Ingo Marzi

University Hospital Frankfurt, Frankfurt, Hesse, Germany

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Publications (399)639.71 Total impact

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    ABSTRACT: Outcome after traumatic brain injury (TBI) in the elderly has not been fully elucidated. The present retrospective observational study investigates the age-dependent outcome of patients suffering from severe isolated TBI with regard to operative and non-operative treatment. Data were prospectively collected in the TraumaRegister DGU(®). Anonymous datasets of 8629 patients with isolated severe blunt TBI (AISHead≥3, AISBody≤1) documented from 2002 to 2011 were analysed. Patients were grouped according to age: 1-17, 18-59, 60-69, 70-79 and ≥80 years. Cranial fractures (44.8%) and subdural haematomas (42.6%) were the most common TBIs. Independent from the type of TBI the group of patients with operative treatment declined with rising age. Subgroup analysis of patients with critical TBI (AISHead=5) revealed standardised mortality ratios (SMRs) of 0.81 (95% CI 0.75-0.87) in case of operative treatment (n=1201) and 1.13 (95% CI 1.09-1.18) in case of non-operative treatment (n=1096). All age groups ≥60 years showed significantly reduced SMRs in case of operative treatment. Across all age groups the group of patients with low/moderate disability according to the GOS (4 or 5 points) was higher in case of operative treatment. Results of this retrospective observational study have to be interpreted cautiously. However, good outcome after TBI with severe space-occupying haemorrhage is more frequent in patients with operative treatment across all age groups. Age alone should not be the reason for limited care or denial of operative intervention. Copyright © 2015. Published by Elsevier Ltd.
    Injury 03/2015; DOI:10.1016/j.injury.2015.02.013 · 2.46 Impact Factor
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    ABSTRACT: aim: Cell based therapy by cultivated stem cells (mesenchymal stem cells (MSC), endothelial progenitor cells (EPC)) in large-sized bone defects have already shown improved vascularization and new bone formation. But these methods are clinically afflicted with disadvantages. Another heterogeneous bone marrow cell population, so called bone marrow-derived mononuclear cells (BMC) has yet been used clinically and showed improved vascularization in ischemic limbs or myocardium. For clinical use a certified process has been established. BMC were isolated from bone marrow aspirate by density gradient centrifugation, washed, cleaned and given back to patients within several hours. This investigation tested the ability of human BMC seeded on b-tricalcium phosphate (β-TCP) and placed into a large rat bone defect to improve bone healing process in vivo. Methods: Human EPC were isolated from buffy coat and MSC or BMC, respectively, were isolated from bone marrow aspirate by density gradient centrifugation. 1.0 x106 cells were loaded onto 750 µl β-TCP (0.7-1.4 mm). Large femural defects (6mm) in athymic rats were created surgically and stabilized with internal fixateur. The remaining defects were filled with β-TCP granules alone (group 1), β-TCP+ EPC/MSC (group 2) or β-TCP+ BMC (group 3). After 8 weeks histomorphometric analysis (new bone formation), radiological µCT-analyses (bony bridging) and biomechanical testing (3-point-bending) were achieved. Moreover a tumorgenicity study were performed to evaluate safety of BMC implantation after 26 weeks. For statistical analysis Kruskal-Wallis-test was used. Results: 8 weeks after implantation of EPC/MSC or BMC respectively, we detected significantly more new bone formation compared to control. In group 2 and 3 bony bridging of the defect was seen. In the control group more chondrocytes and osteoid was detected. In BMC and EPC/MSC group, respectively less chondrocytes and significantly more and advanced bone formation was observed. Biomechanical stability of the bone regenerate was significantly enhanced if BMC and EPC/MSC, respectively were implanted compared to control. Moreover, no tumor formation was detected neither macroscopically nor histologically after 26 weeks of BMC implantation. Discussion: Implanted BMC suggests that a heterogeneous cell population may provide a powerful cellular therapeutic strategy for bone healing in a large bone defect in humans.
    Tissue Engineering Part A 02/2015; DOI:10.1089/ten.TEA.2014.0410 · 4.07 Impact Factor
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    ABSTRACT: The purpose of our study was to evaluate minimally invasive sacroiliac screw fixation for treatment of posterior pelvic instability with the help of CT controlled guidewires, assess its accuracy, safety and effectiveness, and discuss potential pitfalls. 100 guidewires and hollow titan screws were inserted in 38 patients (49.6±19.5 years) suffering from 35 sacral fractures and/or 16 sacroiliac joint disruptions due to 33 (poly-)traumatic, 2 osteoporotic and 1 post-infectious conditions. The guidewire and screw positions were analyzed in multiplanar reconstructions. The mean minimal distance between guidewire and adjacent neural foramina was 4.5±2.01mm, with a distinctly higher precision in S1 than S2. Eight guidewires showed cortical contacts, resulting in a total of 2% mismatched screws with subsequent wall violation. The fracture gaps were reduced from 3.6±0.53mm to 1.2±0.54mm. During follow-up 3 cases of minor iatrogenic sacral impaction (<5mm) due to the bolting and 2 cases of screw loosening were observed. Interventional time was 84.0min with a mean of 2.63 screws per patient whilst acquiring a mean of 93.7 interventional CT-images (DLP 336.7mGycm). The treatment of posterior pelvic instability with a guidewire-based screw insertion technique under CT-imaging results in a very high accuracy and efficacy with a low complication rate. Careful attention should be drawn to radiation levels. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
    European Journal of Radiology 02/2015; 84(2):290-4. DOI:10.1016/j.ejrad.2014.11.017 · 2.16 Impact Factor
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    ABSTRACT: Sliding-gantry computed tomography offers an interesting variety of treatment options for emergency radiology and clinical routine. The Frankfurt 2-room installation provides an interdisciplinary, multifunctional, and cost-effective concept. It is based on a magnetically sealed rail system for the permanent movement of the gantry between 2 adjacent rooms with fixed-mounted tables. In case of emergency or intensive care patients, routine scanning can be performed in room 1 until computed tomography diagnosis is required in room 2 and can then be continued in room 1 again. Moreover, this concept allows the simultaneous handling of 2 emergency patients.
    Journal of Computer Assisted Tomography 01/2015; DOI:10.1097/RCT.0000000000000199 · 1.60 Impact Factor
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    ABSTRACT: Background Although it is often criticised, the lecture remains a fundamental part of medical training because it is an economical and efficient method for teaching both factual and experimental knowledge. However, if administered incorrectly, it can be boring and useless.Feedback from peers is increasingly recognized as an effective method of encouraging self-reflection and continuing professional development. The aim of this observational study is to analyse the impact of written peer feedback on the performance of lecturers in an emergency medicine lecture series for undergraduate students.Methods In this prospective study, 13 lecturers in 15 lectures on emergency medicine for undergraduate medical students were videotaped and analysed by trained peer reviewers using a 21-item assessment instrument. The lecturers received their written feedback prior to the beginning of the next years¿ lecture series and were assessed in the same way.ResultsIn this study, we demonstrated a significant improvement in the lecturers¿ scores in the categories `content and organisation¿ and `visualisation¿ in response to written feedback. The highest and most significant improvements after written peer feedback were detected in the items `provides a brief outline¿, `provides a conclusion for the talk¿ and `clearly states goal of the talk¿.Conclusion This study demonstrates the significant impact of a single standardized written peer feedback on a lecturer¿s performance.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 12/2014; 22(1):71. DOI:10.1186/s13049-014-0071-1 · 1.93 Impact Factor
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    ABSTRACT: Emergency department personnel are at risk of occupational exposure to blood-borne pathogens. Previous studies have shown that the prevalence of human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) virus infections among trauma patients is higher compared to the general population.
    Der Unfallchirurg 11/2014; DOI:10.1007/s00113-014-2657-5 · 0.61 Impact Factor
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    ABSTRACT: The nomenclature for patients with multiple injuries with high mortality rates is highly variable, and there is a lack of a uniform definition of the term polytrauma. A consensus process was therefore initiated by a panel of international experts with the goal of assessing an improved, database-supported definition for the polytraumatized patient. The consensus process involved the following: RESULTS: A total of 28,211 patients in the trauma registry met the inclusion criteria. The mean (SD) age of the study cohort was 42.9 (20.2) years (72% males, 28% females). The mean (SD) ISS was 30.5 (12.2), with an overall mortality rate of 18.7% (n = 5,277) and an incidence of 3% of penetrating injuries (n = 886). Five independent physiologic variables were identified, and their individual cutoff values were calculated based on a set mortality rate of 30%: hypotension (systolic blood pressure ≤ 90 mm Hg), level of consciousness (Glasgow Coma Scale [GCS] score ≤ 8), acidosis (base excess ≤ -6.0), coagulopathy (international normalized ratio ≥ 1.4/partial thromboplastin time ≥ 40 seconds), and age (≥70 years). Based on several consensus meetings and a database analysis, the expert panel proposes the following parameters for a definition of "polytrauma": significant injuries of three or more points in two or more different anatomic AIS regions in conjunction with one or more additional variables from the five physiologic parameters. Further validation of this proposal should occur, favorably by mutivariate analyses of these parameters in a separate data set.
    Journal of Trauma and Acute Care Surgery 11/2014; 77(5):780-786. DOI:10.1097/TA.0000000000000453 · 2.50 Impact Factor
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    ABSTRACT: The purpose of this retrospective monocenter study was to evaluate a monophasic multidetector computed tomography (MDCT) protocol with a fixed delay for patients with polytrauma.A total of 2086 patients were evaluated retrospectively. For the intravenous contrast media, we used a fixed protocol with an injection for an adult patient of 120 mL at a rate of 2 mL/s.In the venous phase, we detected injuries of parenchyma and localized ongoing bleedings in regard to the clinical follow-up, with regard to the easy feasibility and the quickness with only one scan.Monophasic venous injection protocol can detect all injuries in the whole-body MDCT for patients with polytrauma.
    Clinical Imaging 10/2014; DOI:10.1016/j.clinimag.2014.09.011 · 0.60 Impact Factor
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    ABSTRACT: Abstract Background: Trauma patients sustaining abdominal trauma exhibit high risk of organ failure and/or sepsis aggravating morbidity and mortality during the post-traumatic course. The present study re-evaluates L- and I-FABPs (small fatty acid binding proteins) as early biomarkers for abdominal injury (AI) in a large cohort of patients and analyzes their potential as indicators of specific organ failure and their association with sepsis and/or mortality in the post-traumatic course. Methods: This prospective study included 134 multiply traumatized patients (ISS≥16). Fifty-nine had AI (abbreviated AI Scale, AISAbd≥3) and 75 had no AI (noAI). Twenty healthy volunteers served as controls. Plasma I- and L-FABP levels were measured at the admittance to the emergency room (d0) and up to 10 days daily (d1-d10) using ELISA. Sepsis, organ failure, multiple organ failure (MOF) and mortality were assessed. Results: Median L- and I-FABP in the AI-group [258 (IQR=71-500) ng/mL and 328 (IQR=148-640) pg/mL, respectively] were higher compared to noAI-group [30 (IQR=18-50) ng/mL and 60 (IQR=40-202) pg/mL, p>0.05] on d0. Sensitivity and specificity to detect AI were 80% and 75% for L-FABP, 78% and 62% for I-FABP. Both FABPs decline with the post-traumatic course to control levels. On d0 and d1, FABPs correlate with the Sepsis-related Organ Failure Assessment (SOFA) score of the following day (d0: ρ:0.33, ρ:0.46, d1: ρ:0.48, ρ:0.35). No other correlations were found. Eight percent of all patients developed sepsis, 18% pneumonia, 4% urinary tract infection, 3% acute kidney failure and one MOF. FABPs correlated neither with Simplifed Acute Physiology Score (SAPS)-II nor to sepsis. All patients with acute kidney failure demonstrated enhanced L-FAPB levels before the increase of serum creatinine levels. Conclusions: Our results confirm the potential of L- and I-FABP to indicate abdominal injuries initially after trauma. Except L-FABP as indicator of acute kidney failure both FABPs have to be further evaluated as predictors for other organ failures, sepsis and/or mortality.
    Clinical Chemistry and Laboratory Medicine 10/2014; DOI:10.1515/cclm-2014-0354 · 2.96 Impact Factor
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    ABSTRACT: Scoring systems commonly attempt to reduce complex clinical situations into one-dimensional values by objectively valuing and combining a variety of clinical aspects. The aim is to allow for a comparison of selected patients or cohorts. To appreciate the true value of scoring systems in patients with multiple injuries it is necessary to understand the different purposes of quantifying the severity of specific injuries and overall trauma load, being: (1) clinical decision making; (2) triage; (3) planning of trauma systems and resources; (4) epidemiological and clinical research; (5) evaluation of outcome and trauma systems, including quality assessment; and (6) estimation of costs and allocation of resources. For the first two, easy-to estimate scores with immediate availability are necessary, mainly based on initial physiology. More sophisticated scores considering age, gender, injury pattern/severity and more are usually used for research and outcome evaluation, once the diagnostic and therapeutic process has been completed. For score development large numbers of data are necessary and thus, it appears as a logical consequence that large registries as the TraumaRegister DGU(®) of the German Trauma Society (TR-DGU) are used to derive and validate clinical scoring systems. A variety of scoring systems have been derived from this registry, the majority of them with focus on hospital mortality. The most important among these systems is probably the RISC score, which is currently used for quality assessment and outcome adjustment in the annual audit reports. This report summarizes the various scoring systems derived from the TraumaRegister DGU(®) over the recent years.
    Injury 10/2014; 45 Suppl 3:S29-34. DOI:10.1016/j.injury.2014.08.014 · 2.46 Impact Factor
  • Orthopädie und Unfallchirurgie - Mitteilungen und Nachrichten 08/2014; 03(04):390-391. DOI:10.1055/s-0034-1387841
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    ABSTRACT: The purpose of this work was to retrospectively evaluate clinical and radiological results after surgical treatment for scapholunate ligament ruptures.
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    ABSTRACT: OBJECTIVE. The optimal treatment of intervertebral disk lesions accompanying thoracolumbar fractures remains controversial. To evaluate short- and medium-term progression of intervertebral disk lesions accompanying vertebral fractures, MRI scans obtained after trauma were compared with scans obtained at an average follow-up of 1 year, by means of our clinically useful classification of traumatic intervertebral disk lesions. MATERIALS AND METHODS. MRI scans of 54 disks in patients with trauma-induced single-level thoracolumbar fractures were analyzed retrospectively. All patients underwent posterior stabilization using a titanium internal fixator. Exclusion criteria were malignant vertebral collapse, spondylodiskitis, osteoporotic fractures, and degenerative disk disease in the uninjured disks. Morphologic changes and signal alterations of the adjacent disks were compared using routine MRI scans obtained after trauma and at an average follow-up of 1 year. Disks were divided according to their signals into four categories, from grade 0 to grade 3. RESULTS. Of the disks studied after trauma (n = 54), 27.8% were determined to be grade 0, 31.5% were grade 2, and 40.7% were grade 3. In the follow-up examination, MRI detected grade 0 in 13% of disks. Hence, more than 50% of the disks with grade 0 after trauma changed into grade 2 lesions, resulting in 46.3% grade 2 lesions. Grade 3 disk lesions (40.7%) remained the same without any sign of recovery. CONCLUSION. In the current study, we found progressive disk degradation and creeping in instrumented and nonfused segments in thoracolumbar fractures. For further validation, randomized controlled long-term outcome investigations seem mandatory as the next step in future clinical research.
    American Journal of Roentgenology 07/2014; 203(1):140-5. DOI:10.2214/AJR.13.11590 · 2.74 Impact Factor
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    ABSTRACT: Background. Hypoxia-inducible factor-1 α (HIF-1 α ) and NF- κ B play important roles in the inflammatory response after hemorrhagic shock and resuscitation (H/R). Here, the role of myeloid HIF-1 α in liver hypoxia, injury, and inflammation after H/R with special regard to NF- κ B activation was studied. Methods. Mice with a conditional HIF-1 α knockout (KO) in myeloid cell-line and wild-type (WT) controls were hemorrhaged for 90 min (30 ± 2 mm Hg) and resuscitated. Controls underwent only surgical procedures. Results. After six hours, H/R enhanced the expression of HIF-1 α -induced genes vascular endothelial growth factor (VEGF) and adrenomedullin (ADM). In KO mice, this was not observed. H/R-induced liver injury in HIF-1 α KO was comparable to WT. Elevated plasma interleukin-6 (IL-6) levels after H/R were not reduced by HIF-1 α KO. Local hepatic hypoxia was not significantly reduced in HIF-1 α KO compared to controls after H/R. H/R-induced NF- κ B phosphorylation in liver did not significantly differ between WT and KO. Conclusions. Here, deleting HIF-1 α in myeloid cells and thereby in Kupffer cells was not protective after H/R. This data indicates that other factors, such as NF- κ B, due to its upregulated phosphorylation in WT and KO mice, contrary to HIF-1 α , are rather key modulators of inflammation after H/R in our model.
    Mediators of Inflammation 06/2014; 2014:930419. DOI:10.1155/2014/930419 · 2.42 Impact Factor
    This article is viewable in ResearchGate's enriched format
  • B Auner, I Marzi
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    ABSTRACT: Multiple trauma in children is rare so that even large trauma centers will only treat a small number of cases. Nevertheless, accidents are the most common cause of death in childhood whereby the causes are mostly traffic accidents and falls. Head trauma is the most common form of injury and the degree of severity is mostly decisive for the prognosis. Knowledge on possible causes of injury and injury patterns as well as consideration of anatomical and physiological characteristics are of great importance for treatment. The differences compared to adults are greater the younger the child is. Decompression and stopping bleeding are the main priorities before surgical fracture stabilization. The treatment of a severely injured child should be carried out by an interdisciplinary team in an approved trauma center with expertise in pediatrics. An inadequate primary assessment involves a high risk of early mortality. On the other hand children have a better prognosis than adults with comparable injuries.
    Der Chirurg 05/2014; 85(5):451-64. DOI:10.1007/s00104-013-2680-z · 0.52 Impact Factor
  • I Marzi, T Lustenberger
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    ABSTRACT: In patients with severe pelvic fractures, exsanguinating hemorrhage represents the major cause of death within the first 24 h. Despite advances in management, the mortality rate in these patients remains significantly high. Recently, multiple treatment algorithms have been proposed for patients with severe pelvic fractures; however, the optimal modalities in particular in the hemodynamically unstable patient are still a matter of lively debate.This review article focuses on the recent body of knowledge on the different treatment options in patients with severe pelvic fractures and proposes the possible role of each modality in the management of these patients. The MEDLINE database was searched for medical literature addressing the management of severe pelvic fractures with specific attention given to recent, clinically relevant publications. Angiography and embolization have emerged as excellent methods for addressing arterial bleeding. Mechanical pelvic stabilization and surgical hemostasis by pelvic packing, on the other hand, may effectively control venous bleeding and bleeding from the fractured bony surface. However, since there is no precise way to determine the major source of bleeding that is responsible for the hemodynamic instability, controversy remains over the timing and optimal order of angiography, mechanical pelvic stabilization, and packing. The author's own approach to these patients includes angiographic embolization as a first-line treatment only in hemodynamically stable patients with an arterial blush seen in the computed tomography scan, indicating acute arterial bleeding. Hemodynamically unstable patients are immediately transferred to the operating room, where pelvic packing and mechanical stabilization of the pelvic ring are carried out. Optionally, a subsequent postoperative angio-embolization is performed if signs of further bleeding remain present.
    04/2014; DOI:10.1177/1457496914525604
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    ABSTRACT: Trauma remains a major public health problem worldwide. Intentional and unintentional injuries occur in high- as well as in low- and middle-income countries, leading to deaths and millions of disabled individuals. No other disease has had such an impact on individuals, on families, and on society. Interestingly enough, recognizing traumatic injury as a disease, using a disease management model, and providing organized and comprehensive care through the development of trauma systems decreases mortality by 25 % and markedly reduces the burden of the disease. Again, no other disease process has been affected so much by the organization and implementation of care systems.Although we all recognize trauma as the number one killer between the ages of 1 and 45 years worldwide, it was only until recently (August 2012) that the world came together in Rio de Janeiro to learn, debate, and discuss not only modern management strategies, but also to acknowledge our individual and the collective respo ...
    European Journal of Trauma and Emergency Surgery 04/2014; 40(2):105-106. DOI:10.1007/s00068-014-0393-8 · 0.38 Impact Factor
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    ABSTRACT: Purpose Needlestick injuries (NSIs) are a significant health hazard. Occupational transmission of bloodborne pathogens among healthcare workers (HCWs) is rare but has been repeatedly reported in the literature. Methods In October 2010, new regulations were introduced for medical aftercare of HCWs following NSIs at the University Hospital Frankfurt. In June 2013, a university hospital-wide early intervention program was introduced that gives HCWs immediate 24/7/365 access to an HIV postexposure prophylaxis kit after confirmed or probable occupational HIV exposure. Results Interdisciplinary collaboration between the attending surgeon and occupational health as well as infectious disease specialists facilitates optimal postexposure medical treatment of HCWs who suffer NSIs. Complete reporting of NSIs is a prerequisite for achieving optimal treatment of the affected HCWs. Conclusion An NSI is an emergency and needs to be evaluated immediately and, if necessary, treated as soon as possible. A standardized algorithm for initial diagnostic and treatment has proven to be helpful.
    European Journal of Trauma and Emergency Surgery 04/2014; 40(2):151-158. DOI:10.1007/s00068-014-0376-9 · 0.38 Impact Factor
  • European Journal of Trauma 04/2014; 28(2):51-51. DOI:10.1007/s000680200000
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    ABSTRACT: To report our experience using C-arm cone beam CT (C-arm CBCT) combined with the new remote operated positioning and guidance system, iSYS1, for needle guidance during spinal interventions. A C-arm CBCT with a flat panel angiography system was acquired (Artis Zeego; Siemens Healthcare Sector, Forchheim, Germany). Reconstruction of CT-like images and planning of the needle path were performed using a common workstation. The needle holder of iSYS1 acted as a guide during insertion of Kirschner (K) wires. 20 percutaneous K wires were placed in the pedicles at T2-T3, T7-T12, and L1-L2 in a cadaver specimen. Postprocedure C-arm CBCT scans were obtained to confirm the accuracy of the K wire placement. All K wire placements were successfully performed. Mean planning time with Syngo iGuide was 4:16 min, mean positioning time of iSYS1 was 3:35 min, and mean placement time of the K wires was 2:22 min. Mean total intervention time was 10:13 min per pedicle. A mean deviation of 0.35 mm between the planned path and the placed K wire with a mean path length of 6.73 cm was documented. Our results demonstrate the potential of combining C-arm CBCT with iSYS1 for safe and accurate percutaneous placement of pedicle K wires in spinal interventions.
    Journal of Neurointerventional Surgery 03/2014; 7(4). DOI:10.1136/neurintsurg-2013-011034 · 2.50 Impact Factor

Publication Stats

3k Citations
639.71 Total Impact Points

Institutions

  • 2006–2015
    • University Hospital Frankfurt
      Frankfurt, Hesse, Germany
  • 2002–2014
    • Goethe-Universität Frankfurt am Main
      • • Center of Surgery
      • • Klinik für Unfall-, Hand-, und Wiederherstellungschirurgie
      Frankfurt, Hesse, Germany
  • 2013
    • Hospital Frankfurt Hoechst
      Frankfurt, Hesse, Germany
    • Berufsgenossenschaftliche Unfallklinik Murnau
      Murnau, Bavaria, Germany
  • 2010–2012
    • Medical University of South Carolina
      • Department of Pharmaceutical Sciences
      Charleston, South Carolina, United States
    • Universitätsmedizin Göttingen
      • Department of Trauma Surgery and Orthopedics
      Göttingen, Lower Saxony, Germany
  • 1989–2012
    • University of North Carolina at Chapel Hill
      • • Center for Digestive Diseases and Nutrition
      • • Department of Medicine
      • • Department of Pharmacology
      North Carolina, United States
  • 2011
    • Universität Witten/Herdecke
      • Institute for Research in Operative Medicine (IFOM)
      Witten, North Rhine-Westphalia, Germany
  • 2007–2009
    • Orthopädische Universitätsklinik Friedrichsheim
      Frankfurt, Hesse, Germany
    • Martin Luther University Halle-Wittenberg
      Halle-on-the-Saale, Saxony-Anhalt, Germany
  • 1990–2004
    • Universität des Saarlandes
      • • Klinik für Unfall-, Hand- und Wiederherstellungschirurgie
      • • Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie
      Saarbrücken, Saarland, Germany
  • 2000
    • University of Cologne
      Köln, North Rhine-Westphalia, Germany
  • 1993
    • Ludwig Boltzmann Institute for Experimental and Clinical Traumatology
      Wien, Vienna, Austria