Background Muscle ultrasound represents a promising approach to aid diagnoses of neuromuscular diseases in critically ill patients. Unfortunately, standardization of ultrasound measurements in clinical research is lacking, making direct comparisons between studies difficult. Protocols are required to assess qualitative muscle changes during an ICU stay in patients at high risk for the development of neuromuscular acquired weakness (ICUAW). Methods We conducted a retrospective, observational analysis comprised of three prospective observational studies with the aim of diagnosing muscle changes by ultrasound measurement of the quadriceps muscle. Different protocols were used in each of the three studies. In total, 62 surgical, neurocritical care and trauma intensive care patients were serially assessed by different ultrasound protocols during the first week of critical illness. The relative change in ultrasound measurements was calculated for all possible locations, methods and sides. Comparison was obtained using mixed effect models with the location, the height and the side as influencing variables and patients as fixed effect. The relationship between variables and outcomes was assessed by multivariable regression analysis. Results Ultrasound methods and measurement sites of the quadriceps muscles from all protocols were equally effective in detecting muscle changes. During the first week of an ICU stay, two groups were identified: patients with decreased muscle mass on ultrasound (n = 42) and a cohort with enlargement (n = 23). Hospital mortality was significantly increased in the cohort with muscle swelling (8 (19%) versus 12 (52%), p = .013). Conclusions Different approaches of ultrasound measurement during critical-illness are equally able to detect muscle changes. While some patients have a decrease in muscle mass, others show swelling, which may result in a reduced probability of surviving the hospital stay. Causative reasons for these results still remain unclear.

BackgroundIn subarachnoid hemorrhage (SAH), titrating sedation to find a balance between wakefulness with the ability to perform valid clinical examinations on the one hand, and deep sedation to minimize secondary brain damage, on the other hand, is challenging. However, data on this topic are scarce, and current guidelines do not provide recommendations for sedation protocols in SAH.MethodsWe designed a web-based, cross-sectional survey for German-speaking neurointensivists to map current standards for the indication and monitoring of sedation, duration of prolonged sedation, and biomarkers for the withdrawal of sedation.ResultsOverall, 17.4% (37/213) of neurointensivists answered the questionnaire. Most of the participants were neurologists (54.1%, 20/37) and exhibited a long-standing experience in intensive care medicine (14.9 years, SD 8.3). Among indications for prolonged sedation in SAH, the control of intracranial pressure (ICP) (94.6%) and status epilepticus (91.9%) were most significant. With regard to further complications in the course of the disease, therapy refractory ICP (45.9%, 17/37) and radiographic surrogates of elevated ICP, such as parenchymal swelling (35.1%, 13/37), were the most relevant topics for experts. Regular awakening trials were performed by 62.2% of neurointensivists (23/37). All participants used clinical examination for the therapeutic monitoring of sedation depth. A total of 83.8% of neurointensivists (31/37) used methods based on electroencephalography. As a mean duration of sedation before attempting an awakening trial in patients with unfavorable biomarkers, neurointensivists suggested 4.5 days (SD 1.8) for good-grade SAH and 5.6 days (SD 2.8) for poor-grade SAH, respectively. Many experts performed cranial imaging before the definite withdrawal of sedation [84.6% (22/26)], and 63.6% (14/22) of the participants required an absence of herniation, space-occupying lesions, or global cerebral edema. The values of ICP tolerated for definite withdrawal were smaller compared to that of awakening trials (17.3 mmHg vs. 22.1 mmHg), and patients were required to stay below the threshold value for several hours (21.3 h, SD 10.7).ConclusionDespite the paucity of clear recommendations for sedation management in SAH in the pre-existing literature, we found some level of agreement indicating clinical efficacy for certain clinical practices. By mapping the current standard, this survey may help to identify controversial aspects in the clinical care of SAH and thereby streamline future research.

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Akkadian had two words meaning "grain, barley" associated with the SumerogramŠESumerogramˇSumerogramŠE: ˇ se'u(m) and e(y)yû(m). The former is a borrowing from Sumerian, the latter most probably Semitic. New evidence is presented for both words in lexical lists, with care taken to make explicit the philological contexts in which they occur. The question of the etymology of the Semitic word is approached, with an evaluation of the kinds of evidence available. It is suggested that derivation from *h. yy "life" is indeed plausible, although not from the stem-form *h. ayyum. The divine names Ea and H ˘ aya, spouse of Nissaba, are also considered. While Ea and H ˘ aya may be at some remove genetically related to each other and to e(y)yû they should not be considered to be identical in historical epochs. 1 1. The Debate so far The Akkadian word for "barley, grain" is traditionally assumed to bě se'u(m), but has been argued on the basis of the evidence from lexical lists in fact to bêbê u(m), with the use of the sigň SE being used logographically to write the wordû wordˆwordû(m). The elementary sign-list Syllabary A (S a) was used by scribes as a crucial early stage in learning to write. 2 In its version written on tablets from the first millennium, it has variant readings at line 386: manuscript A reads DIŠšeDIˇDIŠDIŠˇDIŠše-e = ˇ SE = ´ u-um; manuscripts I and U read (compositely) DIŠšeDIˇDIŠDIŠˇDIŠše-e = ˇ SE = ˇ se-[u]. 3 1 I am very grateful to A.R. George, D. Schwemer and J.D. Hawkins for reading draughts of this article and preventing me from committing umpteen infelicities of structure, logical errors and unnecessary obfuscations. Any such remain my own fault. I am also grateful to L. Kogan for commenting on some of the ideas. 2 On lexical lists in general, see Cavigneaux 1980-1983; Civil 1995. N. Veldhuis is working on a much-needed primer dedicated to cuneiform lexical lists. In Old Babylonian (OB) Nippur they used the sign-list Ea (monolingual) with its pendant vocabulary Aa (bilingual) in the position that S a occupied in the curriculum. The function of each was to introduce the students to the polyvalence of individual cuneiform signs, although the variety of equivalent Sumerian values given to each sign was more reduced in S a than it was in Ea. 3 MSL 3.40, 386.