Vienna General Hospital

Acute respiratory distress syndrome (ARDS) has traditionally been managed with population-based, protocolized mechanical ventilation strategies designed to limit ventilator-induced lung injury. While these approaches have improved outcomes, they fail to account for the pronounced biological, mechanical, radiological, and temporal heterogeneity that characterizes ARDS. Accumulating evidence shows that patients differ markedly in functional lung size, recruitability, chest wall mechanics, inflammatory burden, and tolerance to ventilatory stress, making uniform ventilatory targets physiologically imprecise and, at times, harmful. This narrative review examines the evolution from conventional lung-protective ventilation toward a precision-based paradigm that aligns ventilatory support with individual patient physiology. We conceptualize ARDS not as a static syndrome but as a dynamic spectrum, viewing the injured lung as a heterogeneous mechanical system susceptible to regionally amplified stress and strain. Within this framework, we discuss key principles underlying precision ventilation, including functional lung size (the "baby lung"), driving pressure, mechanical power, patient-ventilator interaction, spontaneous breathing-associated injury, and the time-dependent evolution of lung mechanics. We synthesize current evidence supporting mechanical, biological, and radiological subphenotyping as complementary strategies to individualize ventilatory management, while critically appraising their current limitations. This review also evaluates bedside tools that may operationalize precision ventilation in clinical practice, including esophageal pressure monitoring, lung ultrasound, and electrical impedance tomography, and examines the role of artificial intelligence as a clinician-directed decision-support aid rather than a prescriptive substitute for physiological reasoning. Implications for clinical trial design, ethical considerations, and future directions toward predictive and adaptive ventilation strategies are also addressed. Precision mechanical ventilation represents a shift from rigid thresholds toward proportional, physiology-guided intervention across the disease trajectory. By integrating evolving lung mechanics, ventilatory load, and patient effort over time, this approach provides a coherent framework for safer and more effective mechanical ventilation in ARDS while preserving the core principles of lung protection.

Background: The piezoelectric saw is a technology used in osteotomies, providing precise and minimally invasive cuts, especially in areas close to vital structures. Despite its advantages, limitations such as prolonged surgical time and restrictions in use for larger bones have motivated the development of ultrasonic tips with more efficient geometries. Methods: A laboratory trial was conducted with 40 ultrasonic tips (n = 40), divided into 2 groups: the test group (n = 20), with an ultrasonic tip featuring a multidirectional angular cutting-tooth geometry, and the control (n = 20), with a straight-tooth ultrasonic tip. Two operators performed standardized osteotomies on synthetic bone blocks, with monitoring of variables including cutting time (in seconds), maximum block and blade temperature (in °C), and bone mass loss (in grams). Sample randomization was block-based, and blade coding ensured operator and evaluator blinding. Results: The results showed a statistically significant reduction of approximately 26% in cutting time with the multidirectional ultrasonic tips (Test = 52.85 s; Control = 71.55 s; p < 0.001), regardless of the operator. No significant differences were observed between groups regarding maximum bone temperature (Test = 30.45 °C; Control = 29.40 °C; p = 0.337), blade temperature variation (Test = 5.30 °C; Control = 4.10 °C; p = 0.337), overall temperature variation (Test = -0.19 °C; Control = 0.06 °C; p = 0.285), or bone mass loss (Test = 0.1355 g; Control = 0.0350 g; p = 0.387). A significant interaction between operator and blade type in some variables, such as bone temperature variation (p = 0.001), reinforces the influence of technical experience on the results. Conclusions: The multidirectional angular geometry of the ultrasonic tip significantly improves cutting efficiency without compromising thermal safety, representing a promising advancement for optimizing osteotomies in surgical settings. The use of this new geometry may enhance productivity, particularly in complex procedures, and deserves future clinical investigation to expand its applicability across different surgical specialties, including orthopedics.

Background/Objectives: While most patients resume sports within one year after total knee arthroplasty (TKA), data on whether patients achieve their desired level of sports activity remain limited. This study aimed to evaluate the relationship between desired sports activity levels and postoperative outcomes after TKA and to identify factors associated with achieving the desired activity level. Methods: This retrospective cohort study included 280 patients (63.9% female; mean age, 65.7 years) who underwent primary TKA with a mean follow-up of 28.2 months. The University of California and Los Angeles (UCLA) activity score was used pre- and postoperatively to assess the desired and the achieved activity level. Results: The mean UCLA activity score improved significantly after surgery (from 4.6 to 5.6; p < 0.001). However, the mean preoperative desired UCLA score was significantly higher than the mean postoperative achieved UCLA score (7.1 vs. 5.6; p < 0.001). Overall, 34.6% of patients reached their desired activity level. These patients demonstrated a significantly lower preoperative desired UCLA score (6.1 vs. 7.6; p < 0.001) and a higher postoperative achieved UCLA score (6.7 vs. 5.0; p < 0.001) compared with patients who did not. Male sex, higher preoperative UCLA scores, and lower preoperative desired UCLA scores were identified as independent predictors of achieving the desired activity level. Conclusions: The present study demonstrated that despite excellent Knee Society function and WOMAC scores only 1/3 of patients reach their sport-related desired activity level. Surgeons must ensure that they communicate realistic expectations to patients prior to surgery, in order to avoid dissatisfaction that may arise from unmet expectations.

Background/Objectives: Endoscopic submucosal dissection (ESD) is a state-of-the-art en bloc resection for early gastro-intestinal cancers and precursors developed and validated in Japan. Western expertise with this complex technique remains limited. Tutored training might be optimal for patients and ESD learning. We established ESD tutoring courses led by experienced Japanese experts to provide (i) optimal long-term curative outcomes and low complication rates for patients and (ii) hands-on training on difficult lesions for European endoscopists under direct expert supervision. Methods: Prospective data from 2011 to 2015 (follow-up to 12/2024) were analyzed. A total of 118 neoplasms (50% HGIEN and cancer) in 101 patients (median age 68 [37-91] years; 38% with significant comorbidities) were treated with expert or tutored ESD. Japanese experts performed 28 ESDs, while 22 trained beginners conducted 90 supervised procedures on difficult lesions during 5 live and 20 tutoring events (1-4 days each). Results: Analysis of the complete data showed curative and en bloc resection rates of 88% and 95%, respectively, with no recurrence after R0 resections during a median follow-up of 9.8 [1.5-14.9] years. Long-term survival remained recurrence-free after endoscopic resection of 3 recurrent adenomas (at R1/Rx) and curative surgery/2nd ESD for 5 non-curative ESDs. Adverse events occurred in 9.3% without emergency surgery or 30-day mortality. Comparing expert-only vs. tutored ESD procedures, beginners correctly applied curative ESD indications in 94% of 118 neoplasms. Experts resected larger lesions (22 cm2) at a rate of 9.3 cm2/h in 121 min. Tutored beginners achieved a 75% [25-100] self-completion rate on 33% smaller lesions in 112 min. Conclusions: ESD tutoring courses led by Japanese experts ensure excellent patient outcomes and standardized procedural training. This model may foster professional ESD performance across European referral centers.

BackgroundSurgical treatment for osteoarthritis of the hip includes hip resurfacing (HR) and total hip arthroplasty (THA) via various surgical approaches. The discussion about the benefits and preferability of each procedure is highly controversial. We aimed to quantify the patients’ utilization of opioids within the first 30 days following surgery and hypothesized that there are no differences in pain, medication, ability to walk, and function between direct anterior approach THA (DAA-THA), posterior approach THA (PA-THA), and HR.MethodsThis retrospective study evaluated 207 hips in 199 patients (DAA: 126 hips, PA: 59, HR: 21), who underwent surgery for primary osteoarthritis between 2020 and 2022. Patients used an app (SeamlessMD, Toronto, Canada) to report pain, utilization of opioids, additional pain medication, walking distance, swelling, and wound drainage for 30 days and HOOS-JR and satisfaction at one month after surgery. Results were compared between the groups after adjusting for age and BMI and patient satisfaction was correlated with pain and function.ResultsOpioid cessation was 99% 20 days after surgery. HOOS-JR improvement from pre- to postoperative was 23 points on average (-29-82, SD 15) and was significant in all groups (p < 0.001). No differences in pain, the dosage of opioids and complications were found between DAA-THA, PA-THA and HR.ConclusionThe current data showed a high rate of opioid cessation (99%) within 3 weeks following hip reconstructive surgery. DAA-THA, PA-THA, and HR provided comparable opioid usage, function, and a low early complication rate within the first month after surgery.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12891-025-09337-w.

Background: Large-scale data on the diagnostic performance of functional imaging in metastatic pheochromocytoma/paraganglioma (PPGL) are scarce. Objective: To analyze the diagnostic accuracy of functional imaging for the assessment of metastases during long-term follow-up (FU). Design: Retrospective cohort study, 1991-2025. Setting: Referral center. Outcomes: Sensitivity and specificity of 123MIBG-, 18F-DOPA-, 68GaDOTA-based and 18FDG PET/CT. Patients: Patients with metastatic PPGL and without PPGL, ≥1 functional imaging prior to first diagnosis and/or during FU and FU ≥ 3 months. Results: 59 123MIBG-, 101 18F-DOPA-, 11 18FDG- and 74 68GaDOTA-based PET/CT were performed in 57 patients with metastatic PPGL and 37 123MIBG-, 323 18F-DOPA-, 259 18FDG- and 641 68GaDOTA-based imaging in 527 patients without PPGL. FU was 11.6 ± 11.4 and 5.1 ± 4.7 years, respectively. Sensitivity for the detection of all metastases (total cohort) by patient-based analysis was comparable between 18F-DOPA (77%), both 68GaDOTA-based tracers combined (67%) and 123MIBG (72%); lesion-based analysis was better for 18F-DOPA (94%) than for 68GaDOTA (85%) and 123MIBG (67%). Specificity (patient- and lesion-based) of 18F-DOPA vs. 68GaDOTA (96-99%) was comparable and better than 123MIBG (73%) and 18FDG (75%). Conclusions: Sensitivity of 18F-DOPA was superior to 68GaDOTA for the detection of all and bone metastases in the total cohort and in patients with PCC, that of 68GaDOTA was better for bone metastases with PGL, specificity was comparable and for both was better than for 18FDG and 123MIBG. Given the beneficial pharmaceutical properties and favorable diagnostic performance, 18F-DOPA may be a good alternative to 68GaDOTA-based tracers for the functional imaging of metastatic PPGL.