At-level and above-level hypersensitivity was assessed in patients with chronic complete thoracic spinal cord injury (SCI). Patients were classified using somatosensory mapping (brush, cold, pinprick) and assigned into 2 groups (ie, patients with at-level hypersensitivity [SCIHs, n = 8] and without at-level hypersensitivity [SCINHs, n = 7]). Gender and age-matched healthy subjects served as controls. Quantitative sensory testing (QST), electrically- and histamine-induced pain and itch, laser Doppler imaging, and laser-evoked potentials (LEP) were recorded at-level and above-level in SCI-patients. Six of 8 SCIHs, but 0 of 7 SCINHs patients suffered from neuropathic below-level pain. Clinical sensory mapping revealed spreading of hypersensitivity to more cranial areas (above-level) in 3 SCIHs. Cold pain threshold measures confirmed clinical hypersensitivity at-level in SCIHs. At level and above-level hypersensitivity to electrical stimulation did not differ significantly between SCIHs and SCINHs. Mechanical allodynia, cold, and pin-prick hypersensitivity did not relate to impaired sensory function (QST), axon reflex flare, or LEPs. Clinically assessed at-level hypersensitivity was linked to below-level neuropathic pain, suggesting neuronal hyperexcitability contributes to the development of neuropathic pain. However, electrically evoked pain was not significantly different between SCI patients. Thus, SCI-induced enhanced excitability of nociceptive processing does not necessarily lead to neuropathic pain. QST and LEP revealed no crucial role of deafferentation for hypersensitivity development after SCI.Perspective: At-level hypersensitivity after complete thoracic SCI is associated with neuropathic below-level pain if evoked by clinical sensory stimuli. QST, LEP, and electrically-induced axon reflex flare sizes did not indicate somatosensory deafferentation in SCIHs. (C) 2016 by the American Pain Society

OBJECTIVES:Widespread sensory deficits resembling hemihypoesthesia occur in 20% to 40% of chronic pain patients on the side of pain, independent of pain etiology, and have been termed nondermatomal sensory deficits (NDSDs). Sensory profiles have rarely been investigated in NDSDs.MATERIALS AND METHODS:Quantitative sensory testing according to the protocol of the German Research Network on Neuropathic Pain (DFNS) was performed in the face, hand, and foot of the painful body side and in contralateral regions in chronic pain patients. Twenty-five patients with NDSDs and 23 without NDSDs (termed the pain-only group) were included after exclusion of neuropathic pain. Comprehensive clinical and psychiatric evaluations were carried out.RESULTS:NDSD in chronic pain was associated with high burden of disease and more widespread pain. Only in the NDSD group were significantly higher thresholds for mechanical and painful stimuli found in at least 2 of 3 regions ipsilateral to pain. In addition, we found a bilateral loss of function for temperature and vibration detection, and a gain of function for pressure pain in certain regions in patients with NDSD. Sensory loss and gain of function for pressure pain correlated with pain intensity in several regions.DISCUSSION:This may indicate a distinct sensory profile in chronic non-neuropathic pain and NDSD, probably attributable to altered central pain processing and sensitization. The presence of NDSD in chronic non-neuropathic pain may be regarded as a marker for higher burden of pain disease.

BackgroundAt high concentration, the TRPV-1 agonist capsaicin de-sensitizes nociceptors and reduces the intra-epidermal nerve density.MethodsWe investigated the effects of a 5x10cm capsaicin 8% patch on C- and A-delta-nociceptor activation in ten healthy subjects before and at days 1-3-7-21 after patch application. Thermal thresholds, infrared thulium-YAG laser-evoked potentials (LEP) and heat pain (numeric rating scale, NRS, 0-10), electrically induced pain (10 pulses, 1.5-fold pain threshold intensity, five randomized series of 5-10-20-50-100Hz), and axon-reflex flare (laser Doppler imaging) were recorded.ResultsThermal hypoesthesia developed upon capsaicin 8% treatment. Warmth detection thresholds increased at day 1-3, heat pain thresholds were increased by about 2.6 degrees C after day 3, and laser-evoked heat pain remained significantly reduced for 7days. Axon-reflex flare responses (days 1-3), but not supra-threshold electrically induced pain were significantly reduced by the capsaicin patch.ConclusionsAxonal nociceptor function assessed by electrical excitability tests supplements threshold tests of nociceptive endings. The differential analgesic effects of 8% capsaicin patches may be attributed to the kinetics of capsaicin and the different depth of nociceptive nerve fibres, yet, the time course does not match the long-lasting analgesia observed in neuropathic pain patients treated with the same patch.What does this study add?Axonal nociceptor function assessed by supra-threshold electrical excitability tests did not coincide with capsaicin-induced transduction changes supplementing threshold measures of terminal nociceptor endings. Threshold measurements do not reflect the sustained effect of pain relief seen in neuropathic pain patients. Capsaicin-sensitive nociceptors responsible for spontaneous pain are either not specifically tested with currently available sensory stimulation protocols or have higher capsaicin sensitivity or slower recovery under neuropathic conditions.

Editor—In 2013 Wikkelsø and co-workers published a conclusive literature review about fibrinogen concentrate (FBC) therapy in bleeding patients in the Cochrane database.1Wikkelso A Lunde J Johansen M et al.Fibrinogen concentrate in bleeding patients.Cochrane Database Syst Rev. 2013; 8 (CD008864)Crossref Scopus (124) Google Scholar They unambiguously stated that up to now there is not one large, unbiased study with adequate statistical power that justifies an indication for the use of FBC beyond the negligible group of patients with bleeding due to proven selective hypofibrinogenaemia. In conclusion they said, ‘Included trials are of low quality with high risk of bias and are underpowered to detect mortality, benefit or harm. More research is urgently needed.’ The entire group had no conflicts of interest. In response Kozek-Langenecker and colleagues2Kozek-Langenecker S Fries D Spahn DR Zacharowski III, K Fibrinogen concentrate: clinical reality and cautious Cochrane recommendation.Br J Anaesth. 2014; 112: 784-787Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar published an Editorial in the British Journal of Anaesthesia (BJA), expressing their unhappiness about the cautious conclusions of the authors. We learned that Wikkelsø and co-workers were not notified by the editors of BJA let alone asked for a comment, though the title of the respective editorial, ‘Fibrinogen concentrate: Clinical reality and cautious Cochrane recommendation’ explicitly and critically address this group and this particular publication. This basically means that a highly prestigious anaesthetic journal gave a single group a forum for their personal opinion. In our mind BJA hereby left its duty of neutrality, probably unintended, by leaving the criticised group out. The authors in question2Kozek-Langenecker S Fries D Spahn DR Zacharowski III, K Fibrinogen concentrate: clinical reality and cautious Cochrane recommendation.Br J Anaesth. 2014; 112: 784-787Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar – all - correctly disclosed their conflicts of interest. The liberal use of fibrinogen concentrate (FBC) in settings without proven benefit has been repeatedly promoted by them and affiliated groups,3Sadeghi M Atefyekta R Azimaraghi O et al.A randomized, double blind trial of prophylactic fibrinogen to reduce bleeding in cardiac surgery.Braz J Anesthesiol. 2014; 64: 253-257Crossref Scopus (28) Google Scholar, 4Spahn DR Severe bleeding in surgical and trauma patients: the role of fibrinogen replacement therapy.Thromb Res. 2012; 130: S15-S19Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar and we are worried therapists may feel pressurised that way. We believe that the frequent and increasing application of FBC all over the world and its impressive sales figures are the consequence of ‘scientific marketing’ rather than scientific evidence. To shine a light on the financial dimensions of the issue, we considered one of the suggested indications, open heart surgery, and a single population. Administering 2 g FBC to each of 100 000 patients undergoing cardiac surgery per year in Germany would be equivalent to a sales volume of nearly 75 million Euros (75 000 000). Against this background therapists would be wise to contemplate alternative opinions.1Wikkelso A Lunde J Johansen M et al.Fibrinogen concentrate in bleeding patients.Cochrane Database Syst Rev. 2013; 8 (CD008864)Crossref Scopus (124) Google Scholar, 5Stanworth SJ Hunt BJ The desperate need for good-quality clinical trials to evaluate the optimal source and dose of fibrinogen in managing bleeding.Crit Care. 2011; 15: 1006Crossref PubMed Scopus (18) Google Scholar, 6Ozier Y Hunt BJ Against: Fibrinogen concentrate for management of bleeding: against indiscriminate use.J Thromb Haemost. 2011; 9: 6-8Crossref PubMed Scopus (36) Google Scholar, 7von Bormann B Suksompong S Zander R Therapy with fibrinogen concentrate: clinical and ethical considerations.Transfusion. 2013; 53: 1137-1138Crossref PubMed Scopus (3) Google Scholar Attitude to benefits and indications of a drug can be characterised as either ‘reluctant’ or ‘enthusiastic’. Regarding the generous use of FBC we are reluctant. To our liking enthusiasm for a drug so expensive, whose effects are only suggested but not yet proven1Wikkelso A Lunde J Johansen M et al.Fibrinogen concentrate in bleeding patients.Cochrane Database Syst Rev. 2013; 8 (CD008864)Crossref Scopus (124) Google Scholar, 8Aubron C Reade MC Fraser JF Cooper DJ Efficacy and safety of fibrinogen concentrate in trauma patients-a systematic review.J Crit Care. 2014; 29: 471-477PubMed Google Scholar, 9Lunde J Stensballe J Wikkelso A Johansen M Afshari A Fibrinogen concentrate for bleeding - a systematic review.Acta Anaesthesiol Scand. 2014; 58: 1061-1074Crossref PubMed Scopus (46) Google Scholar, 10Bilecen S Peelen LM Kalkman CJ Spanjersberg AJ Moons KG Nierich AP Fibrinogen concentrate therapy in complex cardiac surgery.J Cardiothorac Vasc Anesth. 2013; 27: 12-17Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 11Wafaisade A Lefering R Maegele M et al.Administration of fibrinogen concentrate in exsanguinating trauma patients is associated with improved survival at 6 hours but not at discharge.J Trauma Acute Care Surg. 2013; 74: 383-387Crossref Scopus (54) Google Scholar is not comprehensible. It is explicitly not our intention to impute dubious motives to the ‘enthusiastic’ authors or to question their integrity. However, we have to face that candid critics judge medical literature to be undermined with flaws and bias,12Kicinski M How does under-reporting of negative and inconclusive results affect the false-positive rate in meta-analysis? A simulation study.BMJ Open. 2014; 4: e004831Crossref Scopus (36) Google Scholar saying that ‘competition and conflicts of interest distort too many medical findings’.13Ioannidis JP An epidemic of false claims. Competition and conflicts of interest distort too many medical findings.Sci Am. 2011; 304: 16Crossref PubMed Scopus (55) Google Scholar The large amount of ‘enthusiastic’ FBC-literature, entirely sponsored by producers of the drug will further inspire this negative attitude. We are convinced our system should be challenged. Is it really enough to simply declare conflicts of interest without consequences? Is the COPE statement still effective? Langer and colleagues reviewed 297 guidelines drawn up by German specialist societies in the years 2009–2011,14Langer T Conrad S Fishman L et al.Conflicts of interest among authors of medical guidelines: an analysis of guidelines produced by German specialist societies.Dtsch Arztebl Int. 2012; 109: 836-842PubMed Google Scholar concluding, ‘Standards to deal with conflicts of interest are lacking and should be urgently developed.’ It is the duty of scientific bodies, universities, IRBs, journals/editors to make every effort to limit bias in scientific literature. Disclosure of authors’ research-related perks and publishing companies’ economic ties to drug companies could be an additional instrument to adhere to the path of virtue. None declared.

von Bormann, Benno DrMed, MD; Suksompong, Sirilak MD; Schleinzer, Wolf MD Author Information

Objectives: Widespread sensory deficits occur in 20-40% of chronic pain patients on the side of pain, independent of pain aetiology, and are known as nondermatomal sensory deficits (NDSDs). NDSDs can occur in absence of central or peripheral nervous system lesions. We hypothesised that NDSDs were associated with cerebral grey matter changes in the sensory system and in pain processing regions, detectable with voxel-based morphometry. Methods: Twenty-five patients with NDSDs, 23 patients without NDSDs (pain-only), and 29 healthy controls were studied with high resolution structural MRI of the brain. A comprehensive clinical and psychiatric evaluation based on Diagnostic and Statistical Manual was performed in all patients. Results: Patients with NDSDs and pain-only did not differ concerning demographic data and psychiatric diagnoses, although anxiety scores (HADS-A) were higher in patients with NDSDs. In patients with NDSDs, grey matter increases were found in the right primary sensory cortex, thalamus, and bilaterally in lateral temporal regions and the hippocampus/fusiform gyrus. Pain-only patients showed a bilateral grey matter increase in the posterior insula and less pronounced changes in sensorimotor cortex. Conclusions: Dysfunctional sensory processing in patients with NDSDs is associated with complex changes in grey matter volume, involving the somatosensory system and temporal regions.

Background: About 20–/INS;40% of chronic pain patients have widespread sensory deficits often in hemisensory distribution ipsilateral to the site of pain, a phenomenon termed non-dermatomal sensory deficits (NDSDs). Patients with NDSDs show no pathological findings in standard investigations, but decreased activity in the sensory system has /INS;been found in PET and fMRI studies.

European Journal of Pain SupplementsVolume 5, Issue S1 p. 155-155 F411 HOW TO ASSESS THE NEED FOR SOCIAL WORKERS HELP A. Ljutow, A. Ljutow Centre for Pain Medicine, Swiss Paraplegic Centre, NottwilSearch for more papers by this authorW. Schleinzer, W. Schleinzer Centre for Pain Medicine, Swiss Paraplegic Centre, NottwilSearch for more papers by this authorM. Metzger, M. Metzger Soziale Arbeit, Hochschule Luzern, Luzern, SwitzerlandSearch for more papers by this author A. Ljutow, A. Ljutow Centre for Pain Medicine, Swiss Paraplegic Centre, NottwilSearch for more papers by this authorW. Schleinzer, W. Schleinzer Centre for Pain Medicine, Swiss Paraplegic Centre, NottwilSearch for more papers by this authorM. Metzger, M. Metzger Soziale Arbeit, Hochschule Luzern, Luzern, SwitzerlandSearch for more papers by this author First published: 30 January 2012 https://doi.org/10.1016/S1754-3207(11)70532-6Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume5, IssueS1September 2011Pages 155-155 RelatedInformation

European Journal of Pain SupplementsVolume 4, Issue S1 p. 122-122 431 TREATMENT OF NEUROPATHIC PAIN WITH INTRATHECAL ZICONOTIDE E. Vogt, E. Vogt Swiss Paraplegic Center, Nottwil, SwitzerlandSearch for more papers by this authorL.M. Macrea, L.M. Macrea Swiss Paraplegic Center, Nottwil, SwitzerlandSearch for more papers by this authorW. Schleinzer, W. Schleinzer Swiss Paraplegic Center, Nottwil, SwitzerlandSearch for more papers by this author E. Vogt, E. Vogt Swiss Paraplegic Center, Nottwil, SwitzerlandSearch for more papers by this authorL.M. Macrea, L.M. Macrea Swiss Paraplegic Center, Nottwil, SwitzerlandSearch for more papers by this authorW. Schleinzer, W. Schleinzer Swiss Paraplegic Center, Nottwil, SwitzerlandSearch for more papers by this author First published: 06 January 2012 https://doi.org/10.1016/S1754-3207(10)70436-3Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume4, IssueS1April 2010Pages 122-122 RelatedInformation

Central neuropathic pain is difficult to treat, but delta 9-Tetrahydrocannabinol (delta 9-THC) may be a promising therapeutic agent. We administered in 172 patients on average 7.5 mg delta 9-THC over 7 months. Of these, 48 patients prematurely withdrew due to side effects, insufficient analgesia, or expense of therapy. Thus, 124 patients were assessed retrospectively in a multicenter telephone survey. Reported changes in pain intensity, recorded on a numeric rating scale (NRS), Pain Disability Index (PDI), Medical Outcomes Short-Form (SF-12), Quality of Life Impairment by Pain (QLIP), Hospital Anxiety Depression Scale (HADS), and amount of concomitant pain medication were recorded. Psychometric parameters (PDI, SF-12, QLIP, HADS) and pain intensity improved significantly during delta 9-THC treatment. Opioid doses were reduced and patients perceived THC therapy as effective with tolerable side effects. About 25% of the patients, however, did not tolerate the treatment. Therapy success and tolerance can be assessed by a transient delta 9-THC titration and its maintained administration for several weeks. The present survey demonstrates its ameliorating potential for the treatment of chronic pain in central neuropathy and fibromyalgia. A supplemental delta 9-THC treatment as part of a broader pain management plan therefore may represent a promising coanalgesic therapeutic option.

European Journal of PainVolume 13, Issue S1 p. S229a-S229 798 INTRODUCING AN ELECTRONIC PATIENT RECORD IN A MULTIDISCIPLINARY PAIN CLINIC A. Ljutow, A. Ljutow Swiss Paraplegic Centre Institute for Anaesthesiology and Pain Medicine, Nottwil, SwitzerlandSearch for more papers by this authorW. Schleinzer, W. Schleinzer Swiss Paraplegic Centre Institute for Anaesthesiology and Pain Medicine, Nottwil, SwitzerlandSearch for more papers by this author A. Ljutow, A. Ljutow Swiss Paraplegic Centre Institute for Anaesthesiology and Pain Medicine, Nottwil, SwitzerlandSearch for more papers by this authorW. Schleinzer, W. Schleinzer Swiss Paraplegic Centre Institute for Anaesthesiology and Pain Medicine, Nottwil, SwitzerlandSearch for more papers by this author First published: 12 January 2012 https://doi.org/10.1016/S1090-3801(09)60801-6Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume13, IssueS1September 2009Pages S229a-S229 RelatedInformation

A complex electronic patient record was implemented in an interdisciplinary pain clinic. The goal was to create a tool that would allow structured access to the entries made by all specialty groups and permit data analysis for statistical and scientific purposes by means of integrated, coded fields. An electronic workflow was developed to facilitate the processing of documents. All entries dictated were converted to digital form and recorded directly into the electronic chart. Additional features included a structured medication list and a connection to the hospital's pre-existing electronic records. The various elements to be included in the chart were determined by an interdisciplinary team and progressively implemented using a commercially available system as a basis. In conclusion, implementation of a complex electronic patient record provides a valuable instrument for quality control, interdisciplinary collaboration and improved efficiency in a large, multimodal pain clinic.

In einer interdisziplinären Schmerzklinik wurde eine komplexe elektronische Krankenakte implementiert. Als Ziel wurde die Schaffung eines Werkzeugs definiert, das strukturierten Zugriff auf die Dokumentation aller Fachgruppen erlaubt und über die Integration kodierter auswertbarer Felder Möglichkeiten zur Datenauswertung für statistische und wissenschaftliche Zwecke gibt. Ein elektronischer Workflow sollte den Weg von Dokumenten vereinfachen und leicht nachvollziehbar machen. Alle Diktate wurden digitalisiert und direkt in den PC aufgenommen. Weitere Punkte waren die strukturierte Medikamentenerfassung und die Anbindung an bestehende EDV-Systeme des Hauses. Die verschiedenen Elemente der Akte wurden durch ein interdisziplinäres Team definiert und schrittweise auf der Basis eines bereits verfügbaren kommerziellen Systems umgesetzt.

Dieses Symposium (Nottwil/Luzern Schweiz, 20./21. Januar 2006) gibt einen Überblick über aktuelle klinische und experimentelle Ergebnisse zur autologen Transfusion. Hauptthemen waren die routinemäßige in-line Leukozytendepletion von Eigenkonserven, immunologische Aspekte der autologen Spende und Re-Transfusion, spezielle Aufbereitungmassnahmen von bakteriell kontaminiertem Wundblut in der Kieferchirurgie, Pro und Contra hinsichtlich Sinnhaftigkeit / Notwendigkeit von autologer Transfusion/Eigenblutspende, autologes Plättchengel sowie medizinische und ökonomische Aspekte der Benchmark-Studie zur Erythrozytentransfusion in Österreich. Der Kongressbericht wird publiziert in ,AINS' (Thieme); entsprechende Einzelpublikationen erscheinen auf Englisch in 'Transfusion Medicine and Hemotherapy' (Karger Inc.) und auf Deutsch in ,Anästhesieologie und Intensivmedizin' (DIOmed).

BACKGROUND The use of pulsed radiofrequency (PRF) for treatment of the medial branch is controversial. STUDY DESIGN A retrospective study of the results of PRF treatment of the medial branch in 48 patients with chronic low back pain was carried out. Patients who did not respond were offered treatment with conventional radiofrequency heat lesions. PATIENT MATERIAL Patients were included who had low back pain and >50% pain relief following a diagnostic medial branch block. The mean age was 53.1 +/- 13.5 years, the mean duration of pain was 11.4 +/- 10.9 years (range 2-50). Nineteen patients had undergone surgery. METHODS Pain scores on a numeric rating scale of 1-10 were noted before and after the diagnostic nerve block, before the procedure, and at 1-month and 4-month follow-up. PRF was applied for 2 minutes at a setting of 2 x 20 ms/s and 45 V at a minimum of two levels using a 22G electrode with a 5 mm active tip. Heat lesions were made at 80 degrees C for 1 minute. OUTCOME DEFINITION: A successful outcome was defined as a >60% improvement on the numeric rating scale at 4-month follow-up. RESULTS In 21/29 nonoperated patients and 5/19 operated patients, the outcome was successful. In the unsuccessful patients who were subsequently treated with heat lesions, the success rate was 1/6. CONCLUSION The setup of our study does not permit a comparison with the results of continuous radiofrequency (CRF) for the same procedure, other than the detection of an obvious trend. When comparing our results with various studies on CRF of the medial branch such a trend could not be found. Based on these retrospective data, prospective and randomized trials, for example, radiofrequency vs PRF are justified.

ZusammenfassungTrotz medizinischem Fortschritt, der Rückenmarkverletz-ten relative Gesundheit und Lebenserwartung zurückgibt, ist der chronische Schmerz bei dieser Patientengruppe häufig eine bedeutende Herausforderung. In die-ser Übersichtsarbeit sollen die Behandlungsoptionen zur Schmerztherapie bei Rückenmarkverletzten zusammenfassend dargestellt werden, beginnend mit konservativmedikamentösen und physikalischen Therapieformen bis hin zu chirurgisch-invasiven, einschließlich neuromodulatorischer und neuroablativer Verfahren, auf die hier schwerpunktmäßig eingegegangen werden soll. Üblicherweise ist keine einzelne Behandlung effizient, son-dern ein selektives, individuelles meist kombiniertes Therapieprogramm notwendig.

This symposium (Nottwil/Lucerne, Switzerland, January 20./21. 2006,) gives you the latest review / clinical results / experimental data on autologous transfusion: Routine leucodepletion of preoperative autologous deposit, immunological perspectives, special processing of bacterially contaminated autologous blood, pro and con concerning autologous blood supply as a reasonable alternative, autologous platelet gel, the Austrian benchmark study on RBC-transfusion. The report on this symposium is published in 'AINS' (Thieme); papers will be published in detail in English in "Transfusion Medicine and Hemotherapy" (Karger Inc.) and in German in "Anästhesiologie und Intensivmedizin" (DIOmed Inc.).