BACKGROUND: Opioid rotation can be indicated due to drug side effects, drug interactions or inadequate effect of treatment with opioids. For the determination of the oral morphine equivalence, a practice tool has been published with the long-term use of opioids in chronic nontumor-related pain (LONTS) guidelines. In contrast, several apps are available that have not yet been evaluated.
METHODS: Apps and web applications for opioid conversion were searched using Google Play Store®, iOS App Store® and the Google® search engine. German and English language apps with calculator functions were included. Using the apps, 16 test cases from clinical practice were calculated and the deviation from the recommendation of the LONTS guidelines was calculated.
RESULTS: A total of 17 apps were identified, 11 named the origin of the algorithm and 3 of them defined the literature sources. None of the apps and web applications had a quality seal, and none could solve all cases. Deviations of the resulting oral morphine equivalents of up to 179% from the guideline-compliant conversion were identified and 4 apps warned for overdosing.
CONCLUSIONS: Although the apps and web applications simplify conversion between opioids, there is high variance in conversion factors and sometimes a relevant deviation from evidence-based tables. Overall, there is a high risk of false opioid dosing.
UNASSIGNED: HINTERGRUND: Aufgrund von Arzneimittelnebenwirkungen, Medikamenteninteraktionen oder wegen inadäquater Wirkung bei der Behandlung mit Opioiden kann eine Opioidrotation indiziert sein. Zur Bestimmung der oralen Morphinäquivalenz ist mit der Leitlinie „Langzeitanwendung von Opioiden bei chronischen nicht-tumorbedingten Schmerzen (LONTS)“ ein Praxiswerkzeug veröffentlicht. Dem gegenüber stehen mehrere Apps, die bislang nicht bewertet wurden.
METHODS: Mittels Google Play Store®, iOS App Store® und der Suchmaschine Google® wurden Apps zur Opioidkonversion gesucht. Deutsch- und englischsprachige Apps mit Kalkulatorfunktion wurden eingeschlossen. Mit den Apps wurden 16 Testfälle aus der klinischen Praxis kalkuliert und die Abweichung von der Empfehlung der LONTS-Leitlinie berechnet.
UNASSIGNED: Insgesamt wurden 17 Apps identifiziert. Elf benannten die Herkunft des Algorithmus, 3 davon benannten Literaturquellen. Keine App wies ein Qualitätssiegel auf, zudem ließen sich mit keiner App sämtliche Fälle lösen. Es wurden Abweichungen der resultierenden oralen Morphinäquivalente um +179 % von der leitliniengerechten Umrechnung identifiziert. Vier Apps warnten vor Überdosierungen.
UNASSIGNED: Obwohl die Apps die Umrechnung zwischen Opioiden vereinfachen, besteht eine hohe Varianz der Umrechnungsfaktoren und teils eine große Abweichung von evidenzbasierten Tabellen. Insgesamt besteht ein hohes Risiko von Opioidfehldosierungen.

Traditional pedicle screws are the gold standard for lumbar spine fixation; however, cortical screws along the midline cortical bone trajectory may be advantageous when lumbar decompression is required. While biomechanic investigation of both techniques exists, cortical screw performance in a multi-level lumbar laminectomy and fusion model is unknown. Furthermore, longer-term viability of cortical screws following cyclic fatigue has not been investigated.
Fourteen human specimens (L1-S1) were divided into cortical and pedicle screw treatment groups. Motion was captured for the following conditions: intact, bilateral posterior fixation (L3-L5), fixation with laminectomy at L3-L5, fixation with laminectomy and transforaminal lumbar interbody fusion at L3-L5 both prior to, and following, simulated in vivo fatigue. Following fatigue, screw pullout force was collected and \"effective shear stress\" [pullout force/screw surface area] (N/mm2) was calculated; comparisons and correlations were performed.
In flexion-extension and lateral bending, all operative constructs significantly reduced motion compared to intact (P < 0.05), regardless of pedicle or cortical screws; only posterior fixation with and without laminectomy significantly reduced motion in axial rotation (P < 0.05). Pedicle screws significantly increased average pullout strength (944.2 N vs. 690.2 N, P < 0.05), but not the \"effective shear stress\" (1.01 N/mm2 vs. 1.1 N/mm2, P > 0.05).
In a posterior laminectomy and fusion model, cortical screws provided equivalent stability to pedicle screw fixation, yet had significantly lower screw pullout force. No differences in \"effective shear stress\" warrant further investigation of the effect of screw length/diameter in the aforementioned screw trajectories.

暂无摘要。

This paper describes the diagnostic criteria for bilateral vestibulopathy (BVP) by the Classification Committee of the Bárány Society. The diagnosis of BVP is based on the patient history, bedside examination and laboratory evaluation. Bilateral vestibulopathy is a chronic vestibular syndrome which is characterized by unsteadiness when walking or standing, which worsen in darkness and/or on uneven ground, or during head motion. Additionally, patients may describe head or body movement-induced blurred vision or oscillopsia. There are typically no symptoms while sitting or lying down under static conditions.The diagnosis of BVP requires bilaterally significantly impaired or absent function of the vestibulo-ocular reflex (VOR). This can be diagnosed for the high frequency range of the angular VOR by the head impulse test (HIT), the video-HIT (vHIT) and the scleral coil technique and for the low frequency range by caloric testing. The moderate range can be examined by the sinusoidal or step profile rotational chair test.For the diagnosis of BVP, the horizontal angular VOR gain on both sides should be <0.6 (angular velocity 150-300°/s) and/or the sum of the maximal peak velocities of the slow phase caloric-induced nystagmus for stimulation with warm and cold water on each side <6°/s and/or the horizontal angular VOR gain <0.1 upon sinusoidal stimulation on a rotatory chair (0.1 Hz, Vmax = 50°/sec) and/or a phase lead >68 degrees (time constant of <5 seconds). For the diagnosis of probable BVP the above mentioned symptoms and a bilaterally pathological bedside HIT are required.Complementary tests that may be used but are currently not included in the definition are: a) dynamic visual acuity (a decrease of ≥0.2 logMAR is considered pathological); b) Romberg (indicating a sensory deficit of the vestibular or somatosensory system and therefore not specific); and c) abnormal cervical and ocular vestibular-evoked myogenic potentials for otolith function.At present the scientific basis for further subdivisions into subtypes of BVP is not sufficient to put forward reliable or clinically meaningful definitions. Depending on the affected anatomical structure and frequency range, different subtypes may be better identified in the future: impaired canal function in the low- or high-frequency VOR range only and/or impaired otolith function only; the latter is evidently very rare.Bilateral vestibulopathy is a clinical syndrome and, if known, the etiology (e.g., due to ototoxicity, bilateral Menière\'s disease, bilateral vestibular schwannoma) should be added to the diagnosis. Synonyms include bilateral vestibular failure, deficiency, areflexia, hypofunction and loss.

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on \"positioning therapy for prophylaxis or therapy of pulmonary function disorders\" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of \"early mobilization\"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

OBJECTIVE: To prospectively evaluate the influence of observer experience, consensus assessment, and abduction and external rotation (ABER) view on the diagnostic performance of magnetic resonance arthrography (MRA) in patients with traumatic anterior-shoulder instability (TASI).
METHODS: Fifty-eight MRA examinations (of which 51 had additional ABER views) were assessed by six radiologists (R1-R6) and three teams (T1-T3) with different experience levels, using a seven-lesion standardized scoring form. Forty-five out of 58 MRA examination findings were surgically confirmed. Kappa coefficients, sensitivity, specificity, and differences in percent agreement or correct diagnosis (p-value, McNemar\'s test) were calculated per lesion and overall per seven lesion types to assess diagnostic reproducibility and accuracy.
RESULTS: Overall kappa ranged from poor (k = 0.17) to moderate (k = 0.53), sensitivity from 30.6-63.5%, and specificity from 73.6-89.9%. Overall, the most experienced radiologists (R1-R2) and teams (T2-T3) agreed significantly more than the lesser experienced radiologists (R3-R4: p = 0.014, R5-R6; p = 0.018) and teams (T2-T3: p = 0.007). The most experienced radiologist (R1, R2, R3) and teams (T1, T2) were also consistently more accurate than the lesser experienced radiologists (R4, R5, R6) and team (T3). Significant differences were found between R1-R4 (p = 0.012), R3-R4 (p = 0.03), and T2-T3 (p = 0.014). The overall performance of consensus assessment was systematically higher than individual assessment. Significant differences were established between T1-T2 and radiologists R3-R4 (p<0.001, p = 0.001) and between T2 and R3 (p<0.001/p = 0.001) or R4 (p = 0.050). No overall significant differences were found between the radiologists\' assessments with and without ABER.
CONCLUSIONS: The addition of ABER does not significantly improve overall diagnostic performance. The radiologist\'s experience level and consensus assessment do contribute to higher reproducibility and accuracy.

Emergency medicine services and training in Emergency Medicine (EM) has developed to a large extent in developed countries but its establishment is far from optimal in developing countries. In India, Medical Council of India (MCI) has taken great steps by notifying EM as a separate specialty and so far 20 medical colleges have already initiated 3-year training program in EM. However, there has been shortage of trained faculty, and ambiguity regarding curriculum, rotation policy, infrastructure, teachers\' eligibility qualifications and scheme of examination. Academic College of Emergency Experts in India (ACEE-India) has been a powerful advocate for developing Academic EM in India. The ACEE\'s Education Development Committee (EDC) was created to chalk out guidelines for staffing, infrastructure, resources, curriculum, and training which may be of help to the MCI and the National Board of Examinations (NBE) to set standards for starting 3-year training program in EM and develop the departments of EM as centers of quality education, research, and treatment across India. This paper has made an attempt to give recommendations so as to provide a uniform framework to the institutions, thus guiding them towards establishing an academic Department of EM for starting the 3-year training program in the specialty of EM.

BACKGROUND: Our objective was to analyze patterns of tooth movement and changes of arch dimension by superimposing 3-dimensional (3D) virtual models.
METHODS: The sample consisted of 24 Korean adults with Class I malocclusion and minimal crowding, treated by first premolar extractions, sliding mechanics (0.022-in MBT brackets [3M Unitek, Monrovia, Calif] with 0.019 × 0.025-in stainless steel wire) and moderate anchorage. The 3D virtual maxillary casts at pretreatment and posttreatment were superimposed with the best-fit method. Linear and angular variables were measured with 3Txer program (Orapix, Seoul, Korea). Wilcoxon signed rank and Mann-Whitney tests were used for statistical analysis.
RESULTS: There was no significant difference in the individual tooth movement between the right and left sides (P > 0.05). For the movement of each tooth, the maxillary central incisors (U1), lateral incisors (U2), and canines (U3) were significantly inclined lingually, extruded, and moved posteriorly and laterally. The maxillary second premolar (U5), first molar (U6), and second molar (U7) had significant mesial inward rotation, anterior movement, and contracted toward the midsagittal plane. The ratio of anteroposterior movement between the maxillary anterior and posterior teeth was 5:1. The amounts of contraction in U5, U6, and U7 were 1.4, 1.3, and 1.2 mm, respectively. When the amount of change between the adjacent teeth were compared, the linguoversion in U1 was significantly greater than that of U2. U3 and U5 showed significant opposite movements in all variables. There were differences only in angulation and vertical displacement between U6 and U7.
CONCLUSIONS: Superimposition of 3D virtual models could be a guideline for precise virtual treatment planning.

暂无摘要。

OBJECTIVE: To provide guidelines for operative vaginal birth in the management of the second state of labour.
METHODS: Nonoperative techniques, episiotomy, and Caesarean section are compared to operative vaginal birth.
RESULTS: Reduced fetal and maternal morbidity and mortality.
METHODS: MEDLINE and Cochrane databases were searched using the key words \"vacuum\" and \"birth\" as well as \"forceps\" and \"birth\" for literature published in English from january 1970 to June 2004. The level of evidence and quality of recommendations made are described using the Evaluation of Evidence from the Canadian Task Force on the Periodic Health Examination.
CONCLUSIONS: (1) Nonoperative interventions such as one-to-one support, partogram use, oxytocin use, and delayed pushing in women using epidurals will decrease need for operative birth (I-A). (2) Manual rotation may be used alone or in conjunction with instrumental birth with little or no increased risk to the pregnant women or the fetus (III-B). (3) Routine episiotomy is not necessary for an assisted vaginal birth (II-1E). (4) When operative intervention in the second stage of labour is required, the options, risks, and benefits of vacuum, forceps, and Caesarean section much be considered. The choice of intervention needs to be individualized, as one is not clearly safer or more effective than the other (II-B). (5) Failure of the chosen method, vacuum and/or forceps, to achieve delivery of the fetus in a reasonable time should be considered an indication for abandonment of the method (III-C). (6) Adequate clinical experience and appropriate training of the operator are essential to the safe performance of operative deliveries. Hospital credentialing boards should grant privileges for performing these techniques only to an appropriately trained individual who demonstrates adequate skills (III-C).
RESULTS: The Clinical Practice Obstetrics Committee and Executive and Council of the Society of Obstetricians and Gynaecologists of Canada approved these guidelines.