Introduction Dopexamine may be a therapeutic option to improve hepatosplanchnic perfusion in sepsis. To investigate this possibility, we administered dopexamine in an experimental sepsis model in rats.

Background: The ROTEM™ clot lysis index, describing the decrease in firmness of a clot with time, predicts mortality in various settings. The variability of the clot lysis index in surgical procedures and the involved pathophysiological mechanisms are unknown. We therefore compared pre- and postoperative clot lysis indices in liver transplantation (LTX) procedures, determined the eventual association with mortality, and investigated the mechanisms underlying decreased clot lysis index using inhibitors of fibrinolysis and clot retraction, respectively. Methods: In this retrospective cohort study, data on pre- and post-transplant ROTEM™ findings as obtained with EXTEM (tissue factor activation), INTEM (intrinsic system activation), FIBTEM (extrinsic system activation and inhibition of clot retraction), APTEM (extrinsic system activation and fibrinolysis inhibition), conventional laboratory coagulation tests, blood loss, transfusion of blood products, and outcome were registered. Results: Pre-transplant clot lysis indices showed a broad distribution ranging from 75% to 99% independent of the activator used (EXTEM, INTEM). During the surgical procedure, median clot lysis index values markedly increased from 92% to 97% (EXTEM) and 93% to 98% (INTEM), respectively (p < 0.0001 each). Aprotinin had no effect on either pre- or postsurgical clot lysis indices. Inhibition of platelet clot retraction with cytochalasin D (FIBTEM) markedly increased the preoperative clot lysis index. High pre- and post-transplantation clot lysis indices were associated with increased mortality irrespective of the activator used (EXTEM, INTEM) and the inhibition of fibrinolysis (APTEM). Inhibition of clot retraction (FIBTEM) abolished the association of clot lysis index with mortality in both pre- and post-transplantation samples. Conclusion: Both pre- and postoperative ROTEM™ clot lysis indices predict mortality in patients following liver transplantation. Inhibitor experiments reveal that the clot lysis index is not an indicator of fibrinolysis, but indicates platelet clot retraction. The marked increase of clot lysis index during liver transplantation is caused by a decrease in clot retraction with eventual consequences for clot stability, retraction of wound margins, and reperfusion of vessels in case of thrombosis.

Dacryocystocele may represent a rare type of connatal stenosis of the lacrimal duct. If conservative measures fail and in case of secondary inflammation, probing or regular surgery is usually recommended. We report on 15 neonates suffering from 18 connatal dacryocystoceles which were presented to the clinic of ophthalmology at the 16th (6 - 44) day of life. There was a definite female preponderance (65 %). Conservative treatment (external massage, at times i. v. antibiotic therapy) had proven to be ineffective. The neonates were subjected to outpatient nasal endoscopy and the ballooning cyst of the inferior nasal meatus was managed by endoscopic marsupialization in 14 cases applying local anesthesia. Two nasal cysts had to be operated on in general anesthesia due to obstructing local anatomy which obviated endoscopical microsurgery. Three additional dacryocystoceles have been detected incidentally in 2 neonates being subjected to surgery in general anesthesia for choanal atresia and lacrimal probing respectively. The corresponding dacryocystoceles were managed by concomitant endonasal microsurgery. We advocate interdisciplinary (ophthalmological and rhinological) outpatient examination in all neonates with suspected dacryocystoceles. Diagnosis is based on palpation, probing and nasal endoscopy applying local anesthesia together with mucosal decongestion. Microsurgical marsupialization immediately follows and will lead to persisting relief of symptoms.

Determination of Functional Residual Capacity (FRC) can be performed through washout methods, indicator gas dilution or bodyplethysmography. Some of these techniques have been adapted for use in intensive care patients whilst being mechanically ventilated. However, most measurement setups are bulky, cumbersome to use and their running costs are high. Hence FRC measurement has not become a routine method in intensive care although it offers considerable advantages in the management of ventilated patients such as the determination of "best PEEP", the detection of progressive alveolar collapse in the course of acute lung injury and during weaning from mechanical ventilation. Up to now most efforts to improve and simplify FRC measurement were made at the expense of accuracy. An ideal method ought to be accurate, easy to handle and cost-effective. It should supply not only FRC data but also information about intrapulmonary gas distribution and dead space. These demands can be met using modern data acquisition software. The pros and cons of all methods available for FRC measurement are discussed in view of their suitability for intensive care patients. A conventional nitrogen washout using emission spectroscopy for measurement of nitrogen concentration gives satisfying exact values for the determination of the parameters mentioned above. The measurement error can be lowered under 5% by special corrections for flow and nitrogen signal (delay and rise times, changes of gas viscosity). For flow measurement a normal pneumotachograph can be used. Using a laptop computer for data acquisition the bed-side monitor fulfills most of the demands in intensive care. It is then also possible to measure indices of intrapulmonary gas distribution such as Alveolar Mixing Efficiency and Lung Clearance Index.

Bilateral congenital cataract is genetic in at least 25% of cases. In contrast, unilateral congenital cataract is usually sporadic. Genetic heterogeneity is significant with the involvement of more than 30 genes having been identified to date. Phenotypes are defined by the location and morphology of the lens opacities. Mutations in the same gene may result in different phenotypes (clinical heterogeneity), and mutations in different genes may be associated with similar phenotypes (genetic heterogeneity). The mode of inheritance is mostly autosomal dominant but autosomal recessive and X-linked modes also occur. Expressivity may be variable and penetrance reduced. In X-linked cataract, carriers may show carrier signs. A precise pedigree analysis and a clinical examination of further family members are mandatory for correct genetic counselling. Metabolic cataract may be diagnosed biochemically. Molecular genetic analysis is not offered routinely to date with the exemption of a few genes.

Due to growing technisation of intensive care the number of devices with integrated alarm systems is steadily increasing. However, most of the sounding alarms are false alarms causing high levels of frustration, aggression and inappropriate behaviour amongst the medical personnel. All this jeopardises patient care. The high number of alarms also disturb the patients interrupting their sleep and provokes anxiety, and also increases the already high noise level in intensive care units and the operating theatre alike. In the interest of the medical staff and our patients, we should reduce the high frequency of false alarms by using modern alarm algorithms techniques, lower both noise exposure and stress load with the help of modern individualized alarm systems and by increasing awareness on the dangers of alarm fatigue through training and by using individualized patient-related alarm limits. Despite economic challenges hospitals and intensive care units should optimize staffing, thereby lowering the risk to patients and improving employee satisfaction.

Fibrosis syndrome has been a well-known clinical entity for more than a century. Nevertheless, there are still some unresolved questions concerning its etiology, chronological course, and optimal timing of surgery. On the basis of their experience in 12 cases (2 unilateral, 10 bilateral, 7 with eye muscles and/or lid surgery), the authors attempt to help answer these questions.

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