Articles

Can the cytokine adsorber CytoSorb^® help to mitigate cytokine storm and reduce mortality in critically ill patients? A propensity score matching analysis

A cytokine storm is life threatening for critically ill patients and is mainly caused by sepsis or severe trauma. In combination with supportive therapy, the cytokine adsorber Cytosorb^® (CS) is increasingly used ...

Authors: Christina Scharf, Ines Schroeder, Michael Paal, Martin Winkels, Michael Irlbeck, Michael Zoller and Uwe Liebchen

Noninvasive ventilation vs. high-flow nasal cannula oxygen for preoxygenation before intubation in patients with obesity: a post hoc analysis of a randomized controlled trial

Critically ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. We hypothesized that pre-oxygenation with noninvasive ventilation before intubation as c...

Authors: Maeva Rodriguez, Stéphanie Ragot, Rémi Coudroy, Jean-Pierre Quenot, Philippe Vignon, Jean-Marie Forel, Alexandre Demoule, Jean-Paul Mira, Jean-Damien Ricard, Saad Nseir, Gwenhael Colin, Bertrand Pons, Pierre-Eric Danin, Jérome Devaquet, Gwenael Prat, Hamid Merdji…

Platelet activation in critically ill COVID-19 patients

Microvascular, arterial and venous thrombotic events have been largely described during severe coronavirus disease 19 (COVID-19). However, mechanisms underlying hemostasis dysregulation remain unclear.

Authors: Nader Yatim, Jeremy Boussier, Richard Chocron, Jérôme Hadjadj, Aurélien Philippe, Nicolas Gendron, Laura Barnabei, Bruno Charbit, Tali-Anne Szwebel, Nicolas Carlier, Frédéric Pène, Célia Azoulay, Lina Khider, Tristan Mirault, Jean-Luc Diehl, Coralie L. Guerin…

Myeloid phenotypes in severe COVID-19 predict secondary infection and mortality: a pilot study

De-regulated host response to severe coronavirus disease 2019 (COVID-19), directly referring to the concept of sepsis-associated immunological dysregulation, seems to be a strong signature of severe COVID-19. ...

Authors: Clémence Marais, Caroline Claude, Nada Semaan, Ramy Charbel, Simon Barreault, Brendan Travert, Jean-Eudes Piloquet, Zoé Demailly, Luc Morin, Zied Merchaoui, Jean-Louis Teboul, Philippe Durand, Jordi Miatello and Pierre Tissières

Early warning of bloodstream infection in elderly patients with circulating microparticles

The difficulty of early diagnosis of bloodstream infection in the elderly patients leads to high mortality. Therefore, it is essential to determine some new methods of early warning of bloodstream infection in...

Authors: Tingting Liu, Jiang Wang, Yaping Yuan, Jionghe Wu, Chao Wang, Yueqin Gu and Hongxia Li

High risk of patient self-inflicted lung injury in COVID-19 with frequently encountered spontaneous breathing patterns: a computational modelling study

There is on-going controversy regarding the potential for increased respiratory effort to generate patient self-inflicted lung injury (P-SILI) in spontaneously breathing patients with COVID-19 acute hypoxaemic...

Authors: Liam Weaver, Anup Das, Sina Saffaran, Nadir Yehya, Timothy E. Scott, Marc Chikhani, John G. Laffey, Jonathan G. Hardman, Luigi Camporota and Declan G. Bates

Prevalence and prognostic value of various types of right ventricular dysfunction in mechanically ventilated septic patients

Right ventricle (RV) dilation in combination with elevated central venous pressure (CVP), which is a state of RV congestion, is seen as a sign of RV failure (RVF). On the other hand, RV systolic function is us...

Authors: Hongmin Zhang, Wei Huang, Qing Zhang, Xiukai Chen, Xiaoting Wang and Dawei Liu

A rational approach on the use of extracorporeal membrane oxygenation in severe hypoxemia: advanced technology is not a panacea

Veno-venous extracorporeal membrane oxygenation (ECMO) is a helpful intervention in patients with severe refractory hypoxemia either because mechanical ventilation cannot ensure adequate oxygenation or because...

Authors: Evangelia Akoumianaki, Annemijn Jonkman, Michael C. Sklar, Dimitris Georgopoulos and Laurent Brochard

Mental health outcomes of ICU and non-ICU healthcare workers during the COVID-19 outbreak: a cross-sectional study

Intensive care workers are known for their stressful work environment and for a high prevalence of mental health outcomes. The aim of this study was to evaluate the mental health, well-being and changes in lif...

Authors: Hannah Wozniak, Lamyae Benzakour, Grégory Moullec, Niccolò Buetti, Alice Nguyen, Sandrine Corbaz, Pauline Roos, Laure Vieux, Jean-Claude Suard, Rafaël Weissbrodt, Jérôme Pugin, Jacques A. Pralong and Sara Cereghetti

Correction to: Performance of the ROX index to predict intubation in immunocompromised patients receiving high-flow nasal cannula for acute respiratory failure

Authors: Virginie Lemiale, Guillaume Dumas, Alexandre Demoule, Frederic Pène, Achille Kouatchet, Magali Bisbal, Saad Nseir, Laurent Argaud, Loay Kontar, Kada Klouche, Francois Barbier, Amelie Seguin, Guillaume Louis, Jean-Michel Constantin, Julien Mayaux, Florent Wallet…

Energetic dysfunction in sepsis: a narrative review

Growing evidence associates organ dysfunction(s) with impaired metabolism in sepsis. Recent research has increased our understanding of the role of substrate utilization and mitochondrial dysfunction in the pa...

Authors: Sebastien Preau, Dominique Vodovar, Boris Jung, Steve Lancel, Lara Zafrani, Aurelien Flatres, Mehdi Oualha, Guillaume Voiriot, Youenn Jouan, Jeremie Joffre, Fabrice Huel, Nicolas De Prost, Stein Silva, Eric Azabou and Peter Radermacher

Gender disparity in critical care publications: a novel Female First Author Index

Bibliometric analyses show gender bias against women in scientific publications and citations. We hypothesized that a metric of an individual senior author’s inclusivity of women as first authors in critical c...

Authors: Sowmya Chary, Karin Amrein, Djøra I. Soeteman, Sangeeta Mehta and Kenneth B. Christopher

Long-term quality of life in necrotizing soft-tissue infection survivors: a monocentric prospective cohort study

Compared to other life-threatening infection survivors, long-term health-related quality of life (QOL) of patients surviving necrotizing soft-tissue infections (NSTI) and its determinants are little known.

Authors: Tomas Urbina, Florence Canoui-Poitrine, Camille Hua, Richard Layese, Aline Alves, Rachida Ouedraogo, Romain Bosc, Emilie Sbidian, Olivier Chosidow, Armand Mekontso Dessap and Nicolas de Prost

Transpulmonary thermodilution in patients treated with veno-venous extracorporeal membrane oxygenation

We tested the effect of different blood flow levels in the extracorporeal circuit on the measurements of cardiac stroke volume (SV), global end-diastolic volume index (GEDVI) and extravascular lung water index...

Authors: Gregor Loosen, Alice Marguerite Conrad, Michael Hagman, Nils Essert, Manfred Thiel, Thomas Luecke and Joerg Krebs

The Italian document: decisions for intensive care when there is an imbalance between care needs and resources during the COVID-19 pandemic

In early 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published clinical ethics recommendations for the allocation of intensive care during COVID-19 pandemic eme...

Authors: Luigi Riccioni, Francesca Ingravallo, Giacomo Grasselli, Davide Mazzon, Emiliano Cingolani, Gabrio Forti, Vladimiro Zagrebelsky, Riccardo Zoja and Flavia Petrini

Proceedings of Reanimation 2021, the French Intensive Care Society International Congress

Authors:

Diaphragm dysfunction, lung aeration loss and weaning-induced pulmonary oedema in difficult-to-wean patients

Diaphragm dysfunction and weaning-induced pulmonary oedema are commonly involved during weaning failure, but their physiological interactions have been poorly reported. Our hypothesis was that diaphragm dysfun...

Authors: Martin Dres, Emmanuel Rozenberg, Elise Morawiec, Julien Mayaux, Julie Delemazure, Thomas Similowski and Alexandre Demoule

Rapid-flow expulsion maneuver in subglottic secretion clearance to prevent ventilator-associated pneumonia: a randomized controlled study

Following endotracheal intubation, clearing secretions above the endotracheal tube cuff decreases the incidence of ventilator-associated pneumonia (VAP); therefore, subglottic secretion drainage (SSD) is widel...

Authors: Ying Li, Xue Yuan, Bing Sun, Hai-chao Li, Hui-wen Chu, Li Wang, Yu Zhao, Xiao Tang, Rui Wang, Xu-yan Li, Zhao-hui Tong and Chen Wang

Intra-dialytic hypotension following the transition from continuous to intermittent renal replacement therapy

Transition from continuous renal replacement therapy (CRRT) to intermittent renal replacement therapy (IRRT) can be associated with intra-dialytic hypotension (IDH) although data to inform the definition of ID...

Authors: William Beaubien-Souligny, Yifan Yang, Karen E. A. Burns, Jan O. Friedrich, Alejandro Meraz-Muñoz, Edward G. Clark, Neill K. Adhikari, Sean M. Bagshaw and Ron Wald

Prevalence and risk factors of hemodynamic instability associated with preload-dependence during continuous renal replacement therapy in a prospective observational cohort of critically ill patients

Hemodynamic instability is a frequent complication of continuous renal replacement therapy (CRRT). Postural tests (i.e., passive leg raising in the supine position or Trendelenburg maneuver in the prone positi...

Authors: Guillaume Chazot, Laurent Bitker, Mehdi Mezidi, Nader Chebib, Paul Chabert, Louis Chauvelot, Laure Folliet, Guillaume David, Judith Provoost, Hodane Yonis and Jean-Christophe Richard

The Ockham’s razor for estimating the needs of ICU beds during a pandemic

It is possible to monitor an epidemic evolution by plotting the number of patients, or its log-transform, as a function of time. However, these representations do not allow quick identifications of significant...

Authors: Pierre Squara

Correction to: Elevated plasma IL-6 and CRP levels are associated with adverse clinical outcomes and death in critically ill SARS-CoV-2 patients: infammatory response of SARS-CoV-2 patients

An amendment to this paper has been published and can be accessed via the original article.

Authors: Jean-Rémi Lavillegrand, Marc Garnier, Agathe Spaeth, Nathalie Mario, Geofroy Hariri, Antoine Pilon, Enora Berti, Fabienne Fieux, Sara Thietart, Tomas Urbina, Matthieu Turpin, Lucie Darrivere, Muriel Fartoukh, Franck Verdonk, Guillaume Dumas, Alain Tedgui…

Protective ventilation and outcomes of critically ill patients with COVID-19: a cohort study

Approximately 5% of COVID-19 patients develop respiratory failure and need ventilatory support, yet little is known about the impact of mechanical ventilation strategy in COVID-19. Our objective was to describ...

Authors: Juliana C. Ferreira, Yeh-Li Ho, Bruno Adler Maccagnan Pinheiro Besen, Luiz Marcelo Sa Malbouisson, Leandro Utino Taniguchi, Pedro Vitale Mendes, Eduardo Leite Vieira Costa, Marcelo Park, Renato Daltro-Oliveira, Roberta M. L. Roepke, Joao M. Silva-Jr, Maria Jose Carvalho Carmona and Carlos R. R. Carvalho

Short-term health-related quality of life, physical function and psychological consequences of severe COVID-19

Survivors of severe COVID-19 are at risk of impaired health-related quality of life (HRQoL) and persistent physical and psychological disability after ICU and hospital discharge. The subsequent social burden i...

Authors: Luca Carenzo, Alessandro Protti, Francesca Dalla Corte, Romina Aceto, Giacomo Iapichino, Angelo Milani, Alessandro Santini, Chiara Chiurazzi, Michele Ferrari, Enrico Heffler, Claudio Angelini, Alessio Aghemo, Michele Ciccarelli, Arturo Chiti, Theodore J. Iwashyna, Margaret S. Herridge…

Mental health and stress among ICU healthcare professionals in France according to intensity of the COVID-19 epidemic

We investigated the impact of the COVID-19 crisis on mental health of professionals working in the intensive care unit (ICU) according to the intensity of the epidemic in France.

Authors: Alexandra Laurent, Alicia Fournier, Florent Lheureux, Guillaume Louis, Saad Nseir, Gwenaelle Jacq, Cyril Goulenok, Grégoire Muller, Julio Badie, Bélaïd Bouhemad, Marjolaine Georges, Paul-Michel Mertes, Hamid Merdji, Vincent Castelain, Caroline Abdulmalak, Olivier Lesieur…

Individualization of PEEP and tidal volume in ARDS patients with electrical impedance tomography: a pilot feasibility study

In mechanically ventilated patients with acute respiratory distress syndrome (ARDS), electrical impedance tomography (EIT) provides information on alveolar cycling and overdistension as well as assessment of r...

Authors: Tobias Becher, Valerie Buchholz, Daniel Hassel, Timo Meinel, Dirk Schädler, Inéz Frerichs and Norbert Weiler

Target arterial PO₂ according to the underlying pathology: a mini-review of the available data in mechanically ventilated patients

There is an ongoing discussion whether hyperoxia, i.e. ventilation with high inspiratory O₂ concentrations (F_IO₂), and the consecutive hyperoxaemia, i.e. supraphysiological arterial O₂ tensions (PaO₂), have a pla...

Authors: Julien Demiselle, Enrico Calzia, Clair Hartmann, David Alexander Christian Messerer, Pierre Asfar, Peter Radermacher and Thomas Datzmann

Impact of dexamethasone on the incidence of ventilator-associated pneumonia and blood stream infections in COVID-19 patients requiring invasive mechanical ventilation: a multicenter retrospective study

Dexamethasone decreases mortality in patients with severe coronavirus disease 2019 (COVID-19) and has become the standard of care during the second wave of pandemic. Dexamethasone is an immunosuppressive treat...

Authors: Ines Gragueb-Chatti, Alexandre Lopez, Dany Hamidi, Christophe Guervilly, Anderson Loundou, Florence Daviet, Nadim Cassir, Laurent Papazian, Jean-Marie Forel, Marc Leone, Jean Dellamonica and Sami Hraiech

Acute kidney injury in SARS-CoV2-related pneumonia ICU patients: a retrospective multicenter study

While acute kidney injury (AKI) is frequent in severe SARS-CoV2-related pneumonia ICU patients, few data are still available about its risk factors.

Authors: Guillaume Geri, Michael Darmon, Lara Zafrani, Muriel Fartoukh, Guillaume Voiriot, Julien Le Marec, Saafa Nemlaghi, Antoine Vieillard-Baron and Elie Azoulay

Sleep alterations just after extubation do not predict short-term respiratory failure, but…

Authors: Dominique Robert

Correction to: Impact of systematic screening for AmpC-hyperproducing Enterobacterales intestinal carriage in intensive care unit patients

An amendment to this paper has been published and can be accessed via the original article.

Authors: Elsa Manquat, Matthieu Le Dorze, Gauthier Pean De Ponflly, Hanaa Benmansour, Rishma Amarsy, Emmanuelle Cambau, Benjamin Soyer, Benjamin Glenn Chousterman and Hervé Jacquier

Infectious events in patients with severe COVID-19: results of a cohort of patients with high prevalence of underlying immune defect

Empirical antibiotic has been considered in severe COVID-19 although little data are available regarding concomitant infections. This study aims to assess the frequency of infections, community and hospital-ac...

Authors: Anastasia Saade, Giulia Moratelli, Guillaume Dumas, Asma Mabrouki, Jean-Jacques Tudesq, Lara Zafrani, Elie Azoulay and Michael Darmon

Lipid and lipoprotein predictors of functional outcomes and long-term mortality after surgical sepsis

Sepsis is a life-threatening, dysregulated response to infection. Lipid biomarkers including cholesterol are dynamically regulated during sepsis and predict short-term outcomes. In this study, we investigated ...

Authors: Faheem W. Guirgis, Christiaan Leeuwenburgh, Lyle Moldawer, Gabriela Ghita, Lauren Page Black, Morgan Henson, Elizabeth DeVos, David Holden, Phil Efron, Srinivasa T. Reddy and Frederick A. Moore

Resuscitative endovascular balloon occlusion of the aorta vs epinephrine in the treatment of non-traumatic cardiac arrest in swine

The administration of epinephrine in the management of non-traumatic cardiac arrest remains recommended despite controversial effects on neurologic outcome. The use of resuscitative endovascular balloon occlus...

Authors: Alice Hutin, Yaël Levy, Fanny Lidouren, Matthias Kohlhauer, Pierre Carli, Bijan Ghaleh, Lionel Lamhaut and Renaud Tissier

The autonomic nervous system in septic shock and its role as a future therapeutic target: a narrative review

The autonomic nervous system (ANS) regulates the cardiovascular system. A growing body of experimental and clinical evidence confirms significant dysfunction of this regulation during sepsis and septic shock. ...

Authors: Marta Carrara, Manuela Ferrario, Bernardo Bollen Pinto and Antoine Herpain

Fluid-induced harm in the hospital: look beyond volume and start considering sodium. From physiology towards recommendations for daily practice in hospitalized adults

Iatrogenic fluid overload is a potential side effect of intravenous fluid therapy in the hospital. Little attention has been paid to sodium administration as a separate cause of harm. With this narrative revie...

Authors: Niels Van Regenmortel, Lynn Moers, Thomas Langer, Ella Roelant, Tim De Weerdt, Pietro Caironi, Manu L. N. G. Malbrain, Paul Elbers, Tim Van den Wyngaert and Philippe G. Jorens

Radiological pattern in ARDS patients: partitioned respiratory mechanics, gas exchange and lung recruitability

The ARDS is characterized by different degrees of impairment in oxygenation and distribution of the lung disease. Two radiological patterns have been described: a focal and a diffuse one. These two patterns co...

Authors: Silvia Coppola, Tommaso Pozzi, Martina Gurgitano, Alessandro Liguori, Ejona Duka, Francesca Bichi, Arianna Ciabattoni and Davide Chiumello

Characteristics, management, and prognosis of elderly patients with COVID-19 admitted in the ICU during the first wave: insights from the COVID-ICU study

The COVID-19 pandemic is a heavy burden in terms of health care resources. Future decision-making policies require consistent data on the management and prognosis of the older patients (> 70 years old) with CO...

Authors: Martin Dres, David Hajage, Said Lebbah, Antoine Kimmoun, Tai Pham, Gaëtan Béduneau, Alain Combes, Alain Mercat, Bertrand Guidet, Alexandre Demoule and Matthieu Schmidt

Simplified frontal EEG in adults under veno-arterial extracorporeal membrane oxygenation

EEG-based prognostication studies in intensive care units often rely on a standard 21-electrode montage (_stdEEG) requiring substantial human, technical, and financial resources. We here evaluate whether a simplif...

Authors: Cyril Touchard, Jérôme Cartailler, Geoffroy Vellieux, Etienne de Montmollin, Pierre Jaquet, Ruben Wanono, Jean Reuter, Marylou Para, Lila Bouadma, Jean-François Timsit, Marie-Pia d’Ortho, Nathalie Kubis, Anny Rouvel Tallec and Romain Sonneville

Specific exposure of ICU staff to SARS-CoV-2 seropositivity: a wide seroprevalence study in a French city-center hospital

Most hospital organizations have had to face the burden of managing the ongoing COVID-19 outbreak. One of the challenges in overcoming the influx of COVID-19 patients is controlling patient-to-staff transmissi...

Authors: Emmanuel Vivier, Caroline Pariset, Stephane Rio, Sophie Armand, Fanny Doroszewski, Delphine Richard, Marc Chardon, Georges Romero, Pierre Metral, Matthieu Pecquet and Adrien Didelot

Virtual reality vs. Kalinox® for management of pain in intensive care unit after cardiac surgery: a randomized study

The management of pain and anxiety remains a challenge in the intensive care unit. By distracting patients, virtual reality (VR) may have a role in painful procedures. We compared VR vs. an inhaled equimolar m...

Authors: Driss Laghlam, Cecile Naudin, Lucas Coroyer, Vincent Aidan, Julien Malvy, Ghilas Rahoual, Philippe Estagnasié and Pierre Squara

Convalescent plasma therapy and mortality in COVID-19 patients admitted to the ICU: a prospective observational study

This study aimed to quantify the potential survival benefit of convalescent plasma therapy (CVP) in critically ill patients with acute respiratory failure related to coronavirus disease-2019 (COVID-19).

Authors: Stefan Hatzl, Florian Posch, Nazanin Sareban, Martin Stradner, Konrad Rosskopf, Alexander C. Reisinger, Philipp Eller, Michael Schörghuber, Wolfgang Toller, Zdenka Sloup, Florian Prüller, Katharina Gütl, Stefan Pilz, Alexander R. Rosenkranz, Hildegard T. Greinix, Robert Krause…

Perceived inequity, professional and personal fulfillment by women intensivists in France

The medical workforce has been feminized for the last two decades worldwide. Nonetheless, women remain under-represented among intensivists. We conducted a survey among French women intensivists to assess thei...

Authors: Caroline Hauw-Berlemont, Cécile Aubron, Nadia Aissaoui, Laetitia Bodet-Contentin, Florence Boissier, Muriel Sarah Fartoukh, Mercedes Jourdain, Julien Le Marec, Julia Pestel, Charlotte Salmon Gandonnière, Fabienne Tamion and Olfa Hamzaoui

Role of sleep on respiratory failure after extubation in the ICU

Sleep had never been assessed immediately after extubation in patients still in the ICU. However, sleep deprivation may alter respiratory function and may promote respiratory failure. We hypothesized that slee...

Authors: Arnaud W. Thille, Stephanie Barrau, Clément Beuvon, Damien Marie, Faustine Reynaud, Justine Bardin, Adrien Pépin-Lehalleur, Vanessa Bironneau, Jean-Claude Meurice, Rémi Coudroy, Jean-Pierre Frat, René Robert, Christophe Rault and Xavier Drouot

Malignant pertussis in infants: factors associated with mortality in a multicenter cohort study

Malignant pertussis (MP) affects young infants and is characterized by respiratory distress, perpetual tachycardia and hyperleukocytosis up to 50 G/l, leading to multiple organ failure and death in 75% of case...

Authors: Mathilde Coquaz-Garoudet, Dominique Ploin, Robin Pouyau, Yoav Hoffmann, Julien-Frederic Baleine, Benoît Boeuf, Hugues Patural, Anne Millet, Marc Labenne, Renaud Vialet, Didier Pinquier, Marie Cotillon, Jérôme Rambaud and Etienne Javouhey

Transcranial sonographic assessment of the third ventricle in neuro-ICU patients to detect hydrocephalus: a diagnostic reliability pilot study

Transcranial sonography is a point-of-care tool recommended in intensive care units (ICU) to monitor brain injured patients. Objectives of the study was to assess feasibility and reliability of the third ventr...

Authors: Rémy Widehem, Paul Bory, Frédéric Greco, Frédérique Pavillard, Kévin Chalard, Alexandre Mas, Flora Djanikian, Julie Carr, Nicolas Molinari, Samir Jaber, Pierre-François Perrigault and Gerald Chanques

Response to the letter to the Editor “Regional citrate anticoagulation for intermittent hemodialysis in the intensive care. What is the optimal set-up?” by Gubensek et al.

Authors: Christophe Leroy and Alexandre Lautrette

Regional citrate anticoagulation for intermittent hemodialysis in the intensive care: what is the optimal setup?

Authors: Jakob Gubensek and Vanja Persic

Admission criteria and management of critical care patients in a pandemic context: position of the Ethics Commission of the French Intensive Care Society, update of April 2021

Intensive care unit professionals have experience in critical care and its proportionality, collegial decision-making, withholding or withdrawal of treatment deemed futile, and communication with patients’ rel...

Authors: Olivier Lesieur, Jean Pierre Quenot, Zoé Cohen-Solal, Raphaëlle David, Laure De Saint Blanquat, Maxime Elbaz, Bénédicte Gaillard Le Roux, Cyril Goulenok, Sylvain Lavoué, Virginie Lemiale, Emmanuelle Mercier, Chaouki Mezher, Benoît Misset, Gwendolyn Penven, Anne Laure Poujol, Bertrand Quentin…

Circadian rhythms in septic shock patients

Despite the intensive efforts to improve the diagnosis and therapy of sepsis over the last decade, the mortality of septic shock remains high and causes substantial socioeconomical burden of disease. The funct...

Authors: Gunnar Lachmann, Bharath Ananthasubramaniam, Viktor A. Wünsch, Lara-Marie Scherfig, Clarissa von Haefen, Cornelia Knaak, Andreas Edel, Lukas Ehlen, Barbara Koller, Anton Goldmann, Hanspeter Herzel, Achim Kramer and Claudia Spies