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BACKGROUND: A good safety culture may be predominantly defined by an open and unsanctioned communication about critical and erroneous courses. In an effort to improve patient safety various instruments, such as the critical incident reporting system (CIRS) or in terms of patient handover, the use of the situation, background, assessment, recommendation (SBAR) system patient handover, have been developed and are recommended by the German Society of Anaesthesiology and Intensive Care Medicine (DGAI). This study aimed at identifying how anesthesiologists perceive the safety culture in their current department and whether CIRS or SBAR are already established or not. MATERIAL AND METHODS: All registered members of the DGAI and the Professional Association of German Anaesthesiologists (BDA, n = 19,042) were invited to participate in an online survey on patient safety. In this survey there was a focus on the perceived safety culture and the experience with CIRS and SBAR. RESULTS: Of the participants 76.6% (n = 1372) stated that their department of anesthesiology has a good safety culture, while in 23.4% (n = 419) there was not. For the whole hospital the safety culture was only rated as being positive by 54.3% (n = 949) of the respondents. An open communication about critical and erroneous courses occurred in 76.5% (n = 1375) according to the participants, 23.0% (n = 408) had the impression that in the case of errors the respective person was being denounced. In one third of the participants' departments (n = 630, 36.6%) there were no morbidity and mortality conferences. The acronym CIRS was familiar to 98.9% (n = 1801) of the participants, 84.8% (n = 1544) of the surveyed anesthesiologists reported that CIRS was established in their departments. Critical incidents have been reported via CIRS by 54.4% (n = 839) of the respondents. Only 29.4% (n = 462) of the participants received regular feedback on CIRS reports. The acronym SBAR as a handover tool is unknown to the majority of the surveyed participants (n = 1181, 63.7%) and 86.1% (n = 1554) consider using an instrument in order to improve handover quality as possibly being beneficial. CONCLUSION: Anesthesiologists rate the quality of the safety culture of their own anesthesiology department to be higher compared to their hospital in general. In some hospitals there is denouncement in cases of erroneous courses according to the respondents. In the patients' point of view morbidity and mortality conferences should be established more often. CIRS is known to almost every surveyed anesthetist but feedback on a regular basis is sparse. This contradicts the claims of the German Coalition for Patient Safety. The acronym SBAR is unknown to the majority of surveyed participants despite the recommendation of the DGAI to implement it. There is a wish for tools in order to enhance the quality of handovers.

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BACKGROUND: The purpose of this study was to evaluate the impact of continuous lateral rotational therapy (CLRT) on respiratory complications and mortality in patients suffering from trauma. METHODS: The literature databases PubMed®/Medline® and the Cochrane Library® were systematically searched for prospective controlled trials comparing continuous lateral rotational therapy to conventional manual positioning in trauma patients. RESULTS: A total of 8 publications (n= 422 patients) with comparable age and injury severity were included in the meta-analysis. A significant reduction in the incidence of nosocomial pneumonia (OR: 0.33, [95%CI: 0.17, 0.65], p=0.001) was observed in patients treated prophylactically with continuous lateral rotational therapy. When used with therapeutic intention, CLRT had no impact on the incidence of pneumonia. There were no significant differences in mortality, duration of mechanical ventilation, or ICU length of stay. CONCLUSIONS: Analogous to studies evaluating CLRT in medical or mixed patient collectives, CLRT reduced the rates of nosocomial pneumonia in trauma patients. This, however, had no impact on overall mortality. The level of evidence of the studies included was limited by several factors. An adequately powered, well-designed multi-centre randomised controlled trial is required, to validly assess the utility of CLRT for the prevention and treatment of pulmonary complications in patients suffering from trauma. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

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Knowledge about placebo mechanisms in patients with chronic pain is scarce. Fibromyalgia syndrome (FM) is associated with dysfunctions of central pain inhibition, and because placebo analgesia entails activation of endogenous pain inhibition, we hypothesized that long-term exposure to FM pain would negatively affect placebo responses. In our study we examined the placebo group (n = 37, mean age 45 years) from a 12-week, randomized, double-blind, placebo-controlled trial investigating the effects of milnacipran or placebo. Twenty-two patients were classified as placebo nonresponders and 15 as responders, according to the Patient Global Impression of Change scale. Primary outcome was the change in pressure pain sensitivity from baseline to post-treatment. Secondary outcomes included ratings of clinical pain (visual analog scale), FM effect (Fibromyalgia Impact Questionnaire), and pain drawing. Among placebo responders, longer FM duration was associated with smaller reductions in pressure pain sensitivity (r = .689, P = .004), but not among nonresponders (r = -.348, P = .112). In our study we showed that FM duration influences endogenous pain regulation, because pain levels and placebo-induced analgesia were negatively affected. Our results point to the importance of early FM interventions, because endogenous pain regulation may still be harnessed at that early time. Also, placebo-controlled trials should take FM duration into consideration when interpreting results. PERSPECTIVE: This study presents a novel perspective on placebo analgesia, because placebo responses among patients with chronic pain were analyzed. Long-term exposure to fibromyalgia pain was associated with lower placebo analgesia, and the results show the importance of taking pain duration into account when interpreting the results from placebo-controlled trials.

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UNLABELLED: Antidepressant drugs are commonly used to treat fibromyalgia, but there is little knowledge about their mechanisms of action. The aim of this study was to compare the cerebral and behavioral response to positive treatment effects of antidepressants or placebo. Ninety-two fibromyalgia patients participated in a 12-week, double-blind, placebo-controlled clinical trial with milnacipran, a serotonin-norepinephrine reuptake inhibitor. Before and after treatment, measures of cerebral pain processing were obtained using functional magnetic resonance imaging. Also, there were stimulus response assessments of pressure pain, measures of weekly pain, and fibromyalgia impact. Following treatment, milnacipran responders exhibited significantly higher activity in the posterior cingulum compared with placebo responders. The mere exposure to milnacipran did not explain our findings because milnacipran responders exhibited increased activity also in comparison to milnacipran nonresponders. Stimulus response assessments revealed specific antihyperalgesic effects in milnacipran responders, which was also correlated with reduced clinical pain and with increased activation of the posterior cingulum. A short history of pain predicted positive treatment response to milnacipran. We report segregated neural mechanisms for positive responses to treatment with milnacipran and placebo, reflected in the posterior cingulum. The increase of pain-evoked activation in the posterior cingulum may reflect a normalization of altered default mode network processing, an alteration implicated in fibromyalgia pathophysiology. PERSPECTIVE: This study presents neural and psychophysical correlates to positive treatment responses in patients with fibromyalgia, treated with either milnacipran or placebo. The comparison between placebo responders and milnacipran responders may shed light on the specific mechanisms involved in antidepressant treatment of chronic pain.

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INTRODUCTION: Patients with fibromyalgia syndrome (FMS) generally present with chronic widespread pain, accompanied by a range of additional and non-specific symptoms, such as fatigue, disturbed sleep, and cognitive dysfunction, which tend to increase with overall severity. Previous studies have shown moderate cognitive impairment in patients with FMS, but there are few valid data explicitly assessing the relevance of these findings to everyday functions, such as driving ability. Therefore, we studied patients with FMS to assess the impact of FMS on tests that predict driving ability. METHODS: Female patients with FMS were prospectively compared to a historical control group of healthy volunteers. The test battery comprised assessments of visual orientation, concentration, attention, vigilance, motor coordination, performance under stress, and reaction time. RESULTS: A total of 43 patients were matched to 129 controls. The results indicated that the patients' psychomotor and cognitive performances were significantly non-inferior when compared to healthy controls (with 0.05% alcohol), with the exception of motor coordination. Patients and healthy controls showed an age-related decline in test performance. Correlations were smaller in patients and reversed for vigilance which was linked to a greater FMS symptom load in younger patients. CONCLUSION: The results of the present study demonstrate that, in general, the driving ability of patients with FMS was not inferior to that of healthy volunteers based on a standardized computer-based test battery. However, variables, such as younger age, depression, anxiety, fatigue, pain, and poor motor coordination, likely contribute to the subjective perception of cognitive dysfunction in FMS.

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OBJECTIVE: There is vast evidence to support the presence of brain aberrations in patients with fibromyalgia (FM), and it is possible that central plasticity is critical for the transition from acute to chronic pain. The aim of the present study was to investigate the relationship between brain structure and function in patients with FM. METHODS: Functional connectivity of the brain during application of intermittent pressure-pain stimuli and measures of brain structure were compared between 26 patients with FM and 13 age- and sex-matched healthy controls. Magnetic resonance imaging (MRI) was performed to obtain high-resolution anatomic images and functional MRI scans of the brain, which were used for measurements of pain-evoked brain activity. RESULTS: FM patients displayed a distinct overlap between decreased cortical thickness, decreased brain volumes, and decreased functional regional coherence in the rostral anterior cingulate cortex. The morphometric changes were more pronounced with longer exposure to FM pain. In addition, there was evidence of an association between structural and functional changes in the mesolimbic areas of the brain and the severity of comorbid depression symptoms in FM patients. CONCLUSION: The combined integration of structural and functional measures allowed for a unique characterization of the impact of FM pain on the brain. These data may lead to the identification of early structural and functional brain alterations in response to pain, which could be used to develop markers for predicting the development of FM and other pain disorders.

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BACKGROUND: Perioperative vascular function has been widely studied using noninvasive techniques that measure reactive hyperemia as a surrogate marker of vascular function. However, studies are limited to a static setting with patients tested at rest. We hypothesized that exercise would increase reactive hyperemia as measured by digital thermal monitoring (DTM) in association to patients' cardiometabolic risk. METHODS: Thirty patients (58 ± 9 years) scheduled for noncardiac surgery were studied prospectively. Preoperatively, temperature rebound (TR) following upper arm cuff occlusion was measured before and 10 minutes after exercise. Data are presented as means ± SD. Statistical analysis utilized ANOVA and Fisher's exact test, with P values <0.05 regarded as significant. RESULTS: Following exercise, TR-derived parameters increased significantly (absolute: 0.53 ± 0.95 versus 0.04 ± 0.42°C, P=0.04, and % change: 1.78 ± 3.29 versus 0.14 ± 1.27 %, P=0.03). All patients with preoperative cardiac risk factors had a change in TR (after/before exercise, ΔTR) with values falling in the lower two tertiles of the study population (ΔTR <1.1%). CONCLUSION: Exercise increased the reactive hyperemic response to ischemia. This dynamic response was blunted in patients with cardiac risk factors. The usability of this short-term effect for the preoperative assessment of endothelial function warrants further study.

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AIM: The inflammatory response following tissue injury after major surgery is known to affect endothelial function and vascular reactivity. In this study we evaluated the utility of bedside Digital Thermal Monitoring (DTM) as a surrogate for evaluating vascular function in the postoperative period. METHODS: Ischemia-induced reactive hyperemia variables were measured in sixty patients scheduled for major thoracic surgery using DTM (VENDYS 5000BC; Endothelix, Inc., Houston, TX, USA) at baseline and at 24, 48, 72 hours, and day 5 postoperatively. Furthermore, baseline DTM variables (TR, aTR and AUCTR) and postoperative kinetics of these variables were compared among patients with and without preoperative chemo-radiation and cardiovascular risk factors. RESULTS: There were no significant differences in the DTM parameters measured at baseline and on each of the studied postoperative days. Compared to the baseline, the lowest measures of all variables were observed 24 hrs postoperatively and the highest measures of all variables were observed at 72 hrs. Patients with abdominal obesity and smoking had lower DTM values than the rest of the study group. CONCLUSIONS: In our study, DTM as measured by the VENDYS 5000BC DTM system (Endothelix, Inc.) did not reveal significant changes in ischemia-induced reactive hyperemia (vascular reactivity) between the baseline and after surgery in the postoperative period. Patients with certain cardiovascular risk factors (abdominal obesity, smoking) had a significant lower DTM signal. Whether this novel non-invasive technique is able to serve as a perioperative diagnostic tool for patients in a clinical setting warrants further study.

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BACKGROUND: Brachial artery reactivity testing (BART)--a surrogate test of microvascular function--predicts cardiac risk in the nonsurgical population and associates it with adverse outcome after vascular surgery. This pilot study investigated BART-derived variables, including flow-mediated dilation (FMD), in preoperative risk stratification for major thoracic surgery. METHODS: After institutional review board approval, BART was performed in 63 patients before major thoracic surgery. Ultrasonography recorded two-dimensional images and Doppler flow signals of the brachial artery preoperatively at baseline and after induced reactive hyperemia. Variables derived using BART were correlated with preoperative risk factors, established risk scores, and postoperative complications. RESULTS: The median preoperative FMD value in patients without postoperative complications was 11.5%. This value was used to delineate all patients into two groups: low (FMD < 11.5%) and high (FMD ≥ 11.5%) FMD cohorts. Patients in the low FMD group experienced more postoperative complications: 54% versus 30% had one or more adverse postoperative event, and 11% versus 0% had three or more adverse postoperative events (p < 0.001), respectively. The low FMD group required longer intensive care unit (3.9 ± 2.0 days versus 0.9 ± 0.3 days; p = 0.015) and hospital (14.0 ± 3.3 days versus 6.8 ± 0.6 days; p = 0.007) stays. This cutoff point for FMD accurately predicted 71% of the patients with adverse postoperative events, achieving 71.4% (95% confidence interval, 54.7 to 88.2) sensitivity and 48.6% (95% confidence interval, 32.0 to 65.1) specificity. CONCLUSIONS: Using BART, preoperative microvascular dysfunction can be identified in patients at increased risk for postoperative complications. These data suggest that larger observational studies and studies exploring preoperative optimization strategies aimed at improving microvascular function are warranted.

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BACKGROUND: There is evidence for augmented processing of pain and impaired endogenous pain inhibition in Fibromyalgia syndrome (FM). In order to fully understand the mechanisms involved in FM pathology, there is a need for closer investigation of endogenous pain modulation. In the present study, we compared the functional connectivity of the descending pain inhibitory network in age-matched FM patients and healthy controls (HC).We performed functional magnetic resonance imaging (fMRI) in 42 subjects; 14 healthy and 28 age-matched FM patients (2 patients per HC), during randomly presented, subjectively calibrated pressure pain stimuli. A seed-based functional connectivity analysis of brain activity was performed. The seed coordinates were based on the findings from our previous study, comparing the fMRI signal during calibrated pressure pain in FM and HC: the rostral anterior cingulate cortex (rACC) and thalamus. RESULTS: FM patients required significantly less pressure (kPa) to reach calibrated pain at 50 mm on a 0-100 visual analogue scale (p < .001, two-tailed). During fMRI scanning, the rACC displayed significantly higher connectivity to the amygdala, hippocampus, and brainstem in healthy controls, compared to FM patients. There were no regions where FM patients showed higher rACC connectivity. Thalamus showed significantly higher connectivity to the orbitofrontal cortex in healthy controls but no regions showed higher thalamic connectivity in FM patients. CONCLUSION: Patients with FM displayed less connectivity within the brain's pain inhibitory network during calibrated pressure pain, compared to healthy controls. The present study provides brain-imaging evidence on how brain regions involved in homeostatic control of pain are less connected in FM patients. It is possible that the dysfunction of the descending pain modulatory network plays an important role in maintenance of FM pain and our results may translate into clinical implications by using the functional connectivity of the pain modulatory network as an objective measure of pain dysregulation.

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BACKGROUND: In a pilot study we could show that hydroxyethyl starch (HES) induced a significant reduction of endothelium-dependent relaxation (EDR) and the endothelium-derived hyperpolarizing factor (EDHF). In this follow-up study we investigated whether this effect of HES was dose-dependent and whether it could be replicated with other colloids like dextran (DX) and gelatin (GL). METHODS: Rings of fresh porcine coronary arteries were consecutively tested with or without HES, DX or GL (5, 10, or 20 mg/ml). Indomethacin was added in all measurements to eliminate prostacyclin effects. Prostaglandin F2α was used for contraction and bradykinin (BK, 10⁻¹° to 10⁻5 M) for inducing EDR. After blocking nitric oxide (NO) by N-nitro-L-arginine (L-NNA), the experiments were repeated to assess the EDHF-mediated relaxation response to BK. RESULTS: HES induced a reduction in EDR for the BK concentrations of 10⁻8 and 10⁻7 M (n = 10; p < 0.05). After NO blockage with L-NNA, the relaxation response was reduced especially for the BK concentrations of 10⁻6 and 10⁻5 M (p < 0.05). GL showed a reduction in EDR with or without NO blockage with L-NNA especially for the BK concentrations of 10⁻6 and 10⁻5 M (n = 14; p < 0.05). DX induced a significant reduction in EDR for the BK concentrations of 10⁻7 and 10⁻6 M (n = 12; p < 0.05). After NO blockage with L-NNA, the relaxation response was reduced especially for the BK concentrations of 10⁻6 and 10⁻5 M (p < 0.05). CONCLUSION: For clinically relevant concentrations of HES, DX and GL a significant reduction in both NO-induced and NO-/prostacyclin-independent EDR can be found in epicardial coronary arteries of the pig.

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OBJECTIVE: Mood disturbance is common among patients with fibromyalgia (FM), but the influence of psychological symptoms on pain processing in this disorder is unknown. We undertook the present study to investigate the differential effect of depressive symptoms, anxiety, and catastrophizing on 1) pain symptoms and subjective ratings of general health status and 2) sensitivity to pain and cerebral processing of pressure pain. METHODS: Eighty-three women (mean ± SD age 43.8 ± 8.1 years) who fulfilled the American College of Rheumatology 1990 criteria for the classification of FM participated in the study. Patients rated pain intensity (100-mm visual analog scale [VAS]), severity of FM (Fibromyalgia Impact Questionnaire), general health status (Short Form 36), depressive symptoms (Beck Depression Inventory), anxiety (State-Trait Anxiety Inventory), and catastrophizing (Coping Strategies Questionnaire). Experimental pain in the thumb was induced using a computer-controlled pressure stimulator. Event-related functional magnetic resonance imaging was performed during administration of painful stimuli representing 50 mm on a pain VAS, as well as nonpainful pressures. RESULTS: A correlation analysis including all self-ratings showed that depressive symptoms, anxiety, and catastrophizing scores were correlated with one another (P < 0.001), but did not correlate with ratings of clinical pain or with sensitivity to pressure pain. However, the subjective rating of general health was correlated with depressive symptoms and anxiety (P < 0.001). Analyses of imaging results using self-rated psychological measures as covariates showed that brain activity during experimental pain was not modulated by depressive symptoms, anxiety, or catastrophizing. CONCLUSION: Negative mood in FM patients can lead to a poor perception of one's physical health (and vice versa) but does not influence performance on assessments of clinical and experimental pain. Our data provide evidence that 2 partially segregated mechanisms are involved in the neural processing of experimental pain and negative affect.

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BACKGROUND: Increasing the cross-sectional area (CSA) of the right internal jugular vein facilitates cannulation and decreases complications. Maneuvers such as the Trendelenburg tilt position and ventilation with a positive end-expiratory pressure (PEEP) may increase the CSA of the right internal jugular vein. We determined the changes in the CSA in response to different maneuvers. METHODS: The CSA (cm(2)) of the right internal jugular vein was assessed in 50 anesthetized adult cardiothoracic surgery patients using 2-dimensional ultrasound. First, the CSA was measured in response to supine position with no PEEP (control condition, S0) and compared with 5 different randomly ordered maneuvers: (1) PEEP ventilation with 5 cm H(2)O (S5), (2) PEEP with 10 cm H(2)O (S10), (3) a 20 degrees Trendelenburg tilt position with a PEEP of 0 cm H(2)O (T0), (4) a 20 degrees Trendelenburg tilt position combined with a PEEP of 5 cm H(2)O (T5), and (5) a 20 degrees Trendelenburg tilt position combined with a PEEP of 10 cm H(2)O (T10). RESULTS: All maneuvers increased the CSA of the right internal jugular vein with respect to the control condition S0 (all P < 0.05). S5 increased the CSA on average by 15.9%, S10 by 22.3%, T0 by 39.4%, T5 by 38.7%, and T10 by 49.7%. CONCLUSION: In a comparison of the effectiveness of applying different PEEP levels and/or the Trendelenburg tilt position on the CSA of the right internal jugular vein, the Trendelenburg tilt position was most effective.

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Over the years, many have viewed Fibromyalgia syndrome (FMS) as a so-called "functional disorder" and patients have experienced a concomitant lack of interest and legitimacy from the medical profession. The symptoms have not been explained by peripheral mechanisms alone nor by specific central nervous system mechanisms. In this study, we objectively evaluated the cerebral response to individually calibrated pain provocations of a pain-free body region (thumbnail). The study comprised 16 female FMS patients and 16 individually age-matched controls. Brain activity was measured using functional magnetic resonance imaging (fMRI) during individually calibrated painful pressures representing 50 mm on a visual analogue scale (VAS) ranging from 0 to 100 mm. Patients exhibited higher sensitivity to pain provocation than controls as they required less pressure to evoke equal pain magnitudes (U(A)=48, p<.002). Despite lower pressures applied in patients at VAS 50 mm, the fMRI-analysis revealed no difference in activity in brain regions relating to attention and affect or regions with sensory projections from the stimulated body area. However, in the primary link in the descending pain regulating system (the rostral anterior cingulate cortex) the patients failed to respond to pain provocation. The attenuated response to pain in this brain region is the first demonstration of a specific brain region where the impairment of pain inhibition in FMS patients is expressed. These results validate previous reports of dysfunctional endogenous pain inhibition in FMS and advance the understanding of the central pathophysiologic mechanisms, providing a new direction for the development of successful treatments in FMS.

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