Characteristics and special challenges of neonatal emergency transports

BACKGROUND

As a rule, newborns do not require special medical care. If unexpected complications occur peripartum or postpartum, support from and transport to specialised neonatal hospitals might be needed.

METHODS

In a retrospective study, all transport protocols of a supraregional paediatric‑neonatological maximum care hospital in northwestern Germany from 01.10.2018 through 30.09.2021 were analysed. The particular focus was on transports of newborns (<7 days) and the leading symptoms that led to contact.

RESULTS

A total of 299 patients were included (average age of 15.4 h, 61.6 % males). The average complete transport time was approximately 2 h. Five leading neonatal diseases (respiratory, infectious, asphyxia, cardiac, haematological) were found to represent the causes of >80 % of transfers. Respiratory adaptation disorders are the main reason for transferring a newborn to a centre, whereas asphyxia is the most severe condition. The various symptoms differ in their time of onset, a factor which must be taken into account in practice. Differences were also found between different types of hospitals: while a large proportion of transports were carried out from maternity hospitals (80.6 %), children transported from children's hospitals were generally more severely ill.

DISCUSSION

Transfers of neonates, especially from maternity hospitals to neonatal intensive care units due to special neonatal diseases, are not rare. In times of increasingly scarce resources, the effective care of sick or at-risk neonates is essential. For low-population regions, this means professional cooperation between maximum care providers and smaller children's hospitals and maternity-only hospitals.

Impact of daily artificial gravity on autonomic cardiovascular control following 60-day head-down tilt bed rest

Impaired cardiovascular autonomic control following space flight or immobilization may limit the ability to cope with additional hemodynamic stimuli. Head-down tilt bedrest is an established terrestrial analog for space flight and offers the opportunity to test potential countermeasures for autonomic cardiovascular deconditioning. Previous studies revealed a possible benefit of daily artificial gravity on cardiovascular autonomic control following head-down tilt bedrest, but there is a need for efficiency in a long-term study before an artificial gravity facility would be brought to space. We hypothesized that artificial gravity through short-arm centrifugation attenuates functional adaptions of autonomic function during head-down tilt bed rest. 24 healthy persons (8 women, 33.4 ± 9.3 years, 24.3 ± 2.1 kg/m2) participated in the 60-day head-down tilt bed rest (AGBRESA) study. They were assigned to three groups, 30 min/day continuous, or 6(5 min intermittent short-arm centrifugation, or a control group. We assessed autonomic cardiovascular control in the supine position and in 5 minutes 80° head-up tilt position before and immediately after bed rest. We computed heart rate variability (HRV) in the time (rmssd) and frequency domain, blood pressure variability, and baroreflex sensitivity (BRS). RR interval corrected rmssd was reduced supine (p = 0.0358) and during HUT (p = 0.0161). Heart rate variability in the high-frequency band (hf-RRI; p = 0.0004) and BRS (p < 0.0001) decreased, whereas blood pressure variability in the low-frequency band (lf-SBP, p = 0.0008) increased following bedrest in all groups. We did not detect significant interactions between bedrest and interventions. We conclude that up to daily 30 min of artificial gravity on a short-arm centrifuge with 1Gz at the center of mass do not suffice to prevent changes in autonomic cardiovascular control following 60-day of 6° head-down tilt bed rest. Clinical Trial Registration: https://drks.de/search/en/trial/DRKS00015677, identifier, DRKS00015677.

Effects of daily artificial gravity training on orthostatic tolerance following 60-day strict head-down tilt bedrest

PURPOSE

Orthostatic intolerance commonly occurs following immobilization or space flight. We hypothesized that daily artificial gravity training through short-arm centrifugation could help to maintain orthostatic tolerance following head-down tilt bedrest, which is an established terrestrial model for weightlessness.

METHODS

We studied 24 healthy persons (eight women; age 33.3 ± 9.0 years; BMI 24.3 ± 2.1 kg/m2) who participated in the 60-days head-down tilt bedrest (AGBRESA) study. They were assigned to 30 min/day continuous or 6 × 5 min intermittent short-arm centrifugation with 1Gz at the center of mass or a control group. We performed head-up tilt testing with incremental lower-body negative pressure until presyncope before and after bedrest. We recorded an electrocardiogram, beat-to-beat finger blood pressure, and brachial blood pressure and obtained blood samples from an antecubital venous catheter. Orthostatic tolerance was defined as time to presyncope. We related changes in orthostatic tolerance to changes in plasma volume determined by carbon dioxide rebreathing.

RESULTS

Compared with baseline measurements, supine and upright heart rate increased in all three groups following head-down tilt bedrest. Compared with baseline measurements, time to presyncope decreased by 323 ± 235 s with continuous centrifugation, by 296 ± 508 s with intermittent centrifugation, and by 801 ± 354 s in the control group (p = 0.0249 between interventions). The change in orthostatic tolerance was not correlated with changes in plasma volume.

CONCLUSIONS

Daily artificial gravity training on a short-arm centrifuge attenuated the reduction in orthostatic tolerance after 60 days of head-down tilt bedrest.

Comparison of denoising tools for the reconstruction of nonlinear multimodal images

Biophotonic multimodal imaging techniques provide deep insights into biological samples such as cells or tissues. However, the measurement time increases dramatically when high-resolution multimodal images (MM) are required. To address this challenge, mathematical methods can be used to shorten the acquisition time for such high-quality images. In this research, we compared standard methods, e.g., the median filter method and the phase retrieval method via the Gerchberg-Saxton algorithm with artificial intelligence (AI) based methods using MM images of head and neck tissues. The AI methods include two approaches: the first one is a transfer learning-based technique that uses the pre-trained network DnCNN. The second approach is the training of networks using augmented head and neck MM images. In this manner, we compared the Noise2Noise network, the MIRNet network, and our deep learning network namely incSRCNN, which is derived from the super-resolution convolutional neural network and inspired by the inception network. These methods reconstruct improved images using measured low-quality (LQ) images, which were measured in approximately 2 seconds. The evaluation was performed on artificial LQ images generated by degrading high-quality (HQ) images measured in 8 seconds using Poisson noise. The results showed the potential of using deep learning on these multimodal images to improve the data quality and reduce the acquisition time. Our proposed network has the advantage of having a simple architecture compared with similar-performing but highly parametrized networks DnCNN, MIRNet, and Noise2Noise.

Design and test of a rigid endomicroscopic system for multimodal imaging and femtosecond laser ablation

Significance

Conventional diagnosis of laryngeal cancer is normally made by a combination of endoscopic examination, a subsequent biopsy, and histopathology, but this requires several days and unnecessary biopsies can increase pathologist workload. Nonlinear imaging implemented through endoscopy can shorten this diagnosis time, and localize the margin of the cancerous area with high resolution.

Aim

Develop a rigid endomicroscope for the head and neck region, aiming for in-vivo multimodal imaging with a large field of view (FOV) and tissue ablation.

Approach

Three nonlinear imaging modalities, which are coherent anti-Stokes Raman scattering, two-photon excitation fluorescence, and second harmonic generation, as well as the single photon fluorescence of indocyanine green, are applied for multimodal endomicroscopic imaging. High-energy femtosecond laser pulses are transmitted for tissue ablation.

Results

This endomicroscopic system consists of two major parts, one is the rigid endomicroscopic tube 250 mm in length and 6 mm in diameter, and the other is the scan-head (10 × 12 × 6    cm 3 in size) for quasi-static scanning imaging. The final multimodal image accomplishes a maximum FOV up to 650    μ m , and a resolution of 1    μ m is achieved over 560    μ m FOV. The optics can easily guide sub-picosecond pulses for ablation.

Conclusions

The system exhibits large potential for helping real-time tissue diagnosis in surgery, by providing histological tissue information with a large FOV and high resolution, label-free. By guiding high-energy fs laser pulses, the system is even able to remove suspicious tissue areas, as has been shown for thin tissue sections in this study.

[Update 2022: interdisciplinary statement on airway management with supraglottic airway devices in pediatric emergency medicine-The laryngeal mask is and remains state of the art : Joint statement of the Institute for Emergency Medicine and Medicine Management (INM), the University Clinic Munich, LMU Munich, Germany, the Working Group for Pediatric Critical Care and Emergency Medicine of the German Interdisciplinary Society for Critical Care and Emergency Medicine (DIVI), the Medical Directors of Emergency Medical Services in Bavaria (ÄLRD), the Scientific Working Group for Pediatric Anesthesia (WAKKA) of the German Society for Anesthesiology and Intensive Care Medicine (DGAI), the Scientific Working Group for Emergency Medicine of the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and the Society of Neonatology and Pediatric Critical Care Medicine (GNPI)]

BACKGROUND

Airway management with supraglottic airway devices (SGA) in life-threatening emergencies in children is increasingly being used. Different specifications of laryngeal masks (LM) and the laryngeal tube (LT) are commonly used devices for this purpose. We present a literature review and interdisciplinary consensus statement of different societies on the use of SGA in pediatric emergency medicine.

MATERIAL AND METHODS

Literature review in the PubMed database and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine. Levels and consensus finding within the group of authors.

RESULTS

The evidence for successful applications of the various types of LM is significantly higher than for LT application. Reported smaller series of successful applications of LT are currently limited to selected research groups and centers. Especially for children below 10 kg body weight there currently exists insufficient evidence for the successful application of the LT and therefore its routine use cannot be recommended. SGAs used for emergencies should have a gastric drainage possibility.

DISCUSSION

Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children currently only the LM can be recommended for alternative (i.e., non-intubation) emergency airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1½, 2, 2½, 3) for out of hospital use and in hospital emergency use and all users should regularly be trained in its application.

The extracellular matrix landscape in salivary gland carcinomas is defined by cellular differentiation via expression of three distinct protein modules

The extracellular matrix (ECM) is an integral part of the tumor microenvironment of carcinomas. Even though salivary gland carcinomas (SGC) display a range of tumor cell differentiation and distinct extracellular matrices, their ECM landscape has not been characterized in depth. The ECM composition of 89 SGC primaries, 14 metastases and normal salivary gland tissues was assessed using deep proteomic profiling. Machine learning algorithms and network analysis were used to detect tumor groups and protein modules that explain specific ECM landscapes. Multimodal in situ studies to validate exploratory findings and to infer a putative cellular origin of ECM components were applied. We revealed two fundamental SGC ECM classes which align with the presence or absence of myoepithelial tumor differentiation. We describe the SGC ECM through three biologically distinct protein modules that are differentially expressed across ECM classes and cell types. The modules have a distinct prognostic impact on different SGC types. Since targeted therapy is rarely available for SGC, we used the proteomic expression profile to identify putative therapeutic targets. In summary, we provide the first extensive inventory of ECM components in SGC, a difficult-to-treat disease that encompasses tumors with distinct cellular differentiation. This article is protected by copyright. All rights reserved.

Multi-Class Cancer Subtyping in Salivary Gland Carcinomas with MALDI Imaging and Deep Learning

Salivary gland carcinomas (SGC) are a heterogeneous group of tumors. The prognosis varies strongly according to its type, and even the distinction between benign and malign tumor is challenging. Adenoid cystic carcinoma (AdCy) is one subgroup of SGCs that is prone to late metastasis. This makes accurate tumor subtyping an important task. Matrix-assisted laser desorption/ionization (MALDI) imaging is a label-free technique capable of providing spatially resolved information about the abundance of biomolecules according to their mass-to-charge ratio. We analyzed tissue micro arrays (TMAs) of 25 patients (including six different SGC subtypes and a healthy control group of six patients) with high mass resolution MALDI imaging using a 12-Tesla magnetic resonance mass spectrometer. The high mass resolution allowed us to accurately detect single masses, with strong contributions to each class prediction. To address the added complexity created by the high mass resolution and multiple classes, we propose a deep-learning model. We showed that our deep-learning model provides a per-class classification accuracy of greater than 80% with little preprocessing. Based on this classification, we employed methods of explainable artificial intelligence (AI) to gain further insights into the spectrometric features of AdCys.

CD138 Is Expressed in Different Entities of Salivary Gland Cancer and Their Lymph Node Metastases and Therefore Represents a Potential Therapeutic Target

Advanced salivary gland carcinomas (SGC) often lack therapeutic options. Agents targeting CD138 have recently shown promising results in clinical trials for multiple myeloma and a preclinical trial for triple-negative breast cancer. Immunohistochemistry for CD138 was performed for all patients who had undergone primary surgery for SGC with curative intent. Findings were validated using matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) imaging. Overall, 111 primary SGC and 13 lymph node metastases from salivary duct carcinomas (SaDu) were evaluated. CD138 expression was found in 60% of all SGC with differing expression across entities (p < 0.01). A mean of 25.2% of the tumor cells in mucoepidermoid carcinoma (MuEp) were positive, followed by epithelial-myoepithelial carcinoma (20.9%), acinic cell carcinoma (16.0%), and SaDu (15.2%). High-/intermediate-grade MuEp showed CD138 expression in a mean of 34.8% of tumor cells. For SaDu, lymph node metastases showed CD138 expression in a mean of 31.2% of tumor cells which correlated with CD138 expression in their primaries (p = 0.01; Spearman’s ρ = 0.71). MALDI-MS imaging confirmed the presence of the CD138 protein in SGC. No significant association was found between clinicopathological data, including progression-free survival (p = 0.50) and CD138 expression. CD138 is expressed in the cell membrane of different entities of SGC and SaDu lymph node metastases and therefore represents a potential target for CD138 targeting drugs.

Health Services Use and Costs in Individuals with Autism Spectrum Disorder in Germany: Results from a Survey in ASD Outpatient Clinics

Introduction

Autism spectrum disorders (ASD) are associated with high services use, but European data on costs are scarce.

Objectives

Utilisation and annual costs of 385 individuals with ASD (aged 4-67 years; 18.2% females; 37.4% IQ < 85) from German outpatient clinics were assessed.

Methods

Client Service Receipt Inventory

Results

Average annual costs per person were 3287 EUR, with psychiatric inpatient care (19.8%), pharmacotherapy (11.1%), and occupational therapy (11.1%) being the largest cost components. Females incurred higher costs than males (4864 EUR vs. 2936 EUR). In a regression model, female sex (Cost Ratio: 1.65), lower IQ (1.90), and Asperger syndrome (1.54) were associated with higher costs.

Conclusions

In conclusion, ASD-related health costs are comparable to those of schizophrenia, thus underlining its public health relevance. Higher costs in females demand further research.

Disclosure

No significant relationships.

POS0162 HOW ACCURATELY CAN WE IDENTIFY RHEUMATOID ARTHRITIS BY ICD-10 CODES? A LINKAGE OF CROSS-SECTIONAL SURVEY DATA WITH CLAIMS DATA

Background

Claims data from health insurance companies are a valuable source in health services research to provide insights on health care provision for an unselected patient collective. However, the available ICD-10 diagnoses have been collected for billing purposes and their validity is not clear.

Objectives

The aim of this analysis was to assess the positive predictive values (PPV) of a ICD-10 diagnosis of rheumatoid arthritis (RA) and additional criteria (specific medication, measurement of inflammatory markers, contact to a rheumatologist) in German claims data using patient-reported confirmed diagnosis as reference/gold standard.

Methods

Within the PROCLAIR project (Linking Patient-Reported Outcomes with CLAims data for health services research In Rheumatology), data from a large German statutory health insurance with 6.6 million persons aged 18 to 79 were used. We identified a random sample of persons for which an ICD-10 code for RA (M05/M06) was available in at least two quarters in outpatient care. The sample was stratified for age (18 to 49, 50 to 64, 65 to 79 years), sex and seropositive (M05)/ seronegative RA (M06). Persons were asked to confirm their RA diagnosis (“What does your attending physician call the disease you are suffering from?”) with answer options “chronic polyarthritis”, “rheumatoid arthritis”, “rheumatism of the joints” “other (please specify)”. The answer was used as the gold standard for RA diagnosis. Analyses were weighted to represent the total RA population of the database. Patient-reported information was linked to the claims data given patient consent. PPVs (% of confirmed RA diagnosis) were calculated for ICD-10-diagnosis or additional examination of inflammatory markers (erythrocyte sedimentation rate/C-reactive protein), prescription of specific medication (disease-modifying anti-rheumatic drugs, non-steroidal anti-rheumatic drugs and glucocorticoids) and contact to a rheumatologist, in the respective year.

Results

We contacted 6,193 persons with a claims diagnosis of RA. Of these 3,184 responding (51%), N=2,535 (81%) confirmed that they had RA. PPVs were 81% for ICD-10 only, 94% in M05 and 76% in M06. When additional criteria were taken into account, PPVs increased to 82% (measure of inflammatory markers), 85% (rheumatologist) and 89% (medication), respectively (Figure 1). However, PPVs ranged from 72% to 76% even if the additional criteria were not fulfilled. PPVs were lowest in men aged 18-49 years and relatively stable among women of all age groups.

Figure 1.

Conclusion

The ICD-10 codes M05 and (less optimal) M06 have high PPVs and are therefore feasible to identify RA in claims data. The prerequisite of specific medication seems to be the most useful one in identifying RA.

Acknowledgements

Supported by the Federal Ministry of Education and Research (grants 01EC1405 and 01EC1902A).

Disclosure of Interests

Johanna Callhoff Paid instructor for: Rheumatologische Fortbildungsakademie GmbH, Grant/research support from: Abbvie, AstraZeneca, BMS, GSK, Galapagos, Lilly, Medac, MSD, Pfizer, Sanofi, UCB, Katinka Albrecht: None declared, Ursula Marschall Employee of: Employee of BARMER, Falk Hoffmann: None declared

Mutually Exclusive Expression of COL11A1 by CAFs and Tumour Cells in a Large panCancer and a Salivary Gland Carcinoma Cohort

Procollagen 11A1 (COL11A1) is a central component of the extracellular matrix in many carcinomas, which is considered to be mainly produced by cancer associated fibroblasts (CAFs). As COL11A1 expression correlates with adverse prognosis and is implicated in chemoresistance, it is a promising putative target. For the first time, we used RNA in-situ hybridization to systematically identify the cells that produce COL11A1 in the ten most prevalent carcinoma types, lymphomas (n = 275) and corresponding normal tissue (n = 55; panCancer cohort). Moreover, as most salivary gland carcinomas (SGC) display distinct stromal architectures, we also analysed 110 SGC. The corresponding protein formation of COL11A1 was determined by MALDI-TOF-MS-Imaging. We report that colon, breast and salivary duct carcinomas are highly infiltrated by COL11A1 positive CAFs (CAFs_COL11A1) and might thus be promising candidates for antidesmoplastic or COL11A1-targeted therapies. The amount of CAFs_COL11A1 correlated significantly with tumour grade, tumour stage and nodal spread in the panCancer cohort. Significant associations between CAFs_COL11A1 and vascular invasion, perineural spread and nodal spread were observed in the SGC cohort. Also, we discovered that tumour cells of intercalated duct derived SGC and CAFs produce COL11A1 in a mutually exclusive manner. Our findings represent a novel mode of extracellular matrix production in carcinomas and could be highly relevant in the future. Our findings elucidate the mode of COL11A1 expression in very different carcinoma types and may aid to categorise tumours in the setting of possible future COL11A1-related therapies.

Notfall-Neuropädiatrie – Der arteriell ischämische Schlaganfall als einer der zeitkritischsten Notfälle bei Kindern und Jugendlichen

Der arteriell ischämische Schlaganfall im Kindes- und Jugendalter gehört zu den zeitkritischsten Notfällen in der Pädiatrie. Dennoch wird er häufig mit einer oft prognostisch relevanten Zeitverzögerung diagnostiziert. Gründe dafür liegen neben der geringen Awareness auch in der zuweilen unspezifischen klinischen Präsentation mit einer herausfordernden Breite kritischer Differenzialdiagnosen sowie in der Fläche noch wenig verzahnter Akutversorgungsstrukturen. Gleichwohl zeigen grundsätzlich die beim Erwachsenen etablierten Revaskularisationsstrategien auch beim Kind ihre möglichen, zum Teil spektakulären Erfolge. Es gilt also, diese nach Möglichkeit auch den betroffenen Kindern zur Verfügung zu stellen, auch wenn hier derzeit ein nicht annähernd vergleichbarer Grad an Evidenz erreicht ist. Postakut ist die ätiologische Aufarbeitung durch die größere Bandbreite zu bedenkender Risikofaktoren besonders komplex, muss aber in der Lage sein, das individuelle Risikoprofil mit Sekundärprophylaxe, Rezidivrisiko und Outcome präzise zu identifizieren. Die Langzeitbetreuung im multiprofessionellen, interdisziplinären Team muss die biopsychosozialen Aspekte des Kindes in seiner jeweiligen Entwicklungsphase berücksichtigen und damit eine bestmögliche Integration des Kindes in sein soziales und schulisches, später berufliches Umfeld realisieren.

Recommendations for treatment of critically ill patients with COVID-19 : Version 3 S1 guideline

Since December 2019 a novel coronavirus (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) has rapidly spread around the world resulting in an acute respiratory illness pandemic. The immense challenges for clinicians and hospitals as well as the strain on many healthcare systems has been unprecedented.The majority of patients present with mild symptoms of coronavirus disease 2019 (COVID-19); however, 5-8% become critically ill and require intensive care treatment. Acute hypoxemic respiratory failure with severe dyspnea and an increased respiratory rate (>30/min) usually leads to intensive care unit (ICU) admission. At this point bilateral pulmonary infiltrates are typically seen. Patients often develop a severe acute respiratory distress syndrome (ARDS).So far, remdesivir and dexamethasone have shown clinical effectiveness in severe COVID-19 in hospitalized patients. The main goal of supportive treatment is to ascertain adequate oxygenation. Invasive mechanical ventilation and repeated prone positioning are key elements in treating severely hypoxemic COVID-19 patients.Strict adherence to basic infection control measures (including hand hygiene) and correct use of personal protection equipment (PPE) are essential in the care of patients. Procedures that lead to formation of aerosols should be carried out with utmost precaution and preparation.

Multimodal Scanning Microscope Combining Optical Coherence Tomography, Raman Spectroscopy and Fluorescence Lifetime Microscopy for Mesoscale Label-Free Imaging of Tissue

Multimodal optical imaging of tissue has significant potential to become an indispensable diagnostic tool in clinical pathology. Conventional bright-field microscopy provides contrast based on attenuation or reflectance of light, having no depth-related information and no molecular specificity. Recent developments in biomedical optics have introduced a variety of optical modalities, such as Raman spectroscopy (RS), fluorescence lifetime imaging microscopy (FLIM) of endogenous fluorophores, optical coherence tomography (OCT), and others, which provide a distinct characteristic, i.e., molecular, chemical, and morphological information, of the sample. To harvest the full analytical potential of those modalities, we have developed a novel multimodal imaging system, which allows the co-registered acquisition of OCT/FLIM/RS on a single device. The present implementation allows the investigation of biological tissues in the mesoscale range, 0.1-5 mm in a correlated manner. Due to the co-registered acquisition of the modalities, it is possible to directly compare and evaluate the corresponding information between the three modalities. Moreover, by additionally preparing and characterizing entire pathological hematoxylin and eosin (H&E) slides of head and neck biopsies, it is also possible to correlate the multimodal spectroscopic information to any location of the ground truth H&E information. To the best of our knowledge, this is the first development and implementation of a compact and clinically applicable multimodal scanning microscope, which combines OCT, FLIM, and RS together with the possibility for co-registering H&E information for a morpho-chemical tissue characterization and a correlation with the pathological ground truth (H&E) of the underlying signal origin directly in a clinical environment.

High-resolution MRI of the human palatine tonsil and its schematic anatomic 3D reconstruction

The palatine tonsils form an important part of the human immune system. Together with the other lymphoid tonsils of Waldeyer's tonsillar ring, they act as the first line of defense against ingested or inhaled pathogens. Although histologically stained sections of the palatine tonsil are widely available, they represent the tissue only in two dimensions and do not provide reference to three‐dimensional space. Such a representation of a tonsillar specimen based on imaging data as a 3D anatomical reconstruction is lacking both in scientific publications and especially in textbooks. As a first step in this direction, the objective of the present work was to image a resected tonsil specimen with high spatial resolution in a 9.4 T small‐bore pre‐clinical MRI and to combine these data with data from the completely sectioned and H&E stained same palatine tonsil. Based on the information from both image modalities, a 3D anatomical sketch was drawn by a scientific graphic artist. In perspective, such studies could help to overcome the difficulty of capturing the spatial extent and arrangement of anatomical structures from 2D images and to establish a link between three‐dimensional anatomical preparations and two‐dimensional sections or illustrations, as they have been found so far in common textbooks and anatomical atlases.

[Childhood emergencies-worsening healthcare bottlenecks for children in a systematic long-term analysis of the EMS system in a German metropolis]

BACKGROUND

Children have the right to the best possible medical care. The lack of treatment capacity is rising steadily and increasingly leads to forced centralized allocation of patients by the emergency medical services (EMS) to pediatric emergency departments that are, officially, temporarily "closed".

AIM

The aim of this study is to present trends in allocation of pediatric emergency patients in greater Munich.

MATERIALS AND METHODS

Retrospective analysis of hospital admissions of children < 18 years of age collected from 01 January 2015 to 31 December 2019 by means of the web-based IT system IVENA eHealth (manis IT, Frankfurt) used by the emergency medical services. The focus of the evaluation is on patients in category II, who are likely to require inpatient admission.

RESULTS

During the 5‑year observation period, a total of 44,549 pediatric patients < 18 years of age (90.6% of total admissions) were admitted to a children's hospital by the ambulance service as category II (SKII) in the Munich metropolitan area. These patients showed an increase in the relative frequency of forced allocations from 1.7% (2015) to 9.4% (2019). Parallel to this, there is an increasing frequency of time intervals over the years in which all children's hospitals were temporarily closed due to lack of treatment availability, especially in the winter half-year.

CONCLUSION

In the examined period from 2015 to 2019, there has been a relevant increase in the number of forced allocations to children's hospitals by the emergency medical services in the Munich area. This observed trend is likely to persist over the coming years, in view of current staff shortages and diminishing hospital capacities.

Fluorescein-Guided Panendoscopy for Head and Neck Cancer Using Handheld Probe-Based Confocal Laser Endomicroscopy: A Pilot Study

Background

White-light endoscopy and microscopy combined with histological analysis is currently the mainstay for intraprocedural tissue diagnosis during panendoscopy for head and neck cancer. However, taking biopsies leads to selection bias, ex vivo histopathology is time-consuming, and the advantages of in-vivo intraoperative decision making cannot be used. Confocal laser endomicroscopy (CLE) has the potential for a rapid and histological assessment in the head and neck operating room.

Methods

Between July 2019 and January 2020, 13 patients (69% male, median age: 61 years) with newly diagnosed head and neck cancer (T3/T4: 46%) underwent fluorescein-guided panendoscopy. CLE was performed from both the tumor and margins followed by biopsies from the CLE spots. The biopsies were processed for histopathology. The CLE images were ex vivo classified blinded with a CLE cancer score (DOC score). The classification was compared to the histopathological results.

Results

Median additional time for CLE during surgery was 9 min. A total of 2,565 CLE images were taken (median CLE images: 178 per patient; 68 per biopsy; evaluable 87.5%). The concordance between histopathology and CLE images varied between the patients from 82.5 to 98.6%. The sensitivity, specificity, and accuracy to detect cancer using the classified CLE images was 87.5, 80.0, and 84.6%, respectively. The positive and negative predictive values were 87.0 and 80.0%, respectively.

Conclusion

CLE with a rigid handheld probe is easy and intuitive to handle during panendoscopy. As next step, the high accuracy of ex vivo CLE image classification for tumor tissue suggests the validation of CLE in vivo. This will evolve CLE as a complementary tool for in vivo intraoperative diagnosis during panendoscopy.

Trophoblast Cell Surface Antigen 2 (Trop-2) Protein is Highly Expressed in Salivary Gland Carcinomas and Represents a Potential Therapeutic Target

Treatment options for unresectable, recurrent or metastatic salivary gland carcinomas (SGC) are scarce. Trophoblast cell surface antigen 2 (Trop-2) is a transmembrane glycoprotein that is involved in a variety of oncogenic cell signaling pathways. Its potential as a target for the antibody-drug conjugate sacituzumab govitecan has already been demonstrated in different tumor entities. The United States Food and Drug Administration approved this antibody-drug conjugate for the treatment of metastatic triple-negative breast cancer. Here, we aimed to investigate Trop-2 protein expression in different entities of SGCs. We retrospectively reviewed the medical records of all patients that underwent surgery for a primary SGC in a tertiary referral center between 1990 and 2014. Immunohistochemical (IHC) staining for Trop-2 was performed and rated as negative, weak, moderate or high using a semiquantitative score. Additionally, representative cases were analyzed using MALDI-mass spectrometry (MS) imaging to confirm the IHC results. The cohort consisted of 114 tumors of the parotid gland (90.4%) and submandibular gland (9.6%). It mainly included mucoepidermoid, salivary duct and adenoid cystic carcinomas. In IHC samples, 44% showed high, 38% moderate and 10% weak expression rates of Trop-2. MALDI-MS imaging confirmed the presence of Trop-2 protein in 80% of the tested tumor samples. This is the first study to demonstrate that several types of SGC express Trop-2 with variable intensity. Since there are currently few systemic treatment options for advanced SGCs, Trop-2 represents a promising target for further clinical studies, for instance, with sacituzumab govitecan.

[Epistaxis and anticoagulation therapy: an analysis based on health insurance data from Lower Saxony]

Hintergrund

Die Epistaxis ist ein häufiges Symptom in der Arztpraxis und assoziiert mit verschiedenen Komorbiditäten und Medikamenten, insbesondere Antikoagulanzien. Trotz ihrer Alltäglichkeit gibt es nur wenige Daten zur Häufigkeit ihres Auftretens und möglichen Risikofaktoren.

Methoden

Die Studie untersuchte anhand einer großen Patientenpopulation (AOK Niedersachsen) über 10 Jahre (2007–2016) die Versorgung von Epistaxis in Niedersachsen. Alter bei Diagnose, Begleitmedikation und Komorbiditäten wurden analysiert und die Prävalenz dargestellt.

Ergebnisse

162.167 Versicherte der AOK Niedersachen wurden zwischen 2007 und 2016 aufgrund einer Epistaxis in 308.947 Fällen ärztlich vorstellig. Die meisten Patienten wurden ausschließlich ambulant behandelt (96,6 %). Über den Studienzeitraum stieg die Prävalenz um 21 % (Anstieg von 8,7 auf 9,3 pro 1000 Versicherte/Jahr) bei stabiler Prävalenz für stationäre Vorstellungen (0,2 pro 1000 Versicherte/Jahr). Die höchsten Prävalenzen fanden sich bei Personen bis 20 und über 80 Jahre. In 17,5 % aller Epistaxisfälle wurden Antithrombotika erfasst (9,5 % orale Antikoagulanzien). Über den Studienzeitraum konnte eine erhöhte Verschreibung von Antikoagulanzien (7,7 % in 2007 auf 11,8 % in 2016, insbesondere NOAK) dokumentiert werden.

Schlussfolgerung

Neben der arteriellen Hypertonie, dem männlichen Geschlecht sowie der typischen Altersverteilung bestand auch häufig eine Medikation mit Antikoagulanzien. Über den untersuchten Zeitraum zeigte sich eine Zunahme von Epistaxisfällen bei gleichzeitig ansteigender Verschreibungshäufigkeit von NOAK, nicht jedoch von schweren hospitalisationsbedürftigen Epistaxisfällen. Eine abschließende Beurteilung hinsichtlich eines möglichen kausalen Zusammenhangs muss in weiteren Studien untersucht werden.

[Debriefing in pediatric emergency care]

Kommunikationsfehler und systembedingte Probleme wirken sich negativ auf Teamarbeit und gemeinsame Entscheidungsfindung aus und können den Patienten Schaden zufügen. Regelmäßige Nachbesprechungen nach kritischen Ereignissen wiederum wirken sich positiv auf die Teamzusammenarbeit und das Patientenoutcome in der Kindernotfallversorgung aus. Das gemeinsame Reflektieren fördert das Lernen, hilft den Teams, sich zu verbessern, und verhindert, dass sich Fehler in Zukunft wiederholen. Dennoch werden Debriefings im präklinischen und klinischen Alltag noch immer qualitativ unzureichend durchgeführt. Gründe dafür sind mangelnde Zeit, Fehlen von erfahrenen Debriefern und fehlende Unterstützung durch Verantwortungsträger. Debriefings können je nach Bedarf zu verschiedenen Zeitpunkten mit unterschiedlicher Dauer stattfinden. Nachbesprechungen können auch rein virtuell oder als sogenannte Hybridveranstaltung durchgeführt werden. Nachbesprechungen sollten sich auf gemeinsames Lernen und das Erarbeiten zukunftsorientierter Verbesserungen konzentrieren. Nicht nur lebensbedrohliche Ereignisse können Nachbesprechungen auslösen, sondern auch potenziell kritische Situationen, wie routinemäßige Intubationen. Debriefing-Skripte fördern eine Strukturierung und ermöglichen selbst unerfahrenen Moderatoren, alle Aspekte zu bearbeiten. Neben der Diskussion schwieriger Abläufe sollten unbedingt positive Leistungen besprochen werden, um diese zu verstärken und das Lernen am Erfolg zu ermöglichen. Dabei sollten die Beweggründe eines Verhaltens erfragt und nicht nur die nach außen sichtbaren Leistungen bewertet werden. Diese Strategie fördert bedarfsgerechtes Lernen und konzentriert sich auf Lösungen. Hilfreich sind dabei spezielle Fragetechniken, echtes Interesse und eine positive Sicherheitskultur.

[S2k Guideline - Recommendations for Inpatient Therapy of Patients with COVID-19]

Since December 2019, the novel coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome - Corona Virus-2) has been spreading rapidly in the sense of a global pandemic. This poses significant challenges for clinicians and hospitals and is placing unprecedented strain on the healthcare systems of many countries. The majority of patients with Coronavirus Disease 2019 (COVID-19) present with only mild symptoms such as cough and fever. However, about 6 % require hospitalization. Early clarification of whether inpatient and, if necessary, intensive care treatment is medically appropriate and desired by the patient is of particular importance in the pandemic. Acute hypoxemic respiratory insufficiency with dyspnea and high respiratory rate (> 30/min) usually leads to admission to the intensive care unit. Often, bilateral pulmonary infiltrates/consolidations or even pulmonary emboli are already found on imaging. As the disease progresses, some of these patients develop acute respiratory distress syndrome (ARDS). Mortality reduction of available drug therapy in severe COVID-19 disease has only been demonstrated for dexamethasone in randomized controlled trials. The main goal of supportive therapy is to ensure adequate oxygenation. In this regard, invasive ventilation and repeated prone positioning are important elements in the treatment of severely hypoxemic COVID-19 patients. Strict adherence to basic hygiene, including hand hygiene, and the correct wearing of adequate personal protective equipment are essential when handling patients. Medically necessary actions on patients that could result in aerosol formation should be performed with extreme care and preparation.

[German recommendations for treatment of critically ill patients with COVID-19-version 3]

Seit Dezember 2019 verbreitet sich das neuartige Coronavirus SARS-CoV‑2 (Severe Acute Respiratory Syndrome – Corona Virus-2) rasch im Sinne einer weltweiten Pandemie. Dies stellt Kliniker und Krankenhäuser vor große Herausforderungen und belastet die Gesundheitssysteme vieler Länder in einem nie dagewesenen Ausmaß. Die Mehrheit der Patienten zeigt lediglich milde Symptome der sogenannten Coronavirus Disease 2019 (COVID-19). Dennoch benötigen etwa 5–8 % eine intensivmedizinische Behandlung. Die akute hypoxämische respiratorische Insuffizienz mit Dyspnoe und hoher Atemfrequenz (>30/Min) führt in der Regel zur Aufnahme auf die Intensivstation. Oft finden sich dann bereits bilaterale pulmonale Infiltrate/Konsolidierungen oder auch Lungenembolien in der Bildgebung. Im weiteren Verlauf entwickeln viele Patienten ein Acute Respiratory Distress Syndrome (ARDS). Eine klinische Wirksamkeit einer medikamentösen Therapie bei schwerer COVID-Erkrankung (hospitalisierte Patienten) ist bisher für Remdesivir und Dexamethason nachgewiesen. Das Hauptziel der supportiven Therapie ist es eine ausreichende Oxygenierung sicherzustellen. Die invasive Beatmung und wiederholte Bauchlagerung sind dabei wichtige Elemente in der Behandlung von schwer hypoxämischen COVID-19 Patienten. Die strikte Einhaltung der Basishygiene, einschließlich der Händehygiene, sowie das korrekte Tragen von adäquater persönlicher Schutzausrüstung sind im Umgang mit den Patienten unabdingbar. Prozeduren, die zur Aerosolbildung führen könnten, sollten falls nötig, mit äußerster Sorgfalt und Vorbereitung durchgeführt werden.

[German recommendations for treatment of critically ill patients with COVID-19-version 3 : S1-guideline]

Seit Dezember 2019 verbreitet sich das neuartige Coronavirus SARS-CoV‑2 (Severe Acute Respiratory Syndrome – Corona Virus-2) rasch im Sinne einer weltweiten Pandemie. Dies stellt Kliniker und Krankenhäuser vor große Herausforderungen und belastet die Gesundheitssysteme vieler Länder in einem nie dagewesenen Ausmaß. Die Mehrheit der Patienten zeigt lediglich milde Symptome der sogenannten Coronavirus Disease 2019 (COVID-19). Dennoch benötigen etwa 5–8 % eine intensivmedizinische Behandlung. Die akute hypoxämische respiratorische Insuffizienz mit Dyspnoe und hoher Atemfrequenz (>30/Min) führt in der Regel zur Aufnahme auf die Intensivstation. Oft finden sich dann bereits bilaterale pulmonale Infiltrate/Konsolidierungen oder auch Lungenembolien in der Bildgebung. Im weiteren Verlauf entwickeln viele Patienten ein Acute Respiratory Distress Syndrome (ARDS). Eine klinische Wirksamkeit einer medikamentösen Therapie bei schwerer COVID-Erkrankung (hospitalisierte Patienten) ist bisher für Remdesivir und Dexamethason nachgewiesen. Das Hauptziel der supportiven Therapie ist es eine ausreichende Oxygenierung sicherzustellen. Die invasive Beatmung und wiederholte Bauchlagerung sind dabei wichtige Elemente in der Behandlung von schwer hypoxämischen COVID-19 Patienten. Die strikte Einhaltung der Basishygiene, einschließlich der Händehygiene, sowie das korrekte Tragen von adäquater persönlicher Schutzausrüstung sind im Umgang mit den Patienten unabdingbar. Prozeduren, die zur Aerosolbildung führen könnten, sollten falls nötig, mit äußerster Sorgfalt und Vorbereitung durchgeführt werden.

Expression Profiling of Extracellular Matrix Genes Reveals Global and Entity-Specific Characteristics in Adenoid Cystic, Mucoepidermoid and Salivary Duct Carcinomas

Simple Summary

The extracellular matrix (ECM), an important factor in tumour metastasis and therapy resistance, has not been studied in salivary gland carcinomas (SGC), so far. In this retrospective study, we profiled the RNA expression of 28 ECM-related genes in 11 adenoid cystic (AdCy), 14 mucoepidermoid (MuEp) and 9 salivary duct carcinomas (SaDu). Also, we validated our results in a multimodal approach. MuEp and SaDu shared a common gene signature involving an overexpression of COL11A1. In contrast, nonhierarchical clustering revealed a more specific gene expression pattern for AdCy, characterized by overexpression of COL27A1. In situ studies at RNA level indicated that in AdCy, ECM production results from tumour cells and not from cancer-associated fibroblasts as is the case in MuEp and SaDu. For the first time, we characterized the ECM composition in SGC and identified several differentially expressed genes, which are potential therapeutic targets.

Abstract

The composition of the extracellular matrix (ECM) plays a pivotal role in tumour initiation, metastasis and therapy resistance. Until now, the ECM composition of salivary gland carcinomas (SGC) has not been studied. We quantitatively analysed the mRNA of 28 ECM-related genes of 34 adenoid cystic (AdCy; n = 11), mucoepidermoid (MuEp; n = 14) and salivary duct carcinomas (SaDu; n = 9). An incremental overexpression of six collagens (including COL11A1) and four glycoproteins from MuEp and SaDu suggested a common ECM alteration. Conversely, AdCy and MuEp displayed a distinct overexpression of COL27A1 and LAMB3, respectively. Nonhierarchical clustering and principal component analysis revealed a more specific pattern for AdCy with low expression of the common gene signature. In situ studies at the RNA and protein level confirmed these results and indicated that, in contrast to MuEp and SaDu, ECM production in AdCy results from tumour cells and not from cancer-associated fibroblasts (CAFs). Our findings reveal different modes of ECM production leading to common and distinct RNA signatures in SGC. Of note, an overexpression of COL27A1, as in AdCy, has not been linked to any other neoplasm so far. Here, we contribute to the dissection of the ECM composition in SGC and identified a panel of deferentially expressed genes, which could be putative targets for SGC therapy and overcoming therapeutic resistance.

[Health care and disease burden in persons with axial spondyloarthritis in Germany]

BACKGROUND

Only very few data are available on the comprehensive care in patients with axial spondylarthritis (axSpA), one of the most frequent inflammatory rheumatic disease.

OBJECTIVE

Description of the comprehensive care and common prescription patterns of medications and other therapies in patients with axSpA depending on the type of medical care by rheumatologists or nonrheumatologists.

METHODS

A cross-sectional analysis was performed based on claims data of the BARMER health insurance company (in 2015) and a questionnaire, which was sent to a representative sample of patients with axSpA (International Classification of Diseases, 10th revision, German modification, ICD-10-GM, code M45) aged 18-79 years. A stratified sample of 5000 patients was used. The patients received a postal questionnaire including questions regarding the disease, health-related and psychological parameters and socioeconomic factors. Claims data consisted of demographic factors, medicinal and nonmedicinal treatment and the extra-articular manifestations inflammatory bowel disease, psoriasis and uveitis.

RESULTS

A total of 1741 patients (mean age 55.9 years, female 46.4%, 86.2% Human Leucocyte Antigen[HLA]-B27 positive) confirmed the diagnosis and answered the questionnaire. The mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) was 4.5 and the mean Bath Ankylosing Spondylitis Functional Index (BASFI) 4.1. Of the patients 46% were treated by rheumatologists. There was a substantial difference between patients in rheumatological care and those who were not in rheumatological care regarding prescriptions for drug treatment of axSpA (91.8% versus 66.4%). This difference was especially prominent for prescriptions of biologic disease-modifying antirheumatic drugs: 34.1% of patients in rheumatological care versus 3.1% of patients treated by nonrheumatologists (p < 0.0001), despite similar disease activity in both groups.

CONCLUSION

The data show that the majority of patients diagnosed with axSpA did not receive regular care from rheumatologists. This seemed to be associated with insufficient medicinal care at least in some of these patients.

Pain And The Use Of Gabapentinoids In German Nursing Home Residents - Results From An Analysis Based On Statutory Health Insurance Data

Background

Gabapentinoids (gabapentin and pregabalin) are psychoactive medications that are increasingly used for different conditions. Since there is evidence that psychotropic drugs, in general, are often inappropriately prescribed in elderly patients, we aimed to determine frequency and indications of gabapentinoid prescribing for nursing home residents.

Methods

We analyzed data from a large German statutory health insurance database. Included were records from people ≥65 years-of-age, who were admitted to a nursing home between January 2010 and December 2014. We determined the number and proportion of common indications for on- and off-label prescriptions, the most frequent co-medications, and the characteristics of patients and prescribers.

Results

Of 127,277 residents, 9539 (7.5%) received gabapentinoids and 4852 initiated treatment (4.0%; with 66.3% pregabalin). Median age of gabapentinoid initiators was 84 years (78.5% females). In these users, on-label prescribing was found in 57.4%, predominantly for neuropathic pain. Other painful conditions were also chief causes (84.7%) for off-label prescribing. Gabapentinoids were mainly started by general practitioners (64.5%) while pain specialists contributed <2%. Forty-six percent of users received additional opioids and in 27.5% gabapentinoids were prescribed only once.

Conclusion

Gabapentinoids were frequently used in nursing home residents. Regular co-prescribing with opioids and psychotropic drugs might indicate employment to improve pain or assist treatment of conditions that are frequently associated with disruptive behavior such as dementia. However, more research is needed to better understand decision-making regarding gabapentinoid prescribing, especially in view of aggressive marketing, uncertain analgesic effects, problematic side effects, and uncritical use in the elderly.

[Outpatient care and disease burden of rheumatoid arthritis : Results of a linkage of claims data and a survey of insured persons]

BACKGROUND

Healthcare of patients with rheumatoid arthritis (RA) in Germany has mainly been evaluated in the past in RA cohorts from specialized arthritis centers. This study investigated rheumatological care on a population basis, using claims data from a nationwide statutory health insurance fund (BARMER GEK) in combination with patient-reported outcomes from a questionnaire survey of insured persons with RA.

METHODS

Data from insurants aged 18-79 years with M05 (seropositive RA) or M06 (other RA, ICD-10) diagnoses were analyzed concerning diagnostics, medication and prescribing physician. A 31-item questionnaire covering patient reported diagnosis, healthcare utilization and burden of illness was sent to a stratified random sample of 6193 insured persons. Data from the respondents regarding rheumatological care and disease status were evaluated.

RESULTS

In 2013 and 2014, a total of 96,921 adults with M05 or M06 diagnosis were insured. The questionnaire was answered by 51% of the sample and of these 81% confirmed the RA diagnosis. RA had been diagnosed by a rheumatologist in 59% of the cases, 70% reported moderate to severe pain and 46% had functional disability. Between at least 40% (claims data) and up to 68% (respondents) were in specialized rheumatological care. Treatment with disease-modifying antirheumatic drugs (DMARDs) was 61% (claims data) and 63% (respondents) in persons in rheumatological care but only 18% outside rheumatological care.

CONCLUSION

The results indicate that specialized rheumatological care is required to provide adequate treatment for patients with RA in Germany. Patients with higher age and patients with M06 diagnosis had less drug prescriptions and were less frequently treated by rheumatologists.

Valor nutritivo de gramíneas do gênero Cynodon consorciadas com amendoim forrageiro

RESUMO O objetivo do presente estudo foi avaliar o valor nutritivo do consórcio forrageiro entre gramíneas do gênero Cynodon (cv. tifton 85 ou coastcross) com Arachis pintoi (amendoim forrageiro). O experimento foi conduzido na Universidade Tecnológica Federal do Paraná, Câmpus Dois Vizinhos, em área de aproximadamente 3000m2. O delineamento experimental foi de blocos ao acaso, com quatro tratamentos e três repetições. Os tratamentos foram: tifton 85 e coastcross em cultivo estreme, tifton 85 + AF e coastcross + AF. Foram avaliados os teores de PB, FDN, FDA, DIVMS, MM e MS das lâminas foliares, colmo+bainha, amendoim forrageiro e da MF disponível da simulação de pastejo. Foi observado que a coastcross tem menor teor de fibra, independentemente do tratamento. O avanço das estações do ano proporcionou menores valores de PB e DIVMS em todos os tratamentos. A simulação de pastejo demonstrou que a tifton 85 tem maiores teores de MS, assim como valores inferiores são encontrados para os consórcios. Quando consorciado com as gramíneas, o amendoim forrageiro reduziu os compostos fibrosos na pastagem, acrescentando maiores teores de PB em pastagem de gramíneas no final do ciclo produtivo.

Identification of Proteomic Markers in Head and Neck Cancer Using MALDI-MS Imaging, LC-MS/MS, and Immunohistochemistry

PURPOSE

The heterogeneity of squamous cell carcinoma tissue greatly complicates diagnosis and individualized therapy. Therefore, characterizing the heterogeneity of tissue spatially and identifying appropriate biomarkers is crucial. MALDI-MS imaging (MSI) is capable of analyzing spatially resolved tissue biopsies on a molecular level.

EXPERIMENTAL DESIGN

MALDI-MSI is used on snap frozen and formalin-fixed and paraffin-embedded (FFPE) tissue samples from patients with head and neck cancer (HNC) to analyze m/z values localized in tumor and nontumor regions. Peptide identification is performed using LC-MS/MS and immunohistochemistry (IHC).

RESULTS

In both FFPE and frozen tissue specimens, eight characteristic masses of the tumor's epithelial region are found. Using LC-MS/MS, the peaks are identified as vimentin, keratin type II, nucleolin, heat shock protein 90, prelamin-A/C, junction plakoglobin, and PGAM1. Lastly, vimentin, nucleolin, and PGAM1 are verified with IHC.

CONCLUSIONS AND CLINICAL RELEVANCE

The combination of MALDI-MSI, LC-MS/MS, and subsequent IHC furnishes a tool suitable for characterizing the molecular heterogeneity of tissue. It is also suited for use in identifying new representative biomarkers to enable a more individualized therapy.

[Non-beneficial therapy and emotional exhaustion in end-of-life care : Results of a survey among intensive care unit personnel]

BACKGROUND

End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play a role in the context of EOLC.

OBJECTIVE

Is the working environment associated with perception of NBT or clinician burnout?

MATERIAL AND METHODS

Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis.

RESULTS

The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91 residents and 26 consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each p ≤ 0.001) and the numbers of weekend working days per month (p = 0.012). Protective factors against burnout included intensive care specialization (p = 0.001) and emotional support within the team (p ≤ 0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each p ≤ 0.001).

DISCUSSION

Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources.

Enhancing fluorescent protein photostability through robot-assisted photobleaching

Improving fluorescent proteins through the use of directed evolution requires robust techniques for screening large libraries of genetic variants. Here we describe an effective and relatively low-cost system for screening libraries of fluorescent protein variants for improved photostability in the context of colonies on a Petri dish. Application of this system to the yellow fluorescent protein mCitrine, led to the development of Citrine2 with improved photostability and similar high fluorescent brightness. The photobleaching robot was constructed using a Lego Mindstorms Ev3 set and a xenon arc lamp, which together create even and high irradiance over an entire Petri dish through patterned illumination.

[Hypothermia-induced ECG changes: characteristic, but not specific]

Hypothermia-induced J‑ or so-called Osborn waves can be detected under therapeutic hypothermia in approximately 20-40% of cases. The occurrence of J‑waves in the context of the targeted temperature management after cardiopulmonary resuscitation is characteristic, but not pathognomonic for hypothermia. An electrocardiographic diagnosis under hypothermia after cardiac arrest should always be done with caution due to the various hypothermia-associated electromechanical changes of the myocardium.

[Differences in chronic back pain and joint disorders among health insurance funds : Results of a cross-sectional study based on the data of the Socioeconomic Panel from 2013]

BACKGROUND

Health services research uses increasingly data from health insurance funds. It is well known that the funds differ with regard to sociodemographic characteristics and morbidity. It is uncertain if there are also differences in the prevalence of musculoskeletal disorders.

OBJECTIVE

To compare the sociodemographic characteristics in various health insurance funds and the prevalence of joint disorders and chronic back pain.

METHOD

The 30^th wave (2013) of the German Socioeconomic Panel served as a database. Average age, sex distribution, nationality, education, and employment status were evaluated according to the health insurance funds. The prevalence of joint disorders and chronic back pain were also stratified according to the insurance funds and standardized according to age and sex.

RESULTS

A total of 19,146 participants were included. Most participants (4,934) were insured by AOK, followed by BKK (2,632) and BARMER GEK (2,398). There were huge differences among the health insurance funds with regard to the sociodemographic characteristics. For example, the proportion of unemployed insurants was between 33.3 % (IKK) and 50.6 % (AOK). The prevalence of joint disorders standardized according to age and sex (20.7 %; 95 % CI: 20.1-21.3) was between 17.4 % (95 % CI: 15.8-19.0; PKV) and 22.4 % (95 % CI: 21.1-23.6; AOK). The prevalence of chronic back pain (18.0 %; 95 % CI: 17.4-18.5) was between 13.5 % (95 % CI: 12.2-14.9; PKV) and 20.6 % (95 % CI: 19.4-21.8; AOK).

CONCLUSION

There are differences in the prevalence of musculoskeletal disorders among health insurance funds. The extrapolation of analyses of one health insurance fund to the German population is thus limited.

A patient cohort on long-term sequelae of sepsis survivors: study protocol of the Mid-German Sepsis Cohort

INTRODUCTION

An increasing number of patients survive sepsis; however, we lack valid data on the long-term impact on morbidity from prospective observational studies. Therefore, we designed an observational cohort to quantify mid-term and long-term functional disabilities after intensive care unit (ICU)-treated sepsis. Ultimately, findings for the Mid-German Sepsis Cohort (MSC) will serve as basis for the implementation of follow-up structures for patients with sepsis and help to increase quality of care for sepsis survivors.

METHODS AND ANALYSIS

All patients surviving ICU-treated sepsis are eligible and are recruited from five study centres in Germany (acute care hospital setting in Jena, Halle/Saale, Leipzig, Bad Berka, Erfurt; large long-term acute care hospital and rehabilitation setting in Klinik Bavaria Kreischa). Screening is performed by trained study nurses. Data are collected on ICU management of sepsis. On written informed consent provided by patients or proxies, follow-up is carried out by trained research staff at 3, 6 and 12 months and yearly thereafter. The primary outcome is functional disability as assessed by (instrumental) activities of daily living. Other outcomes cover domains like mortality, cognitive, emotional and physical impairment, and resource use. The estimated sample size of 3000 ICU survivors is calculated to allow detection of relevant changes in the primary outcome in sepsis survivors longitudinally.

ETHICS AND DISSEMINATION

The study is conducted according to the current version of the Declaration of Helsinki and has been approved by four local/federal responsible institutional ethics committees and by the respective federal data protection commissioners. Results of MSC will be fed back to the patients and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry DRKS00010050.