed in parallel with macrohemodynamic evaluation. In addition, automated cerebrospinal fluid drainage was used to maintain a stable cerebrospinal pressure. After completion of the protocol, animals were sacrificed, and the spinal cord was harvested for histopathological and microsphere analysis. The protocol reveals the feasibility of spinal cord microperfusion measurements using laser-Doppler probes and shows a marked decrease during ischemia as well as recovery after reperfusion. Results showed comparable behavior to fluorescent microsphere evaluation. In conclusion, this new protocol might provide a useful large animal model for future studies using real-time spinal cord microperfusion assessment in ischemia/reperfusion conditions.
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http://dx.doi.org/10.3791/62047DOI Listing
December 2020

Symptoms and probabilistic anatomical mapping of lacunar infarcts.

Neurol Res Pract 2020 3;2:21. Epub 2020 Aug 3.

Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.

Background: The anatomical distribution of acute lacunar infarcts has mainly been studied for supratentorial lesions. In addition, little is known about the association with distinct stroke symptoms, not summarized as classical lacunar syndromes. We aimed to describe the spatial lesion distribution of acute supra- and infratentorial lacunar infarcts and their association with stroke symptoms in patients eligible for thrombolysis.

Methods: All patients enrolled in the WAKE-UP trial (efficacy and safety of magnetic resonance imaging [MRI]-based thrombolysis in wake-up stroke) were screened for lacunar infarcts on diffusion-weighted imaging (DWI). The relationship between the anatomical distribution of supra- and infratentorial lacunar infarcts, their demographic characteristics and acute stroke symptoms, defined by the National Institutes of Health Stroke Scale (NIHSS) score, were correlated and compared.

Results: Maps of lesion distribution from 224 lacunar infarct patients (76 [33.9%] females, mean age [standard deviation] of 63.4 [11.5] years) were generated using computational image mapping methods. Median infarct volume was 0.73 ml (interquartile range [IQR] 0.37-1.15 ml). Median NIHSS sum score on hospital arrival was 4 (IQR 3-6). 165 (73.7%) patients had lacunar infarcts in the supratentorial deep white or grey matter, while 59 (26.3%) patients had infratentorial lacunar infarcts. Patients with supratentorial lacunar infarcts presented with a significantly lower occurrence of deficits in the NIHSS items gaze ( < 0.001) and dysarthria ( = 0.008), but had more often a paresis of the left arm ( = 0.009) and left leg ( = 0.068) compared to patients with infratentorial infarcts.

Conclusions: The anatomical lesion distribution of lacunar infarcts reveals a distinct pattern and supports an association of localization with different stroke symptoms.

Trial Registration: NCT01525290.
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http://dx.doi.org/10.1186/s42466-020-00068-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7650076PMC
August 2020

Nociception level-guided opioid administration in radical retropubic prostatectomy: a randomised controlled trial.

Br J Anaesth 2021 02 20;126(2):516-524. Epub 2020 Nov 20.

Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, Hamburg, Germany. Electronic address:

Background: This RCT investigated the effect of opioid titration by three different nociception monitoring devices or clinical signs during general anaesthesia.

Methods: Ninety-six patients undergoing radical retropubic prostatectomy with propofol/remifentanil anaesthesia were randomised into one of four groups to receive remifentanil guided by one of three nociception monitoring devices (surgical pleth index [SPI], pupillary pain index [PPI], or nociception level [NOL]) or by clinical judgement (control). Intraoperative remifentanil requirement was the primary endpoint, whereas recovery parameters and stress hormone levels were secondary endpoints.

Results: The mean [95% confidence interval {CI}] remifentanil administration rate differed between the groups: control 0.34 (0.32-0.37), SPI 0.46 (0.38-0.55), PPI 0.07 (0.06-0.08), and NOL 0.16 (0.12-0.21) μg kg min(P<0.001). Intraoperative cessation of remifentanil administration occurred in different numbers (%) of patients: control 0 (0%), SPI 1 (4.3%), PPI 18 (75.0%), and NOL 11 (47.8%); P=0.002. The area under the curve analyses indicated differences in cumulative cortisol levels (mg L min) amongst the groups: control 37.9 (33.3-43.1), SPI 38.6 (33.8-44.2), PPI 72.1 (63.1-82.3), and NOL 54.4 (47.6-62.1) (mean [95% CI]). Pairwise group comparison results were as follows: control vs SPI, P=0.830; control vs PPI, P<0.001; control vs NOL, P=0.001; SPI vs PPI, P<0.001; SPI vs NOL, P=0.002; and PPI vs NOL, P=0.009.

Conclusions: The nociception monitoring devices and clinical signs reflect the extent of nociception differently, leading to dissimilar doses of remifentanil. Very low remifentanil doses were associated with an increase and higher remifentanil doses were accompanied by a decrease in serum cortisol concentrations. Use of nociception monitoring devices for guiding intra-operative opioid dosing needs further validation.

Clinical Trial Registration: NCT03380949.
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http://dx.doi.org/10.1016/j.bja.2020.09.051DOI Listing
February 2021

Validation of quantitative assessment of indocyanine green fluorescent imaging in a one-vessel model.

PLoS One 2020 18;15(11):e0240188. Epub 2020 Nov 18.

Department of Vascular Medicine, University Heart Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Objectives: Evaluation of intestinal perfusion remains subjective and depends on the surgeon´s individual experience. Intraoperative quality assessment of tissue perfusion with indocyanine green (ICG) fluorescence using a near-infrared camera system has been described in different ways and for different indications. The aim of the present study was to evaluate fluorescent imaging (FI) in the quantitative assessment of intestinal perfusion in a gastric tube model in pigs and to compare the results to results obtained with florescent microspheres (FM), the gold standard for tissue perfusion.

Methods: Seven pigs (56.0±3.0 kg), both males and females, underwent gastric tube formation after transection and ligation of the gastric arteries, except the right gastroepiploic artery, to avoid collateral blood flow. After baseline assessment (T0), hypotension (T1) was induced by propofol (Karampinis et al 2017) (< 60 mmHg). Then, propofol was paused to obtain normotension (T2, Mean arterial pressure (MAP) 60-90 mmHg). Finally, hypertension (T3, MAP>90 mmHg) was induced by norepinephrine. Measurements were performed in three regions of interest (ROIs) under standardized conditions: the fundus (D1), corpus (D2), and prepyloric area (D3). Hemodynamic parameters and transit-time flow measurement (TTFM) in the right gastroepiploic artery were continuously assessed. FI, FM and the partial pressure of tissue oxygen (TpO2) were quantified in each ROI.

Results: The study protocol could successfully be performed during stable hemodynamics. Flow in the gastroepiploic artery measured by transit time flow measurement (TTFM) was related to hemodynamic changes between the measurements, indicating improved blood flow with increasing MAP. The distal part of the gastric tube (D1) showed significantly (p<0.05) impaired perfusion compared to the proximal parts D3 and D2 using FM. ICG-FI also showed the highest values in D3 and the lowest values in D1 at all hemodynamic levels (T1-T3; p<0,05).

Conclusion: Visual and quantitative assessment of gastric tube perfusion is feasible in an experimental setting using ICG-FI. This might be a promising tool for intraoperative assessment during visceral surgery in the future.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240188PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673564PMC
December 2020

Longitudinal Evaluation of Perineogenital Pain and Postoperative Complications After One-stage Buccal Mucosal Graft Urethroplasty: A Secondary Analysis of a Randomized Controlled Trial.

Eur Urol Focus 2020 Oct 14. Epub 2020 Oct 14.

Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. Electronic address:

Background: Little is known about patient-reported intensity and quality of pain at the receiver site as well as postoperative complications following one-stage buccal mucosal graft urethroplasty (BMGU).

Objective: To evaluate perineogenital pain intensity and quality as well as short-term complications after BMGU, and to describe the impact of pain and complications on stricture recurrence.

Design, Setting, And Participants: A secondary analysis of a randomized controlled trial including 135 patients, who underwent BMGU from 2014 to 2015, was performed.

Intervention: One-stage BMGU.

Outcome Measurements And Statistical Analysis: Patient-reported perineogenital pain was assessed by the Numeric Pain Rating Scale and the Short-form McGill Pain Questionnaire preoperatively and at 1, 5, and 21 d, and 3, 6, and 12 mo postoperatively. Complications were assessed by the Clavien-Dindo classification and the Comprehensive Complication Index. Pain and complications were compared according to stricture recurrence.

Results And Limitations: At a mean follow-up of 21±15 mo, 29 patients (21%) had stricture recurrence. Pain intensity as well as sensory and affective pain quality decreased over time, reaching a minimum at 6 mo. Postoperative complications at days 5 (95% of patients) and 21 (27% of patients) were predominantly "minor" (Clavien-Dindo classification grade≤IIIa). Neither patient-reported perineogenital pain nor cumulative morbidity burden was different between patients with and those without stricture recurrence (all p ≥ 0.05).

Conclusions: Perineogenital pain is frequent after BMGU, but pain intensity and quality decrease over time. The same holds true for postoperative complications, which are frequent but mostly present as minor events. Current findings allow for thorough preoperative patient counseling regarding the expected perineogenital pain intensity and quality over time as well as complications following BMGU.

Patient Summary: In this study, we looked at pain intensity and pain quality as well as complications following buccal mucosal graft urethroplasty. We found that pain in the perineogenital region is frequent, but pain intensity and quality decrease over time. Similarly, postoperative complications are frequent, but mainly present as minor events.
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http://dx.doi.org/10.1016/j.euf.2020.09.018DOI Listing
October 2020

TKA patients experience less improvement than THA patients at 3 and 12 months after surgery. A retrospective observational cohort study.

J Orthop 2020 Sep-Oct;21:517-522. Epub 2020 Sep 17.

Orthopaedic and Joint Replacement Department at the Schoen Clinic Hamburg Eilbek, Dehnhaide 120, D-22081, Hamburg, Germany.

Purpose: To investigate whether WOMAC scores changes after THA or TKA are gender and joint specific.

Methods: Retrospective cohort study. The data of 855 THA and 684 TKA patients were analyzed.

Results: Follow-up time (p < 0.001), gender (p < 0.001), joint (p < 0.001), and interaction FU by joint (p < 0.001) had significant effects on WOMAC total and sub-scores. Patients after TKA perceived less improvement in all dimensions in comparison to THA patients (p < 0.001).

Conclusion: WOMAC score changes after THA or TKA are joint-specific. Patients after TKA perceived less improvement. These results can be used to adjust patients' expectations.
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http://dx.doi.org/10.1016/j.jor.2020.09.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7511647PMC
September 2020

Ultrasound-guided ilioinguinal-iliohypogastric block (ILIHB) or perifocal wound infiltration (PWI) in children: a prospective randomized comparison of analgesia quality, a pilot study.

BMC Anesthesiol 2020 10 3;20(1):256. Epub 2020 Oct 3.

Department of Pediatric Anesthesiology, Altona Children's Hospital, Bleickenallee 38, 22763, Hamburg, Germany.

Background: Ilioinguinal-iliohypogastric block (ILIHB) is a well-established procedure for postoperative analgesia after open inguinal surgery in children. This procedure is effective and safe, especially when ultrasound is used. Data availability for comparing ultrasound-guided blocks versus wound infiltration is still weak. The study was designed to determine the efficacy of ultrasound-guided ILIHB (US-ILIHB) on postoperative pain control in pediatric patients following a inguinal daycase surgery, compared with perifocal wound infiltration (PWI) by the surgeon.

Methods: This randomized, double-blinded trail was conducted in pediatric patients aged from 6 months to 4 years. The total number of children included in the study was 103. Patients were allocated at random in two groups by sealed envelopes. The ILIHB group recieved 0,2% ropivacain for US-ILIHB after anesthesia induction. The PWI group recieved 0,2% ropivacain for PWI performed by a surgeon before wound closure. Parameters recorded included the postoperative pain score, pain frequency, time to first analgesics and consumption of analgesics.

Results: US-ILIHB significantly reduced the occurrence of pain within the first 24 h after surgery (7.7%, p = 0.01). Moreover, the pain-free interval until administration of the first dose of opioids was 21 min longer, on average (p = 0.003), following US-ILIHB compared to perifocal wound infiltration. 72% of children who received US-ILIHB did not require additional opioids, as compared to 56% of those who received PWI.

Conclusion: Thus our study demonstrates that US-ILIHB ensures better postoperative analgesia in children and should be prioritized over postoperative PWI.

Trail Registration: UIHBOPWIIC, DRKS00020987 . Registered 20 March 2020 - Retrospectivley registered.
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http://dx.doi.org/10.1186/s12871-020-01170-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532635PMC
October 2020

The value of CT imaging and CRP quotient for detection of postbariatric complications.

Langenbecks Arch Surg 2021 Feb 17;406(1):181-187. Epub 2020 Sep 17.

Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.

Background: The diagnosis of major complications seems to be more challenging in obese patients. We aimed to show the relevance of routinely assessed clinical and paraclinical parameters as well as the relevance of CT scans in the diagnosis of major complications after bariatric procedures.

Methods: All patients who underwent operations (primary or revisional) in a 3-year period were retrospectively studied after bariatric surgery with a specific focus on the routinely assessed clinical parameters (tachycardia, temperature), paraclinical parameters on postoperative day (POD) 1 and 3 (C-reactive protein (CRP), leukocytes), and additional computed tomography (CT) scan results for the diagnosis of leakage, bleeding, intraabdominal abscess, superficial abscess, and other complications.

Results: A total of 587 patients were examined. In this cohort, 73 CT scans were performed due to suspected intraabdominal or pulmonary complication according to our hospital standard operating procedure. In total, 14 patients (2.4%) had a major complication (Clavien-Dindo grade IV/V). Of those, 10 patients (1.7%) had postoperative leakage. While the correct leakage diagnosis was only found in 33% of the patients by CT scan, the overall specificity of CT as a diagnostic tool for all kinds of complications remained high. Especially for abscess detection, CT scan showed a sensitivity and specificity of 100%. Multivariate analysis showed a significantly higher risk of leakage development characterized by a doubling of postoperative CRP level (odds ratio 4.84 (95% confidence interval 2.01-11.66, p < 0.001)). To simplify the use of CRP as a predictive factor for the diagnosis of leakage, a cut-off value of 2.4 was determined for the CRP quotient (POD3/POD1) with a sensitivity of 0.88 and a specificity of 0.89.

Conclusion: CT diagnostic after bariatric surgery has a high positive predictive value, especially for intraabdominal abscess formation. Nevertheless, CT scan for the diagnosis of leakage has a low sensitivity. Thus, a negative CT scan does not exclude the presence of a leakage. Using the described CRP quotient with a cut-off of 2.4, the risk of early leakage can be easily estimated. Furthermore, in any uncertain case of clinically suspected leakage, diagnostic laparoscopy should be performed.
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http://dx.doi.org/10.1007/s00423-020-01986-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870754PMC
February 2021

Sex Disparities in the Self-Evaluation of Subthalamic Deep Brain Stimulation Effects on Mood and Personality in Parkinson's Disease Patients.

Front Neurol 2020 31;11:776. Epub 2020 Jul 31.

Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Changes in personality are one of the main concerns Parkinson's disease (PD) patients raise when facing the decision to undergo neurosurgery for deep brain stimulation (DBS) of the subthalamic nucleus (STN). While clinical instruments for monitoring functional changes following DBS surgery are well-established in the daily therapeutic routine, personality issues are far less systematically encompassed. Moreover, while sex disparities in the outcomes of STN-DBS therapy have been reported, little is known about the different effects that DBS treatment may have on mood and personality traits in female and male patients. To this aim, the effect of STN-DBS on personality traits was assessed in 46 PD patients (12 women and 34 men) by means of the Freiburg Personality Inventory. The Becks Depression Inventory (BDI-I) and the Parkinson's Disease Questionnaire were used to evaluate patients' level of depression and quality of life (QoL). Patients completed the questionnaires a few days before, within the first year, and 2 years after surgery. The 12 personality traits defined by the FPI-R questionnaire did not change significantly after STN-DBS surgery ( = 0.198). Women declared higher depression scores through all study stages ( = 0.009), but also showed a stronger QoL amelioration after surgery than male patients ( = 0.022). The BDI-I scores of female patients clearly correlated with their levodopa equivalent daily dose (LEDD; = 0.621, = 0.008). Remarkably, in both male and female patients, higher pre-operative LEDDs were related to worse post-operative QoL scores ( = 0.034). These results mitigate the concerns about systematic personality changes due to STN-DBS treatment in PD patients and encourage an early DBS approach, before severe levodopa-induced sequelae may irreparably compromise the patients' QoL. In the future, more focus should lie on sex-related effects, since female patients seem to profit more than male patients from STN-DBS, in terms of reduced depressive symptoms associated with a reduction of the LEDD and amelioration of QoL. These aspects may help to redress the sex imbalance in PD patients treated with DBS, given that women are still strongly under-represented.
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http://dx.doi.org/10.3389/fneur.2020.00776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7412792PMC
July 2020

Cardiovascular dynamics during peroral endoscopic myotomy for esophageal achalasia: a prospective observational study using non-invasive finger cuff-derived pulse wave analysis.

J Clin Monit Comput 2020 Jun 5. Epub 2020 Jun 5.

Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medicine Rostock, Schillingallee 35, 18057, Rostock, Germany.

Peroral endoscopic myotomy (POEM) is natural orifice transluminal endoscopic surgery to treat esophageal achalasia. During POEM, cardiovascular dynamics can be impaired by capnoperitoneum, capnomediastinum, and systemic carbon dioxide accumulation. We systematically investigated changes in cardiovascular dynamics during POEM. We included 31 patients having POEM in this single-center prospective observational study. Before and every 5 min during POEM we measured mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), stroke volume index (SVI), and systemic vascular resistance index (SVRI) using non-invasive finger cuff-derived pulse wave analysis. During POEM, the median MAP was higher than the median baseline MAP of 77 (67;86) mmHg. HR (median at baseline: 67 (60;72) bpm), CI (2.8 (2.5;3.2) L/min/m), SVI (42 (34;51) mL/m), and SVRI (1994 (1652; 2559) dyn × s × cm × m) remained stable during POEM. Mixed model-derived 95% confidence limits of hemodynamic variables during POEM were 72 to 106 mmHg for MAP, 65 to 79 bpm for HR, 2.7 to 3.3 L/min/m for CI, 37 and 46 mL/m for SVI, and 1856 and 2954 dyn × s × cm × m for SVRI. POEM is a safe procedure with regard to cardiovascular dynamics as it does not markedly impair MAP, HR, CI, SVI, or SVRI.
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http://dx.doi.org/10.1007/s10877-020-00541-8DOI Listing
June 2020

Burnout is associated with work-family conflict and gratification crisis among German resident physicians.

BMC Med Educ 2020 May 8;20(1):145. Epub 2020 May 8.

Institute and Polyclinic of Primary Medical Care, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.

Background: Studies investigating the longitudinal predictive value of burnout on both effort-reward imbalance (within the working place) and work-family conflict (between work and private life) in residents are lacking. Former cross-sectional studies showed an association of effort-reward imbalance and work family conflict with an elevated burnout risk in physicians.

Methods: Data acquisition was carried out within the multi-centric, longitudinal, and prospective "KarMed" study in Germany from 2009 until 2016. Yearly surveys including validated scales: the Maslach Burnout Inventory with its three subscales (emotional exhaustion, personal accomplishment, depersonalisation), the Work-Family Conflict Scale, and the Effort-Reward Imbalance Inventory. Further independent variables were gender and parental status.The analyses were based on general linear models and general linear mixed models with repeated measures designs.

Results: Significant time-fixed effects were found for all three subscales of the Maslach Burnout Inventory, with gender effects on the subscales emotional exhaustion and depersonalisation. The parental status had no significant effect on burnout. All estimated means for burnout during 6 years of post-graduate training were higher when work-family conflict and gratification crisis were taken into account. Personal accomplishment increased continuously over time as well showing neither gender differences nor influences by the parental status.

Conclusions: Personal accomplishments might act as a buffer compensating to some extent for the physicians' stress experience. Given that burnout may be associated with poor patient care, there is a need to reduce burnout rates and their associated factors in resident physicians.
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http://dx.doi.org/10.1186/s12909-020-02061-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206716PMC
May 2020

Circulating Endothelial Cells as Promising Biomarkers in the Differential Diagnosis of Primary Angiitis of the Central Nervous System.

Front Neurol 2020 31;11:205. Epub 2020 Mar 31.

Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Diagnosis of primary angiitis of the central nervous system (PACNS) and discrimination of PACNS from its mimics, e. g., reversible cerebral vasoconstriction syndrome (RCVS) or moyamoya disease (MMD) as non-inflammatory vasculopathies, still remain challenging. Circulating endothelial cells (CEC) are well-established markers for endothelial damage and potential biomarkers in PACNS. This study aimed to investigate if CECs may also help to distinguish an active PACNS from its important differentials (RCVS, MMD). CECs were assessed in 47 subjects. Twenty-seven patients with PACNS were included, seven with an active disease (aPACNS), 20 in remission (rPACNS). Seven patients with RCVS/MMD were analyzed. Thirteen healthy subjects served as controls (HC). CECs were measured by immunomagnetic isolation from peripheral venous blood. Mann-Whitney--Tests were applied for between-group comparisons. The Benjamini-Hochberg-procedure was applied to adjust for multiple comparisons. In aPACNS, CECs were significantly elevated compared to HC (480 vs. 40 CEC/ml, < 0.001) and rPACNS (54 CEC/ml, < 0.001). RCVS/MMD patients showed higher CEC levels (288 CEC/ml) than HC ( < 0.001), but lower than those in aPACNS ( = 0.017). An adjustment for multiple comparisons confirmed prior significant differences. An increased CEC value (cut-off 294 CEC/ml) is indicative for an active PACNS [sensitivity 100%, 95% confidence interval (CI) 63-100%; specificity 93%, CI 81-98%]. CECs may serve as biomarkers for diagnosis, treatment monitoring, and also for differential diagnosis of PACNS. CECs seem to be a marker of endothelial injury with higher levels in inflammatory than non-inflammatory vasculopathies. Larger patient samples are required to corroborate these findings.
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http://dx.doi.org/10.3389/fneur.2020.00205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7137900PMC
March 2020

Nanobody-based CD38-specific heavy chain antibodies induce killing of multiple myeloma and other hematological malignancies.

Theranostics 2020 3;10(6):2645-2658. Epub 2020 Feb 3.

Department of Diagnostic and Interventional Radiology and Nuclear medicine, University Medical Center, Hamburg-Eppendorf, Germany.

: CD38 is a target for the therapy of multiple myeloma (MM) with monoclonal antibodies such as daratumumab and isatuximab. Since MM patients exhibit a high rate of relapse, the development of new biologics targeting alternative CD38 epitopes is desirable. The discovery of single-domain antibodies (nanobodies) has opened the way for a new generation of antitumor therapeutics. We report the generation of nanobody-based humanized IgG1 heavy chain antibodies (hcAbs) with a high specificity and affinity that recognize three different and non-overlapping epitopes of CD38 and compare their cytotoxicity against CD38-expressing hematological cancer cells , . : We generated three humanized hcAbs (WF211-hcAb, MU1067-hcAb, JK36-hcAb) that recognize three different non-overlapping epitopes (E1, E2, E3) of CD38 by fusion of llama-derived nanobodies to the hinge- and Fc-domains of human IgG1. WF211-hcAb shares the binding epitope E1 with daratumumab. We compared the capacity of these CD38-specific hcAbs and daratumumab to induce CDC and ADCC in CD38-expressing tumor cell lines and in patient MM cells as well as effects on xenograft tumor growth and survival . : CD38-specific heavy chain antibodies (WF211-hcAb, MU1067-hcAb, JK36-hcAb) potently induced antibody-dependent cellular cytotoxicity (ADCC) in CD38-expressing tumor cell lines and in primary patient MM cells, but only little if any complement-dependent cytotoxicity (CDC). CD38-specific heavy chain antibodies significantly reduced the growth of systemic lymphomas and prolonged survival of tumor bearing SCID mice. : CD38-specific nanobody-based humanized IgG1 heavy chain antibodies mediate cytotoxicity against CD38-expressing hematological cancer cells , . These promising results of our study indicate that CD38-specific hcAbs warrant further clinical development as therapeutics for multiple myeloma and other hematological malignancies.
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http://dx.doi.org/10.7150/thno.38533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7052896PMC
February 2020

Stroke patients treated by thrombectomy in real life differ from cohorts of the clinical trials: a prospective observational study.

BMC Neurol 2020 Mar 5;20(1):81. Epub 2020 Mar 5.

Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.

Background: Randomized controlled trials (RCTs) demonstrated efficacy and safety of endovascular treatment (ET) in anterior circulation large vessel occlusions (LVO). We aimed at investigating how stroke patients treated by thrombectomy in clinical practice and their outcome compare to cohorts and results of thrombectomy trials.

Methods: In a prospective study, we consecutively included stroke patients treated by thrombectomy (2015-2017). Baseline characteristics, procedural and outcome data were analyzed. Outcome was assessed by modified Rankin Scale (mRS) at 90 days. Ordinal regression analysis was performed to identify predictors of outcome.

Results: Thrombectomy was applied in 264 patients (median 75 years, 49.6% female). Median baseline National Institutes of Health Stroke Scale (NIHSS) was 16, 58.0% received concomitant intravenous thrombolysis, 62.1% were referred from external hospitals. Median Alberta Stroke Program Early CT Score (ASPECTS) was 7. Successful recanalization (modified Thrombolysis in Cerebral Infarction Score, mTICI 2b/3) was achieved in 72.0%. Symptomatic intracranial hemorrhage (sICH) occurred in 4.5%. Independent outcome (mRS 0-2) was achieved in 26.2%, poor outcome (mRS 5-6) in 49.2%. Only 33.5% met the stringent enrolment criteria of previous RCTs. Lower age, baseline NIHSS, pre-stroke mRS, higher ASPECTS, and successful recanalization were independent predictors of favourable outcome.

Conclusions: The majority of stroke patients treated by ET in clinical practice would not have qualified for randomization in prior RCTs. Outcome in real-life patient cohorts is worse than in the highly selected cohorts from randomized trials, while rates of successful recanalization, sICH and outcome predictors are the same. Our findings support ET in broader patient populations than in the RCTs and may improve treatment decision in individual stroke patients with LVO in clinical practice.
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http://dx.doi.org/10.1186/s12883-020-01653-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059360PMC
March 2020

Predictors of independent outcome of thrombectomy in stroke patients with large baseline infarcts in clinical practice: a multicenter analysis.

J Neurointerv Surg 2020 Nov 27;12(11):1064-1068. Epub 2020 Feb 27.

Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Objective: To analyze outcome and its predictors after endovascular treatment (ET) in stroke patients suffering from large vessel occlusion with large pre-treatment infarct cores defined by an Alberta Stroke Program Early CT Score (ASPECTS) <6.

Methods: We analyzed data from an industry-independent, multicenter, prospective registry (German Stroke Registry - Endovascular Treatment) which enrolled consecutive patients treated by ET (June 2015-April 2018) with different devices. Multivariate logistic regression analyses identified predictors of independent outcome (IO) defined as a modified Rankin Scale (mRS) 0-2, and mortality at 90 days in patients with ASPECTS <6.

Results: Of 1700 patients included in the analysis, 152 (8.9%) had a baseline ASPECTS <6. Of these, 33 patients (21.6%) achieved IO, and 68 (44.7%) were dead at 90 days. A lower age, lower baseline National Institutes of Health Stroke Scale (NIHSS) score, and successful recanalization (defined as modified Thrombolysis in Cerebral Infarction Score, mTICI 2b/3) were predictors of IO. Successful recanalization had the strongest association with IO (OR 7.0, 95% CI 1.8 to 26.8). Pre-treatment parameters predicting IO were age <70 years (sensitivity 0.79, specificity 0.69) and NIHSS <12 (0.57 and 0.94). A higher age, a pre-stroke mRS score >1, and failed recanalization were predictors of death.

Conclusions: A substantial proportion of stroke patients with an ASPECTS <6 can achieve independence after thrombectomy, in particular, if they are younger, have only moderate baseline stroke symptoms, and no relevant pre-stroke disability. These results may encourage considering thrombectomy in low ASPECTS patients in clinical practice until randomized trials are available.
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http://dx.doi.org/10.1136/neurintsurg-2019-015641DOI Listing
November 2020

Regulation of I and force by PDEs in human-induced pluripotent stem cell-derived cardiomyocytes.

Br J Pharmacol 2020 07 31;177(13):3036-3045. Epub 2020 Mar 31.

Department of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background And Purpose: Phosphodiesterases (PDEs) are important regulators of β-adrenoceptor signalling in the heart. While PDE4 is the most important isoform that regulates I and force in rodent cardiomyocytes, the dominant isoform in adult human cardiomyocytes is PDE3.

Experimental Approach: Given the potential of human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) for biomedical research, this study characterized the contribution of PDE3 and PDE4 isoforms to the regulation of I and force in hiPSC-CMs in an engineered heart tissue (EHT) model.

Key Results: There was a lower abundance of mRNA for PDE3A and 4A in hiPSC-CM EHT than in non-failing human heart samples. Selective inhibition of PDE3 and 4 with cilostamide and rolipram, respectively, showed that, in hiPSC-CM, PDE4 was the predominant isoform for the regulation of I (cilostamide: +1.44-fold; rolipram: +1.77-fold) Furthermore, in contrast to cilostamide, rolipram decreased the EC of isoprenaline about 15-fold.

Conclusion And Implications: The predominance of PDE4 over PDE3 is a peculiarity of hiPSC-CMs and is probably an indicator of immaturity. This finding has implications for the use of hiPSC-CM as pharmacological models to investigate and assess the effects of PDE inhibitors.
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http://dx.doi.org/10.1111/bph.15032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7279982PMC
July 2020

[Burnout and Gratification Crises in Female and Male Physicians during Postgraduate Medical Education in Germany - A Longitudinal Study].

Psychother Psychosom Med Psychol 2020 Aug 17;70(8):319-329. Epub 2020 Jan 17.

Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf.

Several studies have demonstrated high work related stress and burnout symptoms in physicians. The study examined the longitudinal relationships of burnout and gratification crisis during 6 years of postgraduate medical education, controlled for gender and parental status. Data acquisition was carried out within the KarMed-study. Administered were the Maslach Burnout Inventory (MBI-HSS (MP)) (MBI) and the Effort-Reward-Imbalance (ERI). The analyses focused on general linear models and general linear mixed models with repeated measure designs. The amount of burnout perceived at the beginning of the postgraduate medical education is highly associated with the perceived amount of burnout at the end. Gratification crisis were significant for one subscale of the MBI (emotional exhaustion), yet not for personal accomplishment nor depersonalization. Significant time effects were found on all 3 subscales of the MBI, with gender effects on the subscales emotional exaustion and depersonalization. Having kids did not have significant effects, controlled for all measurement points of burnout as well as for gratification crisis. Theoretical implications and practical consequences for doctors, as well as the limitations of the study, are discussed.
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http://dx.doi.org/10.1055/a-1068-9843DOI Listing
August 2020

Effect of hemodialysis on impedance cardiography (electrical velocimetry) parameters in children.

Pediatr Nephrol 2020 04 14;35(4):669-676. Epub 2019 Dec 14.

Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background: Pediatric hemodialysis (HD) patients have a high incidence of cardiovascular morbidity and mortality. The study aim was to investigate whether impedance cardiography (electrical velocimetry, EV) is suitable as a hemodynamic trend monitoring tool in pediatric patients during HD.

Methods: Measurements by EV were obtained before, during, and after HD in a prospective single-center pediatric observational study. In total, 54 dialysis cycles in four different pediatric patients with end-stage kidney disease on chronic HD were included. EV parameters analyzed were heart rate (HR), stroke volume (SV), stroke volume index (SI), cardiac output (CO), cardiac index (CI), thoracic fluid content (TFC), index of contractility (ICON), stroke volume variation (SVV), variation of ICON (VIC), R-R interval (TRR), pre-ejection period (PEP), left ventricular ejection time (LVET), and systolic time ration (STR). Systemic vascular resistance index (SVRI) was calculated.

Results: EV did measure significant changes in cardiovascular parameters associated with HD. The following parameters increased after HD: HR (9%), SVV (19%), VIC (33%), PEP (8%), and STR (18%). A decrease after HD was measured in SV (18%), SI (18%), CO (10%), CI (10%), TFC (10%), ICON (7%), TRR (7%), LVET (8%), and LVET (8%). SVRI was not affected by HD. The changes were correlated to ultrafiltration. HD cycles without fluid withdrawal also altered cardiovascular parameters.

Conclusions: Pediatric HD with and without fluid withdrawal changes hemodynamic EV monitoring parameters. Possibly EV may be useful to optimize HD management in pediatric patients.
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http://dx.doi.org/10.1007/s00467-019-04409-1DOI Listing
April 2020

[Predictors of Utilization of Cardiovascular and Respiratory Emergency Department Visits - what Impact does the Environment have?]

Gesundheitswesen 2021 Feb 15;83(2):105-113. Epub 2019 Oct 15.

Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Hamburg.

Aim: There has been an increasing number of emergency department (ED) visits recently. It is unclear whether, in addition to a shift in services from the outpatient to the inpatient sector, other causes, (e. g. environmental factors), play a role. The aim was to investigate associations between the number of cardiovascular and respiratory ED visits and environmental variables.

Methods: Highly correlated environmental data were subjected to a principal component analysis. By using cross-correlation functions, environmental variables with time lags that showed the highest correlation with the number of ED visits were taken into consideration in the UNIANOVA analysis model, together with, among others, the day of the week and interaction terms.

Results: The final regression model explained 47% of the variation in respiratory ED visits demonstrating main effects for Mondays (B=10.69; p<0.001). Season showed significant effects with highest ED visits in autumn. No direct associations between environmental variables and number of respiratory ED visits were found. The results for the cardiovascular outcome were less expressive (R=0.20). Again, the day of the week had the main effect on cardiovascular ED visits (p<0.001).

Conclusions: The results suggest that weekdays had the main effect on ED visits. In future, we will collect and analyze environmental data at the micro level to achieve a higher model quality and better interpretability.
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http://dx.doi.org/10.1055/a-1005-7161DOI Listing
February 2021

Guiding Opioid Administration by 3 Different Analgesia Nociception Monitoring Indices During General Anesthesia Alters Intraoperative Sufentanil Consumption and Stress Hormone Release: A Randomized Controlled Pilot Study.

Anesth Analg 2020 05;130(5):1264-1273

From the Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background: This pilot study investigated the effect of sufentanil titration by 3 different analgesia monitoring devices or clinical signs during general anesthesia.

Methods: Forty-eight patients undergoing radical retropubic prostatectomy with sevoflurane/sufentanil anesthesia were randomly assigned into 4 groups and received sufentanil guided either by 1 of 3 analgesia monitoring devices (Surgical Pleth Index [SPI], Pupillary Pain Index [PPI], Nociception Level [NoL]) or by clinical judgment (control). The primary end point was intraoperative sufentanil consumption. Adrenocorticotropic hormone (ACTH) and cortisol were measured at 4 time points during the day of surgery. Data were analyzed by Kruskal-Wallis and Mann-Whitney U tests and by mixed model and area under the curve (AUC) analyses for group comparisons and time effects of stress hormones.

Results: The total amount of sufentanil administration (μg·kg·minute·10) differed between the groups (median [quartiles]: control = 5.6 [4.4-6.4], SPI = 7.2 [4.8-8.4], PPI = 2.0 [1.8-2.9], NoL = 3.8 [3.3-5.1]; PPI versus SPI, -5.1 [-6.6 to -1.3], P < .001; NoL versus SPI, -3.0 [-5.2 to 0.2], P = .024; control versus SPI, -1.6 [-3.7 to 1.7], P = .128; NoL versus PPI, 1.7 [0.6-3.4], P < .001; control versus PPI, 3.4 [2.0-4.6], P < .001; control versus NoL, 1.6 [-0.2 to 3.3], P = .017) (Hodges-Lehmann estimator [99% confidence interval {CI}], P values). The AUC analysis indicated differences among groups in cumulative ACTH levels (ng·liter·minute, natural logarithm (ln)-transformed data) of NoL versus PPI (-1.079 [-1.950 to -0.208], P = .001) and PPI versus SPI (1.192 [0.317-2.068], P= .001), as well as differences in cortisol levels (µg·liter·minute) for PPI versus SPI (46,710 [21,145-72,274], P < .001), NoL versus SPI (27,645 [3163-52,126], P = .003), and control versus SPI (31,824 [6974-56,675], P = .001) (differences in means [99% CI], P value). Secondary end points (postoperative recovery, pain level, and analgesia medication) showed no differences.

Conclusions: The type of analgesia nociception monitoring affected the total amount of sufentanil administered. Lower sufentanil doses in the PPI group were associated with an increased endocrine stress response. Titration by SPI caused no opioid reduction compared to the control but was associated with a reduced endocrine stress response.
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http://dx.doi.org/10.1213/ANE.0000000000004388DOI Listing
May 2020

Factors affecting dental DNA in various real post-mortem conditions.

Int J Legal Med 2019 Nov 11;133(6):1751-1759. Epub 2019 Sep 11.

Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Butenfeld 34, 22529, Hamburg, Germany.

Post-mortem DNA degradation is still the real challenge of DNA-based identification in forensic practise. It is a complicated multifactorial process occurring as a result of the combination of several different environmental effects along with the crucial effect of the elapsed post-mortem interval (PMI). The main purpose of the present study is to evaluate the effect of ante- and post-mortem factors on dental DNA in real forensic cases. Ninety-five teeth extracted from 39 corpses, whose bodies were subject to 6 different post-mortem conditions, were used to evaluate dental DNA amount. In total, 179 DNA extracts isolated from the root of the teeth were examined after removing the crown and sectioning each root into apical and cervical portions. DNA concentration was measured using real-time polymerase chain reaction DNA quantitation kit (PowerQuant™ System/Promega). Our results indicate that the post-mortem interval (PMI) is the most important influential factor on dental DNA quantification (p < 0.001). However, in the actual data set, it was confounded with several ante- and post-mortem factors, rendering its actual net effect difficult. The time period of the first 10 days after death yielded the best DNA results from all analysed dental samples. Afterwards, a dramatic decrease in dental DNA was observed in the following time period. Teeth extracted from burnt and fresh corpses yielded the highest amount of DNA, while skeletonized exhumed corpses resulted in the lowest DNA amount. Indeed, dry and indoor conditions demonstrated better results than those in water, outdoors, or buried in the ground. On the other hand, ante-mortem factors including sex, age, tooth type, and tooth root portions did not reveal significant effect on dental DNA yield. We suggest that ante-mortem factors are considerably more subjected to individual variations. Post-mortem factors including PMI, post-mortem conditions, and the relevant surrounding environments have substantial influence on the dental DNA amount yielded.
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http://dx.doi.org/10.1007/s00414-019-02151-9DOI Listing
November 2019

Role of phospholipase A2 receptor 1 antibody level at diagnosis for long-term renal outcome in membranous nephropathy.

PLoS One 2019 9;14(9):e0221293. Epub 2019 Sep 9.

III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background: Membranous nephropathy (MN) is an autoimmune disease induced by circulating antibodies against the podocyte protein phospholipase A2 receptor 1 (PLA2R1-ab) in 80% of patients and represents the leading cause of nephrotic syndrome in adults. PLA2R1-ab levels correlate with disease activity and treatment response. However, their predictive role for long-term renal outcome is not clear.

Methods: The aim of this prospective observational multicenter study was to investigate the predictive role of PLA2R1-ab levels at the time of diagnosis for long-term outcome in a cohort of 243 patients with newly diagnosed biopsy-proven PLA2R1-associated MN. Statistical analyses included Cox proportional hazard models. The primary study endpoint was defined prior to data collection as doubling of serum creatinine or development of end-stage renal disease.

Results: During the median follow-up time of 48 months, 36 (15%) patients reached the study endpoint. Independent predictors for reaching the study endpoint were baseline PLA2R1-ab levels (HR = 1.36, 95%CI 1.11-1.66, p = 0.01), percentage of tubular atrophy and interstitial fibrosis (HR = 1.32, 95%CI 1.03-1.68, p = 0.03), PLA2R1-ab relapse during follow-up (HR = 3.22, 95%CI 1.36-7.60, p = 0.01), and relapse of proteinuria (HR = 2.60, 95%CI 1.17-5.79, p = 0.02). Fifty-four (22%) patients received no immunosuppressive treatment during the study, in 41 (76%) of them PLA2R1-ab spontaneously disappeared during follow-up, 29 (54%) patients had a complete remission of proteinuria, and 19 (35%) had a partial remission. Patients not treated with immunosuppression were more often females and had lower PLA2R1-ab levels, proteinuria, and serum creatinine at baseline compared to patients receiving immunosuppression. However, no conclusion on the efficacy of immunosuppressive therapies can be made, since this was not a randomized controlled study and treatment decisions were not made per-protocol.

Conclusions: PLA2R1-ab levels are, in addition to pre-existing renal damage, predictive factors for long-term outcome and should therefore be considered when deciding the treatment of patients with MN.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221293PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733455PMC
March 2020

Cortical thickness and cognitive performance in asymptomatic unilateral carotid artery stenosis.

BMC Cardiovasc Disord 2019 06 25;19(1):154. Epub 2019 Jun 25.

Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Background: We investigated changes of cortical thickness and its association with cognitive performance in patients with high-grade carotid artery stenosis without ischemic brain lesions.

Methods: We studied 25 patients with unilateral carotid artery stenosis ≥50% and 25 age-matched controls. All subjects underwent T1-weighted MRI, and cortical thickness was measured in 33 regions of interest in each hemisphere, as well as in brain regions belonging to the vascular territory of the middle cerebral artery (MCA). General linear mixed models were fitted to the dependent variable cortical thickness. Cognitive assessment comprised the Stroop Test and Trail Making Test B.

Results: In the linear mixed model, presence of carotid stenosis had no effect on cortical thickness. There was a significant interaction of stenosis and region with a trend towards lower cortical thickness in the MCA region on the side of carotid stenosis. Patients with carotid stenosis performed significantly worse on the Stroop test than controls, but there was no correlation with cortical thickness.

Conclusion: In patients with carotid stenosis without ischemic brain lesions, neither a clear pattern of reduced cortical thickness nor an association of cortical thickness with cognitive function was observed. Our data do not support the hypothesized association of cortical thinning and cognitive impairment in carotid stenosis.
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http://dx.doi.org/10.1186/s12872-019-1127-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593546PMC
June 2019

(Don't) Look at Me! How the Assumed Consensual or Non-Consensual Distribution Affects Perception and Evaluation of Sexting Images.

J Clin Med 2019 May 17;8(5). Epub 2019 May 17.

Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany.

The non-consensual sharing of an intimate image is a serious breach of a person's right to privacy and can lead to severe psychosocial consequences. However, little research has been conducted on the reasons for consuming intimate pictures that have been shared non-consensually. This study aims to investigate how the supposed consensual or non-consensual distribution of sexting images affects the perception and evaluation of these images. Participants were randomly assigned to one of two groups. The same intimate images were shown to all participants. However, one group assumed that the photos were shared voluntarily, whereas the other group were told that the photos were distributed non-consensually. While the participants completed several tasks such as rating the sexual attractiveness of the depicted person, their eye-movements were being tracked. The results from this study show that viewing behavior and the evaluation of sexting images are influenced by the supposed way of distribution. In line with objectification theory men who assumed that the pictures were distributed non-consensually spent more time looking at the body of the depicted person. This so-called 'objectifying gaze' was also more pronounced in participants with higher tendencies to accept myths about sexual aggression or general tendencies to objectify others. In conclusion, these results suggest that prevention campaigns promoting 'sexting abstinence' and thus attributing responsibility for non-consensual distribution of such images to the depicted persons are insufficient. Rather, it is necessary to emphasize the illegitimacy of the non-consensual distribution of sexting images, especially among male consumers of the material.
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http://dx.doi.org/10.3390/jcm8050706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6572565PMC
May 2019