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Abstract Background Metabolic and electrolyte imbalances are some of the reversible causes of cardiac arrest and can be diagnosed even in the pre-hospital setting with a mobile analyser for point-of-care testing (POCT). Methods We conducted a retrospective observational study, which included analysing all pre-hospital resuscitations in the study region between October 2015 and December 2016. A mobile POCT analyser (Alere epoc®) was available at the scene of each resuscitation. We analysed the frequency of use of POCT, the incidence of pathological findings, the specific interventions based on POCT as well as every patient’s eventual outcome. Results N = 263 pre-hospital resuscitations were included and in n = 98 of them, the POCT analyser was used. Of these measurements, 64% were performed using venous blood and 36% using arterial blood. The results of POCT showed that 63% of tested patients had severe metabolic acidosis (pH 6.0 mmol/l/

In this work, we present numerical simulation results of powder injection in W7-X using the EMC3-EIRENE and DIS codes. First, we model powder injection experiments performed in W7-X with the Probe Mounted Powder Injector. The simulation results qualitatively agree with visible imaging measurements. Secondly, we perform predictive simulations to guide the installation of an Impurity Powder Dropper in W7-X, allowing to choose in between several available non-vertical ports to maximize the amount of powder penetrating into the plasma, as well as the verticality of the port, to minimize sticking of the powders in the in-vessel stainless steel guiding tube. Port AEM41 is selected as the best candidate for IPD installation. The robustness of the simulation results has been verified for different plasma densities, powder materials and sizes, powder friction coefficient and changes in the plasma flow.

Boronisation was first used for wall conditioning in W7-X during the OP 1.2b operational period, which was characterized by the use of the fine-grain graphite Test Divertor Unit (TDU) and inertial cooling only. After this period, deposited layers were observed on all inner surfaces. Deposited layers were analyzed on 21 inner wall tiles using ion beam analysis methods, the deposited layers consisted mostly of boron with additional carbon and oxygen. During the operational period OP 2.1 with an actively water cooled divertor made of carbon fiber reinforced carbon, different materials were exposed during two individual boronisations using the multi-purpose manipulator. Deposited boronisation layers on the samples were analyzed using nuclear reaction analysis. The deposited layer thicknesses showed some variation depending on substrate material and surface roughness, but a systematic dependence on material and/or roughness was not observed. Under the typical boronisation conditions at W7-X, one A × h (Ampere times hour) of boronisation results in a boronisation layer with a thickness of about 30 ± 15 × 1015 B-atoms/cm2 (about 3 ± 1.5 nm) at the position of the multi-purpose manipulator. The oxygen gettering capacity of the layers is up to 0.5 – 0.9O/B.

After a long device enhancement phase, scientific operation resumed in 2022. The main new device components are the water cooling of all plasma facing components and the new water-cooled high heat flux divertor units. Water cooling allowed for the first long-pulse operation campaign. A maximum discharge length of 8 min was achieved with a total heating energy of 1.3 GJ. Safe divertor operation was demonstrated in attached and detached mode. Stable detachment is readily achieved in some magnetic configurations but requires impurity seeding in configurations with small magnetic pitch angle within the edge islands. Progress was made in the characterization of transport mechanisms across edge magnetic islands: Measurement of the potential distribution and flow pattern reveals that the islands are associated with a strong poloidal drift, which leads to rapid convection of energy and particles from the last closed flux surface into the scrape-off layer. Using the upgraded plasma heating systems, advanced heating scenarios were developed, which provide improved energy confinement comparable to the scenario, in which the record triple product for stellarators was achieved in the previous operation campaign. However, a magnetic configuration-dependent critical heating power limit of the electron cyclotron resonance heating was observed. Exceeding the respective power limit leads to a degradation of the confinement.

We present the first validated synthetic diagnostic for fast ion loss detectors (FILDs) in the Wendelstein 7-X (W7-X) stellarator. This model has been developed on, and validated against experimental data from, a FILD provided by the National Institute for Fusion Science (NIFS-FILD), with potential future applicability to the existing Faraday Cup FILD (FC-FILD) on W7-X as well as the scintillating FILD (S-FILD) currently under development. A workflow combining Monte Carlo codes BEAMS3D and ASCOT5 is used to track fast ions produced by neutral beam injection from the moment of ionization until they are thermalized or lost from the last closed flux surface, and from there to a virtual plane which serves as a projection of the entrance aperture to the FILD. Simulations in ASCOT5 are analyzed via a geometric method to determine the probability of transmission through the FILD aperture and onto the detector as a function of normalized momentum, pitch angle, gyrophase, and position at the virtual plane. This probability is then applied to the simulated ions arriving from the plasma, producing a simulated signal from a computationally tractable number of simulated fast ions. Simulated signals are presented for two W7-X experiments with neutral beam injection and quantitatively compared with experimental measurements from the NIFS-FILD diagnostic. An estimate of the frequency of charge-exchange with neutral particles in the edge is performed, and it is found that this process may have a significant impact on the measured signals.

Hot spots and bright patterns on plasma-facing components (PFC) in visible light are observed in electron cyclotron resonance heated (ECRH) plasmas at low densities in the stellarator Wendelstein 7-X. The events are often located far outside of any convective plasma loads and led in some cases to damages of diagnostic components, where the interaction zones qualitatively agree with fast particle loss simulations. Reciprocating electric probes indicate that this phenomenon is related to a non-thermal electron population that can have a beam like character, being directed in one parallel direction. Further, the electrons can be trapped on rational flux surfaces and be used to map magnetic islands.

Detached divertor plasmas has been achieved by density ramp in W7-X. During the transition into detachment, the main divertor radiation region moves from the region close to the divertor targets to the region around LCFS. The typical spatial distributions of carbon and hydrogen Balmer lines in detached divertor plasma are presented. They show that the line emissions of CH produced by chemical sputtering is still strong close to the targets. The C I fills up the whole detached divertor plasma and its intensity increases when approaching the targets due to the dissociation from hydrocarbon and self-sputtering. The C II and C III are mainly located at around LCFS region. Meanwhile, the distribution of hydrogen Balmer lines is considerably flatter in detached divertor plasma. The Balmer line ratios indicate that the detached divertor plasma seems to be still in excitation or partial recombination state. This is consistent with the divertor Langmuir probe measurements which shows that the electron temperature near strike line is around 6 eV. Finally, the electron pressure at upstream and downstream position is measured and its ratio shows that the electron pressure drops significantly along the magnetic field lines. However, the pressure can not drop further due to the lack of the volume recombination in detached divertor plasma.

Plasma filaments have been measured with alkali beam emission spectroscopy in the plasma edge, divertor island, and scrape-off layer of Wendelstein 7-X. Due to the high intensity of a 1–2 kHz plasma mode, a new, correlation based conditional averaging algorithm was used to search for filaments in the signals. With that method, effects of different magnetic configurations and density levels on filament properties are observed. In configurations where the islands are small and do not play an important role for the connection length topology, filaments behave similar to tokamaks. In contrast, in configurations with larger magnetic islands and more complex connection length profiles, filaments behave quite differently, for instance they may or may not appear in the inner side of the divertor island depending on the plasma parameters. Coupling between the filaments and lower frequency events are also showed. The role of filaments in the global and local particle transport is briefly discussed.

Drifts affect particle, momentum, and energy transport in the scrape-off layer (SOL) of tokamaks and stellarators, altering plasma flows and creating asymmetries between divertors. To understand how drifts affect SOL transport in the W7-X island divertor, an experiment was performed to compare plasmas with matched core parameters but opposite magnetic field directions, and therefore opposite drift transport directions. Parallel flow measurements made with coherence imaging spectroscopy are interpreted with the aid of a diagnostic forward model and a 1D simple SOL model that includes the $\boldsymbol{\mathbf{E}} \times \boldsymbol{\mathbf{B}}$ drift. In low-density plasmas ( $\overline{n}_\mathrm{e} \lt 2 \times 10^{19}$ m ^−3 ), the poloidal $\boldsymbol{\mathbf{E}} \times \boldsymbol{\mathbf{B}}$ drift induces a large poloidal density asymmetry within the island SOL, as measured by divertor Langmuir probes. This in turn causes the parallel flow stagnation point to shift from the position halfway between targets to the X-point in the drift direction, leading to near-unidirectional flow throughout the SOL. As density increases, the effects of the poloidal $\boldsymbol{\mathbf{E}} \times \boldsymbol{\mathbf{B}}$ drift decrease substantially, resulting in a smaller density asymmetry and the development of a counter-streaming flow pattern. For the entire density range probed in this experiment ( $\overline{n}_\mathrm{e} = 1.5-6\times 10^{19}$ m ^−3 ), the experimental observations are more consistent with the effects of the poloidal $\boldsymbol{\mathbf{E}} \times \boldsymbol{\mathbf{B}}$ drift than the radial $\boldsymbol{\mathbf{E}} \times \boldsymbol{\mathbf{B}}$ drift.

During its second operational campaign (OP 1.2a) W7-X operated with an edge island divertor. Much higher densities (1020m−3) than in to the previous, limiter campaign were achieved. In order to asses this improved performance and the nature of transport with regard to the expected higher densities and other parameters such as the electron and ion temperature, the electric field and plasma flow, measurements at the plasma edge were conducted with reciprocating probe, mounted on a Manipulator. The probe contains a set of Langmuir pins, Mach probes, compensation coils and a set of 3D pick up coils for the measurement of the local magnetic field and fluctuations, and an ion sensitive probe. It has been observed, in addition to differences due to the magnetic configurations, that the magnetic topology is sensitive to the plasma conditions, especially to changes due to a evolving toroidal plasma current. Measurements from divertor cameras showed that an increasing toroidal current in the standard configuration broadened the heat flux and shifted the strike line considerably. These down-stream observation can be complemented with the measurements at the mid-plane with the manipulator mounted probes. During the experiments the edge island remnant was identified with the measured edge plasma profiles and compared with the predictions from the field line tracing code. Those electron densities and temperatures have been used as an input for understanding edge transport with the EMC3-EIRENE modeling. The results from EMC3-EIRENE also help improve the caculated density profiles, since the modelling provides a profile of the effective charge Zeff. Keywords: W7-X, Langmuir probes, Magnetic islands, Plasma edge transport

A 1–2 kHz electromagnetic mode is present in a large fraction of W7-X discharges in the standard magnetic field configurations with 5/5 edge island structure. The power in the mode is significantly reduced in other magnetic configurations. The mode can appear spontaneously and persist for the full duration of a discharge. Its full width at half maximum is typically 100–300 Hz.The 1–2 kHz mode was first observed in visible light emissions from the divertor [1]. Matching spectral peaks were found in measurements of both global and edge plasma parameters, including line-integrated density, diamagnetic energy, and edge floating potential and ion saturation current [2]. An infrared camera recording shows a temperature modulation of ~ 2.5 K due to this mode on a divertor tile where the average temperature was 600 °C. Separate correlation analyses of the high-speed camera recordings, Langmuir probe signals, and Mirnov coil signals all indicate a poloidal velocity of 0.5–10 km/s and m = 2 as a likely poloidal mode number. Langmuir probes mounted on the Multi-Purpose Manipulator show that the fluctuation is present in one of the magnetic islands over a radial distance of at least 5 mm.A database of various diagnostic measurements and dB/dt signals from a Mirnov coil was created using a majority of the discharges from the 2018 campaign on W7-X, in order to shed light on the plasma parameters that are correlated with the existence of the 1–2 kHz mode. The power in the mode is positively correlated to the toroidal current, total external heating power, and core electron temperature. It is negatively correlated with plasma density.

Several risk stratification tools were developed to predict disease progression in coronavirus disease 2019, with no external validation to date. We attempted to validate three previously published risk-stratification tools in a multicenter study. Primary outcome was a composite outcome of development of severe coronavirus disease 2019 disease leading to ICU admission or death censored at hospital discharge or 30 days. We collected data from 169 patients. Patients were 73 years old (59–82 yr old), 66 of 169 (39.1%) were female, 57 (33.7%) had one comorbidity, and 80 (47.3%) had two or more comorbidities. Area under the receiver operating characteristic curve (95% CI) for the COVID-GRAM score was 0.636 (0.550–0.722), for the CALL score 0.500 (0.411–0.589), and for the nomogram 0.628 (0.543–0.714).

In this work we present an analysis of fast-camera imaging of Alcator C-Mod's divertor region and of the plasma cross section in the W7-X stellarator. In C-Mod, the dynamics of intermittent edge plasma filaments are imaged at 397,100 frames per second in an oblique view. An automatic pipeline was developed to reconstruct the filament motion in the R, Z plane of the divertor using EFIT field line projections. Next, we added our fast-framing camera to W7-X's diagnostic suite for the 2017 run campaign, the first with a divertor. It has a tangential view of the machine cross section, including part of a divertor module. The view is coupled to the camera via a coherent fiber bundle. The spatial resolution is 2–4 cm and the typical plasma brightness limits the fastest usable frame rate to 30k frames/s. We observe filaments in the plasma boundary that rotate around the magnetic axis during radiative collapse; filaments were observed in steady state in the limiter configuration of W7-X by Kocsis et al. [1]. We also observe for the first time a 1–2 kHz quasi-coherent fluctuation in divertor target emissions in the W7-X “standard” magnetic configuration. Finally, a rough analysis of edge gas fueling efficiency using fast camera data and S/XB coefficients finds that fueling is less efficient at densities higher than 4 × 1019 m−3. Keywords: C-Mod, W7-X, Filaments, Blobs, Turbulence, Fluctuation

The formation of the radial electric field, $E_\textrm{r}$ in the scrape-off layer (SOL) has been experimentally studied for attached divertor conditions in stellarator W7-X. The main objective of this study is to test the validity in a complex three-dimensional (3D) island divertor of simple models, typically developed in tokamaks, relating $E_\textrm{r}$ in the SOL to the sheath potential drop gradient at the target. Additionally, we investigate the effect of the edge $E_\textrm{r}$ shear on the reduction of density fluctuation amplitude, a well-established phenomenon according to the existing bibliography. The main diagnostic for measurements in the SOL is a V-band Doppler reflectometer that can provide the measurement of the $E_\textrm{r}$ and density fluctuations with good spatial resolution. 3D measurements of divertor parameters have been carried out using infrared cameras, with the exponential decay length of the divertor heat flux ( $\lambda_\mathrm{q}$ ) resulting in a suitable proxy for the model-relevant $\lambda_\mathrm{T}$ , the exponential decay length of the temperature at the divertor. In the investigated attached regimes, it is shown for the first time that the formation of the $E_\textrm{r}$ in the SOL depends on parameters at the divertor, following a $E_\textrm{r} \propto T_\mathrm{e}/\lambda_\mathrm{q}$ qualitatively similar to that found in a tokamak. Then, from the analyzed plasmas, the observed $E_\textrm{r}$ shear at the edge is linked to a moderate local reduction of the amplitude of density fluctuations.

Introduction: Understanding sex differences in the clinical presentation of patients with suspected stroke is important to reduce sex-related disparities and improve care. We aimed to characterize presenting symptoms in women and men with suspected stroke evaluated at our comprehensive stroke center., Methods: This was a retrospective analysis of consecutive patients with suspected stroke treated at the University Hospital Essen between January 2017 and December 2021. Patient characteristics, signs and symptoms as well as final diagnoses in women and men were compared. Logistic regression analysis was performed to assess the association of individual symptoms with a diagnosis of cerebrovascular disease., Results: We included 6069 patients in our analysis. Cerebrovascular disease was diagnosed in 85.2% (2576/3022) of women and 88.0% (2681/3047) of men (p = 0.002). Aphasia (31.4% vs. 27.7%, p = 0.002), neglect (15.5% vs. 12.8%, p = 0.003), gaze deviation (21.0% vs. 18.8%, p = 0.034), as well as nonfocal symptoms including impairments in consciousness (17.0% vs 14.6%, p = 0.012), orientation (42.5 vs. 36.4%, p < 0.001) and completion of tasks (31.2% vs. 26.0%, p < 0.001) were more common among women. Limb ataxia (8.1% vs. 11.2%, p < 0.001) and dysarthria (44.0% vs. 46.8%, p = 0.030) were less frequent in women. Neglect and gaze deviation were independent positive predictors of cerebrovascular disease in women but not in men., Conclusion: Although clinical presentation was similar in both sexes, cortical and nonfocal symptoms were more common among women with suspected stroke. Awareness of sex differences and acknowledgement of the full clinical picture are important to ensure optimal management for women and men with suspected stroke. Our findings might serve as a target for educational programs in order to improve preclinical stroke detection in patients with predominantly nonfocal or subtle symptoms., (The Author(s). Published by S. Karger AG, Basel.)

Acute respiratory infections are a significant challenge in primary care and hospital settings. Viruses are the most common etiology and the overlapping symptomatology among major respiratory viruses, such as influenza, severe acute respiratory syndrome coronavirus 2, and respiratory syncytial virus, requires the use of diagnostic tests that deliver early and accurate results. With the increasing availability of rapid antigen tests (RATS), it is tempting to prefer them over polymerase chain reaction (PCR) tests. However, compelling arguments support the existing recommendations in some European countries to maintain PCR testing for patient management throughout the year. RATs show sensitivities below 30% with lower viral loads, which are common and can have significant clinical implications. RATs perform well at lower cycle threshold (Ct) values, with sensitivity reaching 97.9% for Ct values below 20, which drops significantly for values above 25. Factors affecting viral load include disease stage, vaccination status, and viral variants, all of which can compromise the accuracy of antigen tests. Multi-target PCR tests effectively overcome these issues, ensuring reliable diagnosis. Additionally, the early detection of paucisymptomatic cases is essential in primary care and hospital settings to facilitate isolation and prevent secondary infections. Economic analyses support the use of comprehensive PCR tests, such as triplex-type tests, detecting SARS-CoV-2, influenza viruses, and RSV, as a first-line approach, as they can reduce case numbers and healthcare resource utilization. Maintaining PCR testing year-round is therefore crucial for the effective management of respiratory infections.

Respiratory syncytial virus (RSV) is a seasonal virus known to cause significant morbidity in pediatric patients; however, morbidity in adult patients has not been well investigated. We aimed to characterize adult patients with RSV infection in the emergency department (ED) and their clinical course. During the winter term 2022/23, all adult ED patients were screened for RSV, severe acute respiratory syndrome coronavirus type 2, and influenza infection using point-of-care polymerase chain reaction tests. All symptomatic RSV+ patients were further characterized based on their clinical presentation and course. A group comparison between RSV+ inpatients and RSV+ outpatients was conducted. The potential risk factors for inpatient treatment were evaluated using univariate and multivariate analyses. Of the 135 symptomatic RSV+ patients, 51.9% (70/135) were inpatients. Their length of stay were 9.4 (±10.4) days. Inpatients had a significantly higher mean age, lower oxygen saturation, higher leukocyte count, and higher C-reactive protein levels than outpatients. Among the preconditions, pulmonary diseases, tumors, and immunosuppression were significantly more frequent in the inpatient group. Thirty percent (21/70) of the inpatients required ICU treatment, 11% (8/70) required mechanical ventilation, and 9% (6/70) died. Malaise (P = .021, odds ratio 8.390) and detection of pulmonary infiltrations (P < .001, odds ratio 12.563) were the only independent predictors of inpatient treatment in the multivariate analysis. Our data show that RSV is a medically relevant pathogen among adult ED patients, often requiring inpatient treatment. In particular, elderly patients with some medical preconditions seem to be more prone to a severe course of infection requiring inpatient treatment. Lower respiratory tract involvement, proven by pulmonary infiltrates, seems to be crucial for a more severe disease course., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: We evaluated the ability of the assessment of regional wall motion abnormalities (RWMA) detected via transthoracic echocardiography to predict the presence of obstructive coronary artery disease (CAD) in patients presenting with acute chest pain to the emergency department., Design: Prospective single-centre observational study., Setting: Tertiary care university hospital emergency unit., Participants: Patients presenting to the emergency department with acute chest pain suggestive of obstructive CAD., Primary Outcome Measure: The primary endpoint was defined as the presence of obstructive CAD, requiring revascularisation therapy., Results: Overall, 657 patients (age 58.1±18.0 years, 53% men) were included in our study. RWMA were detected in 76 patients (11.6%). RWMA were significantly more frequent in patients reaching the primary endpoint (26.2% vs 7.6%, p<0.001). In multivariable regression analysis, the presence of RWMA was associated with threefold increased odds of the presence of obstructive CAD (3.41 (95% CI 1.99 to 5.86), p<0.001). Adding RWMA to a multivariable model of the Thrombolysis in Myocardial Infarction (TIMI) risk score, cardiac biomarkers and traditional risk factors significantly improved the area under the curve for prediction of obstructive CAD (95% CI 0.777 to 0.804, p=0.0092)., Conclusion: RWMA strongly and independently predicts the presence of obstructive CAD in patients presenting with acute chest pain to the emergency department., Trial Registration: The study has been registered online (NCT03787797)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

For many years, ventilation has been an essential part of advanced life support (ALS) in cardiopulmonary resuscitation (CPR). Nevertheless, there is little evidence about the best method of ventilation during resuscitation for both out-of-hospital cardiac arrest (OHCA) and inhospital cardiac arrest (IHCA) patients. Effective ventilation is one of the two main keys to successful resuscitation. In this context, the question always arises as to which airway management, along with which ventilation mode, constitutes the best strategy. Conventional ventilation modes are not designed for cardiac arrest and show important limitations that must be considered when used in CPR. Manual ventilation without the use of an automated transport ventilator (ATV) could be shown to be uncontrolled in applied volumes and pressures and should be avoided. Mechanical ventilation with an ATV is therefore superior to manual ventilation, but both volume- and pressure-controlled ventilation modes are significantly influenced by chest compressions. With the newly designed chest compression synchronized ventilation (CCSV), a special ventilation mode for resuscitation is available. Further research should be conducted to obtain more evidence of the effect of ventilation during CPR on outcomes following OHCA and not only about how to secure the airway for ventilation during CPR., (© 2024. The Author(s).)

Background: Stroke mimics are common in the emergency department (ED) and early detection is important to initiate appropriate treatment and withhold unnecessary procedures. We aimed to compare the frequency, clinical characteristics and predictors of non-neurological and neurological stroke mimics transferred to our ED for suspected stroke., Methods: This was a cross-sectional study of consecutive patients with suspected stroke transported to the ED of the University Hospital Essen between January 2017 and December 2021 by the city's Emergency Medical Service. We investigated patient characteristics, preclinical data, symptoms and final diagnoses in patients with non-neurological and neurological stroke mimics. Multinominal logistic regression analysis was performed to assess predictors of both etiologic groups., Results: Of 2167 patients with suspected stroke, 762 (35.2%) were diagnosed with a stroke mimic. Etiology was non-neurological in 369 (48.4%) and neurological in 393 (51.6%) cases. The most common diagnoses were seizures (23.2%) and infections (14.7%). Patients with non-neurological mimics were older (78.0 vs. 72.0 y, p < 0.001) and more likely to have chronic kidney disease (17.3% vs. 9.2%, p < 0.001) or heart failure (12.5% vs. 7.1%, p = 0.014). Prevalence of malignancy (8.7% vs. 13.7%, p = 0.031) and focal symptoms (38.8 vs. 57.3%, p < 0.001) was lower in this group. More than two-fifths required hospitalization (39.3 vs. 47.1%, p = 0.034). Adjusted multinominal logistic regression revealed chronic kidney and liver disease as independent positive predictors of stroke mimics regardless of etiology, while atrial fibrillation and hypertension were negative predictors in both groups. Prehospital vital signs were independently associated with non-neurological stroke mimics only, while age was exclusively associated with neurological mimics., Conclusions: Up to half of stroke mimics in the neurological ED are of non-neurological origin. Preclinical identification is challenging and a high proportion requires hospitalization. Awareness of underlying etiologies and differences in clinical characteristics is important to provide optimal care.

Early treatment is the mainstay of sepsis therapy. We suspected that early recognition of sepsis by prehospital healthcare providers may shorten the time for antibiotic administration in the emergency department. We retrospectively evaluated all patients above 18 years of age who were diagnosed with sepsis or severe infection in our emergency department between 2018 and 2020. We recorded the suspected diagnosis at the time of presentation, the type of referring healthcare provider, and the time until initiation of antibiotic treatment. Differences between groups were calculated using the Kruskal-Wallis rank sum test. Of the 277 patients who were diagnosed with severe infection or sepsis in the emergency department, an infection was suspected in 124 (44.8%) patients, and sepsis was suspected in 31 (11.2%) patients by referring healthcare providers. Time to initiation of antibiotic treatment was shorter in patients where sepsis or infection had been suspected prior to arrival for both patients with severe infections ( p = 0.022) and sepsis ( p = 0.004). Given the well-described outcome benefits of early sepsis therapy, recognition of sepsis needs to be improved. Appropriate scores should be used as part of routine patient assessment to reduce the time to antibiotic administration and improve patient outcomes.

Problem: Regarding transmissible viral diseases such as those caused by SARS-CoV-2 virus, one of the key challenges is isolation management until final diagnosis. This study investigates the influence of SARS-CoV-2 point-of-care (POC) PCR on workflow and efficiency in an emergency department (ED) of a tertiary university hospital., Method: An analysis of 17,875 ED patients receiving either SARS-CoV-2 POC PCR (rapid PCR, 11,686 patients) or conventional laboratory SARS-CoV-2 PCR (conventional PCR, 6,189 patients) was performed. The pathways for both groups were mapped and compared, and process times from admission to diagnosis were measured. Effects on resource management within the ED were quantified. Direct costs due to isolation, loss of capacities, and revenues were calculated for inpatients., Results: The mean time from admission to result was 1.62 h with rapid PCR and 16.08 h with conventional PCR (p < 0.01), reducing the isolation time by 14.46 h. In the first 2 h after testing, test results were available for > 75% of the rapid PCR group and none of the conventional PCR group. Ninety percent of the results were available within 3 h for the rapid PCR and within 21 h for the conventional PCR group. For the conventional PCR group, an increase in direct costs of €35.74 and lost revenues of €421.06 for each inpatient case was detected., Conclusion: Rapid PCR significantly reduces the time-to-results and time for isolation relative to conventional PCR. Although testing costs for rapid PCR are higher, it benefits workflow, reduces total costs, and frees up ward capacity., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Fistera et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Determining SARS-CoV-2 immunity is critical to assess COVID-19 risk and the need for prevention and mitigation strategies. We measured SARS-CoV-2 Spike/Nucleocapsid seroprevalence and serum neutralizing activity against Wu01, BA.4/5 and BQ.1.1 in a convenience sample of 1,411 patients receiving medical treatment in the emergency departments of five university hospitals in North Rhine-Westphalia, Germany, in August/September 2022. 62% reported underlying medical conditions and 67.7% were vaccinated according to German COVID-19 vaccination recommendations (13.9% fully vaccinated, 54.3% one booster, 23.4% two boosters). We detected Spike-IgG in 95.6%, Nucleocapsid-IgG in 24.0%, and neutralization against Wu01, BA.4/5 and BQ.1.1 in 94.4%, 85.0%, and 73.8% of participants, respectively. Neutralization against BA.4/5 and BQ.1.1 was 5.6- and 23.4-fold lower compared to Wu01. Accuracy of S-IgG detection for determination of neutralizing activity against BQ.1.1 was reduced substantially. We explored previous vaccinations and infections as correlates of BQ.1.1 neutralization using multivariable and Bayesian network analyses. Given a rather moderate adherence to COVID-19 vaccination recommendations, this analysis highlights the need to improve vaccine-uptake to reduce the COVID-19 risk of immune evasive variants. The study was registered as clinical trial (DRKS00029414)., (© 2023. The Author(s).)

Aims: We tested the hypothesis that epicardial adipose tissue (EAT) quantification improves the prediction of the presence of obstructive coronary artery disease (CAD) in patients presenting with acute chest pain to the emergency department., Methods and Results: Within this prospective observational cohort study, we included 657 consecutive patients (mean age 58.06 ± 18.04 years, 53% male) presenting to the emergency department with acute chest pain suggestive of acute coronary syndrome between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, haemodynamic instability, or known CAD were excluded. As part of the initial workup, we performed bedside echocardiography for quantification of EAT thickness by a dedicated study physician, blinded to all patient characteristics. Treating physicians remained unaware of the results of the EAT assessment. The primary endpoint was defined as the presence of obstructive CAD, as detected in subsequent invasive coronary angiography. Patients reaching the primary endpoint had significantly more EAT than patients without obstructive CAD (7.90 ± 2.56 mm vs. 3.96 ± 1.91 mm, P < 0.0001). In a multivariable regression analysis, a 1 mm increase in EAT thickness was associated with a nearby two-fold increased odds of the presence of obstructive CAD [1.87 (1.64-2.12), P < 0.0001]. Adding EAT to a multivariable model of the GRACE score, cardiac biomarkers and traditional risk factors significantly improved the area under the receiver operating characteristic curve (0.759-0.901, P < 0.0001)., Conclusion: Epicardial adipose tissue strongly and independently predicts the presence of obstructive CAD in patients presenting with acute chest pain to the emergency department. Our results suggest that the assessment of EAT may improve diagnostic algorithms of patients with acute chest pain., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: T he COVID-19 pandemic led to an alteration of algorithms in emergency medicine, which may influence the management of patients with similar symptoms but underlying cardiovascular diseases. We evaluated key differential diagnoses to acute COVID-19 infection and the prevalence and the prognosis of myocardial injury in patients presenting for suspected COIVD-19 infection., Methods: This prospective observational study includes patients presenting with symptoms suggestive of COVID-19 infection during the pandemic. In patients without COVID-19, leading diagnoses was classified according to ICD-10. Myocardial injury was defined as elevated high-sensitivity Troponin I with at least one value above the 99th percentile upper reference limit and its prevalence together with 90-days mortality rate was compared in patients with vs without COVID-infection., Results: From 497 included patients (age 62.9 ± 17.2 years, 56 % male), 314 (63 %) were tested positive on COVID-19 based on PCR-testing, while another cause of symptom was detected in 183 patients (37 %). Cardiovascular diseases were the most frequent differential diagnoses (40 % of patients without COVID-19), followed by bacterial infection (24 %) and malignancies (16 %). Myocardial injury was present in 91 patients (COVID-19 positive: n = 34, COVID-19 negative: n = 57). 90-day mortality rate was higher in patients with myocardial injury (13.4 vs 4.6 %, p = 0.009)., Conclusion: Cardiovascular diseases represent the most frequent differential diagnoses in patients presenting to a tertiary care emergency department with symptoms suggestive of an acute infection. Screening for cardiovascular disease is crucial in the initial evaluation of symptomatic patients during the COVID pandemic to identify patients at increased risk. Trial Registration: Clinicaltrials.gov Identifier: NCT04327479., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

The plant microbiome can be used to bolster plant defense against abiotic and biotic stresses. Some strains of endophytes, the microorganisms within plants, can directly inhibit the growth of plant fungal pathogens. A previously isolated endophyte from wild Populus (poplar), WPB of the species Burkholderia vietnamiensis , had robust in vitro antifungal activity against pathogen strains that are highly virulent and of concern to Pacific Northwest agriculture: Rhizoctonia solani AG-8, Fusarium culmorum 70110023, and Gaemannomyces graminis var. tritici (Ggt) ARS-A1, as well as activity against the oomycete, Pythium ultimum 217. A direct screening method was developed for isolation of additional anti-fungal endophytes from wild poplar extracts. By challenging pathogens directly with dilute extracts, eleven isolates were found to be inhibitory to at least two plant pathogen strains and were therefore chosen for further characterization. Genomic analysis was conducted to determine if these endophyte strains harbored genes known to be involved in antimicrobial activities. The newly isolated Bacillus strains had gene clusters for production of bacillomycin, fengicyn, and bacillibactin, while the gene cluster for the synthesis of sessilin, viscosin and tolaasin were found in the Pseudomonas strains. The biosynthesis gene cluster for occidiofungin ( ocf ) was present in the Burkholderia vietnamiensis WPB genome, and an ocf deletion mutant lost inhibitory activity against 3 of the 4 pathogens. The new isolates lacked the gene cluster for occidiofungin implying they employ different modes of action. Other symbiotic traits including nitrogen fixation, phosphate solubilization, and the production of auxins and siderophores were investigated. Although it will be necessary to conduct in vivo tests of the candidates with pathogen-infected agricultural crops, the wild poplar tree microbiome may be a rich source of beneficial endophyte strains with potential for biocontrol applications against a variety of pathogens and utilizing varying modes of action.

The coronavirus disease 2019 (COVID-19) pandemic is a major challenge for global healthcare systems. Early and safe triage in the emergency department (ED) is crucial for proper therapy. However, differential diagnosis remains challenging. Rapid antigen testing (RAT) may help to improve early triage and patient safety. We performed a retrospective study of 234 consecutive patients with suspected COVID-19 who presented to our ED in November 2020. All underwent SARS-CoV-2-nasopharyngeal swab testing using both RAT and reverse transcription polymerase chain reaction (RT-PCR). The inpatient treatment was established according to an empirically developed triage algorithm. The accuracy of the suggested algorithm was analyzed based on the rate of outpatients returning within 7 days and inpatients staying for less than 48 hours. COVID-19 inpatients and outpatients were compared for symptoms, vital signs, and C-reactive protein levels. Of the 221 included patients with suspected COVID-19 infection, the diagnosis could be confirmed in 120 patients (54.3%) by a positive RT-PCR result, whereas only 72% of those had a positive antigen test. Of the 56 COVID-19 outpatients, three returned within 7 days with the need for hospital treatment due to clinical deterioration. Among the 64 COVID-19 inpatients, 4 were discharged within 48 hours, whereas 60 stayed longer (mean duration 10.2 days). The suggested triage algorithm was safe and efficient in the first 234 consecutive patients. RAT can confirm a diagnosis in 72% of PCR proven COVID-19 patients and allows early cohort isolation as an important way to save hospital capacity., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Purpose: Considering the highly time-dependent therapeutic effect of endovascular treatment in patients with large vessel occlusion-associated acute ischemic stroke, prehospital identification of large vessel occlusion and subsequent triage for direct transport to a comprehensive stroke center offers an intriguing option for optimizing patient pathways., Methods: This prospective in-field validation study included 200 patients with suspected acute ischemic stroke who were admitted by emergency medical service to a comprehensive stroke center. Ambulances were equipped with smartphones running an app-based Field Assessment Stroke Triage for Emergency Destination scale for transmission prior to admission. The primary measure was the predictive accuracy of the transmitted Field Assessment Stroke Triage for Emergency Destination for large vessel occlusion and the secondary measure the predictive accuracy for endovascular treatment., Results: A Field Assessment Stroke Triage for Emergency Destination ⩾4 revealed very good accuracy to detect large vessel occlusion-related acute ischemic stroke with a sensitivity of 82.4% (95% confidence interval = 65.5-93.2), specificity of 78.3% (95% confidence interval = 71.3-84.3), and an area under the curve c -statistics of 0.89 (95% confidence interval = 0.85-0.94). Field Assessment Stroke Triage for Emergency Destination ⩾4 correctly identified 84% of patients who received endovascular treatment [73.5% specificity (95% confidence interval = 66.4-79.8)] with an area under the curve c -statistics of 0.82 (95% confidence interval = 0.74-0.89). In a hypothetical triage model of an urban setting, one secondary transportation would be avoided with every fifth patient screened., Conclusion: A smartphone app-based stroke triage completed by emergency medical service personnel showed adequate quality for the Field Assessment Stroke Triage for Emergency Destination to identify large vessel occlusion-associated acute ischemic stroke. We demonstrate feasibility of the use of a medical messaging service in prehospital stroke care. Based on these first results, a randomized trial evaluating the clinical benefit of such a triage system in an urban setting is currently in preparation.Clinical Trial Registration: https://clinicaltrials.gov Unique identifier: NCT04404504., Competing Interests: Conflict of interest statement: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: No authors received any payments for work on the submitted manuscript. B.F. and M.K. report modest fees for advisory roles with Allm Inc. R.G.N. reports consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Imperative Care, Medtronic, Phenox, Prolong Pharmaceuticals, and Stryker Neurovascular and stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, and Perfuze. The other authors refer no conflicts of interest., (© The Author(s), 2021.)

Background: The ongoing COVID-19 pandemic remains a major challenge for worldwide health care systems and in particular emergency medicine. An early and safe triage in the emergency department (ED) is especially crucial for proper therapy. Clinical symptoms of COVID-19 comprise those of many common diseases; thus, differential diagnosis remains challenging., Method: We performed a retrospective study of 314 ED patients presenting with conceivable COVID-19 symptoms during the first wave in Germany. All were tested for COVID-19 with SARS-Cov-2-nasopharyngeal swabs. Forty-seven patients were positive. We analyzed the 267 COVID-19 negative patients for their main diagnosis and compared COVID-19 patients with COVID-19 negative respiratory infections for differences in laboratory parameters, symptoms, and vital signs., Results: Among the 267 COVID-19 negative patients, 42.7% had respiratory, 14.2% had other infectious, and 11.2% had cardiovascular diseases. Further, 9.0% and 6.7% had oncological and gastroenterological diagnoses, respectively. Compared to COVID-19 negative airway infections, COVID-19 patients showed less dyspnea (OR 0.440; p = 0.024) but more dysgeusia (OR 7.631; p = 0.005). Their hospital stay was significantly longer (9.0 vs. 5.6 days; p = 0.014), and their mortality significantly higher (OR 3.979; p = 0.014)., Conclusion: For many common ED diagnoses, COVID-19 should be considered a differential diagnosis. COVID-19 cannot be distinguished from COVID-19 negative respiratory infections by clinical signs, symptoms, or laboratory results. When hospitalization is necessary, the clinical course of COVID-19 airway infections seems to be more severe compared to other respiratory infections., Trial Registration: German Clinical Trial Registry DRKS, DRKS-ID of the study: DRKS00021675 date of registration: May 8th, 2020, retrospectively registered., (© 2021. The Author(s).)

Background: A growing number of reports suggest that infection with SARS-CoV-2 often leads to neurological involvement; however, data on the incidence and severity are limited to mainly case reports and retrospective studies., Methods: This prospective, cross-sectional study of 102 SARS-CoV-2 PCR positive patients investigated the frequency, type, severity and risk factors as well as underlying pathophysiological mechanisms of neurological involvement (NIV) in COVID-19 patients., Results: Across the cohort, 59.8% of patients had NIV. Unspecific NIV was suffered by 24.5%, mainly general weakness and cognitive decline or delirium. Mild NIV was found in 9.8%; most commonly, impaired taste or smell. Severe NIV was present in 23.5%; half of these suffered cerebral ischaemia. Incidence of NIV increased with respiratory symptoms of COVID-19. Mortality was higher with increasing NIV severity. Notably, 83.3% with severe NIV had a pre-existing neurological co-morbidity. All cerebrospinal fluid (CSF) samples were negative for SARS-CoV-2 RNA, and SARS-CoV-2 antibody quotient did not suggest intrathecal antibody synthesis. Of the patients with severe NIV, 50% had blood-brain barrier (BBB) disruption and showed a trend of elevated interleukin levels in CSF. Antibodies against neuronal and glial epitopes were detected in 35% of the patients tested., Conclusion: Cerebrovascular events were the most frequent severe NIV and severe NIV was associated with high mortality. Incidence of NIV increased with respiratory symptoms and NIV and pre-existing neurological morbidities were independent risk factors for fatality. Inflammatory involvement due to BBB disruption and cytokine release drives NIV, rather than direct viral invasion. These findings might help physicians define a further patient group requiring particular attention during the pandemic., Competing Interests: Conflict of interest: M. Fleischer reports no disclosures relevant to the manuscript. M. Köhrmann reports no disclosures relevant to the manuscript. S. Dolff reports no disclosures relevant to the manuscript. F. Szepanowski reports no disclosures relevant to the manuscript. K. Schmidt reports no disclosures relevant to the manuscript. F. Herbstreit has received speaker honoraria from Biotest and Maquet Getinge. C. Güngör reports no disclosures relevant to the manuscript. B. Stolte reports no disclosures relevant to the manuscript. Ch. Stadtler reports no disclosures relevant to the manuscript. J. Riße reports no disclosures relevant to the manuscript. O. Witzke has received research grants for clinical studies, speaker’s fees, honoraria and travel expenses from Amgen, Alexion, Astellas, Basilea, Biotest, Bristol-Myers Squibb, Correvio, Chiesi, Gilead, Hexal, Janssen, Dr. F. Köhler Chemie, MSD, Novartis, Roche, Pfizer, Sanofi, TEVA and UCB. M. Fiedler reports no disclosures relevant to the manuscript. A. Mausberg reports no disclosures relevant to the manuscript. C. Kill reports no disclosures relevant to the manuscript. G. Meyer zu Horste has received speaker honoraria and served in advisory boards for LFB Pharma. K. Steiner reports no disclosures relevant to the manuscript. M. Forsting reports no disclosures relevant to the manuscript. U. Sure reports no disclosures relevant to the manuscript. U. Dittmer reports no disclosures relevant to the manuscript. T. Brenner reports no disclosures relevant to the manuscript. C. Kleinschnitz reports no disclosures relevant to the manuscript. M. Stettner served on the scientific advisory and/or received speaker honoraria or travel funding from UCB, Biogen Idec; Grifols, Genzyme, Roche, Merck, Novartis, Octapharma, Sanofi-Aventis, TEVA, and Bayer Healthcare. All authors declare approval of the version that is to be published., (© The Author(s), 2021.)

Background: COVID-19 pandemia is a major challenge to worldwide health care systems. Whereas the majority of disease presents with mild symptoms that can be treated as outpatients, severely ill COVID-19 patients and patients presenting with similar symptoms cross their ways in the emergency department. Especially, the variety of symptoms is challenging with primary triage. Are there parameters to distinguish between proven COVID-19 and without before? How can a safe and efficient management of these inpatients be achieved?, Methods: We conducted a retrospective analysis of 314 consecutive inpatient patients who presented with possible symptoms of COVID-19 in a German emergency department between March and April 2020 and were tested with a SARS-Cov-2 nasopharyngeal swab. Clinical parameters, Manchester Triage System categories, and lab results were compared between patients with positive and negative test results for SARS-Cov-2. Furthermore, we present the existing COVID-19 workflow model of the university hospital in Essen which proved to be efficient during pandemia., Results: Forty-three of the 314 patients (13.7%) were tested positive for COVID-19 by SARS-Cov-2 nasopharyngeal swab. We did not find any laboratory parameter to distinguish safely between patients with COVID-19 and those with similar symptoms. Dysgeusia was the only clinical symptom that was significantly more frequent among COVID-19 patients., Conclusion: Dysgeusia seems to be a typical symptom for COVID-19, which occurred in 14% of our COVID-19 patients. However, no valid parameters could be found to distinguish clinically between COVID-19 and other diseases with similar symptoms. Therefore, early testing, a strict isolation policy, and proper personal protection are crucial to maintain workflow and safety of patients and ED staff for the months to come., Trial Registration: German Clinical Trials registry, DRKS00021675.

Background: Videolaryngoscopy (VL) has become a popular method of intubation (ETI). Although VL may facilitate ETI in less-experienced rescuers there are limited data available concerning ETI performed by paramedics during CPR. The goal was to evaluate the impact VL compared with DL on intubation success and glottic view during CPR performed by German paramedics. We investigated in an observational prospective study the superiority of VL by paramedics during CPR compared with direct laryngoscopy (DL)., Methods: In a single Emergency Medical Service (EMS) in Germany with in total 32 ambulances paramedics underwent an initial instruction from in endotracheal intubation (ETI) with GlideScope® (GVL) during resuscitation. The primary endpoint was good visibility of the glottis (Cormack-Lehane grading 1/2), and the secondary endpoint was successful intubation comparing GVL and DL., Results: In total n = 97 patients were included, n = 69 with DL (n = 85 intubation attempts) and n = 28 VL (n = 37 intubation attempts). Videolaryngoscopy resulted in a significantly improved visualization of the larynx compared with DL. In the group using GVL, 82% rated visualization of the glottis as CL 1&2 versus 55% in the DL group (p = 0.02). Despite better visualization of the larynx, there was no statistically significant difference in successful ETI between GVL and DL (GVL 75% vs. DL 68.1%, p = 0.63)., Conclusions: We found no difference in Overall and First Pass Success (FPS) between GVL and DL during CPR by German paramedics despite better glottic visualization with GVL. Therefore, we conclude that education in VL should also focus on insertion of the endotracheal tube, considering the different procedures of GVL., Trial Registration: German Clinical Trial Register DRKS00020976, 27. February 2020 retrospectively registered.

Background: Guidelines recommend mechanical ventilation with Intermitted Positive Pressure Ventilation (IPPV) during resuscitation. The influence of the novel ventilator mode Chest Compression Synchronized Ventilation (CCSV) on gas exchange and arterial blood pressure compared with IPPV was investigated in a pig model., Methods: In 12 pigs (general anaesthesia/intubation) ventricular fibrillation was induced and continuous chest compressions were started after 3 min. Pigs were mechanically ventilated in a cross-over setting with 5 ventilation periods of 4 min each: Ventilation modes were during the first and last period IPPV (100% O2, tidal volumes = 7 ml/kgKG, respiratory rate = 10/min), during the 2nd, 3rd and 4th period CCSV (100% O2), a pressure-controlled and with each chest compression synchronized breathing pattern with three different presets in randomized order. Presets: CCSVA: P insp = 60 mbar, inspiratory time = 205 ms; CCSVB: P insp = 60 mbar, inspiratory time = 265 ms; CCSVC: P insp = 45 mbar, inspiratory time = 265 ms. Blood gas samples were drawn for each period, mean arterial (MAP) and central venous (CVP) blood pressures were continuously recorded. Results as median (25%/75%percentiles)., Results: Ventilation with each CCSV mode resulted in higher PaO2 than IPPV: PaO2: IPPV first: 19.6(13.9/36.2)kPa, IPPV last: 22.7(5.4/36.9)kPa (p = 0.77 vs IPPV first), CCSVA: 48.9(29.0/58.2)kPa (p = 0.028 vs IPPV first, p = 0.0001 vs IPPV last), CCSVB: 54.0 (43.8/64.1) (p = 0.001 vs IPPV first, p = 0.0001 vs IPPV last), CCSVC: 46.0 (20.2/58.4) (p = 0.006 vs IPPV first, p = 0.0001 vs IPPV last). Both the MAP and the difference MAP-CVP did not decrease during twelve minutes CPR with all three presets of CCSV and were higher than the pressures of the last IPPV period., Conclusions: All patterns of CCSV lead to a higher PaO2 and avoid an arterial blood pressure drop during resuscitation compared to IPPV in this pig model of cardiac arrest.

Background: Continuous peripheral nerve blocks typically are performed with a "through-the-needle technique" and require needles with an inner diameter allowing catheter placement. In case of direct needle-nerve contact, the pencil-point needletip is currently considered less traumatic than are other needle configurations. In this study we determined whether nerve puncture with pencil-point needles is associated with fewer nerve injuries in comparison with Tuohy needles., Methods: In 6 anesthetized pigs the brachial plexus were exposed bilaterally. Up to 8 nerves underwent nerve puncture with a pencil-point or a Tuohy needle. After 48 hours, the nerves were resected during anesthesia. The specimens were processed for visual examination and the detection of inflammatory cells, myelin damage, and intraneural hematoma. The grade of nerve injury was assessed using an objective score ranging from 0 (no injury) to 4 (severe injury)., Results: Fifty-eight nerves, including controls, were examined. According to the applied injury score, there was no significant difference between the pencil-point needle group [median (interquartile range) 3 (3-4)] and the Tuohy needle group [3 (3-4) P = 0.97]. The occurrence of posttraumatic regional inflammation, myelin damage, and intraneural hematoma was similarly high in both groups., Conclusions: Regardless of the needletip configuration applied for nerve puncture, pencil-point and Tuohy needletips may both lead to comparable magnitude of posttraumatic inflammation and considerable structural changes within the nerve. No significant differences were found comparing pencil-point with Tuohy tip-configured needles.

Introduction: Sudden cardiac arrest is one of the most frequent causes of death in the world. In highly qualified emergency medical service (EMS) systems, including well trained emergency physicians, spontaneous circulation may be restored in up to 53% of patients at least until admission to hospital. Compared with these highly qualified EMS systems, in other systems markedly lower success rates are observed. These data clearly show that there are considerable differences between EMS systems concerning treatment success following cardiac arrest and resuscitation, although in all systems international guidelines for resuscitation are used. This study investigates the impact of response time reliability (RTR) on cardio pulmonary resuscitation (CPR) incidence and resuscitation success using return of spontaneous circulation (ROSC) after cardiac arrest (RACA) score and data from seven German EMS systems participating in the German Resuscitation Registry., Methods: Anonymized patient data after out of hospital cardiac arrest from 2006 to 2009 of seven EMS systems in Germany were analysed to socioeconomic factors (population, area, EMS unit hours), process quality (response time reliability, CPR incidence, special CPR measures, prehospital cooling), patient factors (age, gender, cause of cardiac arrest, bystander CPR). Endpoints were defined as ROSC, admission to hospital, 24 hour survival and hospital discharge rate. For statistical analyses, chi-square, odds-ratio and Bonferroni correction were used., Results: 2,330 prehospital CPR from seven centres were included in this analysis. Incidence of sudden cardiac arrest differs from 36.0 to 65.1/100,000 inhabitants/year. We identified two EMS systems (RTR < 70%) reaching the patients within eight minutes in 62.0% and 65.6% while the other five EMS systems (RTR > 70%) achieved 70.4 up to 95.5%. EMS systems arriving relatively later at the patients side (RTR < 70%) less frequently initiate CPR and admit fewer patients alive to hospital (calculated per 100,000 inhabitants/year) (CPR incidence (1/100,000 inhabitants/year) RTR > 70% = 57.2 vs RTR < 70% = 36.1, OR = 1.586 (99% CI = 1.383 to 1.819); P < 0.01) (admitted to hospital with ROSC (1/100,000 inhabitants/year) RTR > 70% = 24.4 vs RTR < 70% = 15.6, OR = 1.57 (99% CI = 1.274 to 1.935); P < 0.01). Using ROSC rate and the multivariate RACA score to predict outcome, the two groups did not differ, but ROSC rates were higher than predicted in both groups (ROSC RTR > 70% = 46.6% vs RTR < 70% = 47.3%, OR = 0.971 (95% CI = 0.787 to 1.196); P = n.s.) (ROSC RACA RTR > 70% = 42.4% vs RTR < 70% = 39.5%, OR = 1.127 (95% CI = 0.911 to 1.395); P = n.s.)., Conclusion: This study demonstrates that on the level of EMS systems, faster ones will more often initiate CPR and will increase number of patients admitted to hospital alive. Furthermore it is shown that with very different approaches, all adhering to and intensely training in the ERC guidelines 2005, superior and, according to international comparison, excellent success rates following resuscitation may be achieved.

Background: In regional anaesthesia, there is a risk of direct nerve injury. The purpose of this study was to determine whether the diameter of the applied needle is associated with the magnitude of nerve injury after needle nerve perforation., Methods: In five anaesthetized pigs, the brachial plexus were exposed bilaterally. Up to eight nerves underwent needle nerve perforation using a 24 G pencil-point cannula (small diameter) or a 19 G pencil-point needle (large diameter). After 48 h, the nerves were resected during anaesthesia. The specimens were processed for visual examination and the detection of inflammatory cells, myelin damage and intraneural haematoma. The grade of nerve injury was scored ranging from 0 (no injury) to 4 (severe injury)., Results: Forty-eight nerves were examined. The applied injury score was significantly lower in the small-diameter group [median (inter-quartile range) 2.0 (2.0-2.0)] compared with the large-diameter group [3.5 (3.0-4.0) P<0.01]. Myelin damage and intraneural haematoma occurred predominantly in the large-diameter group. Signs of post-traumatic regional inflammation were comparable among both groups., Conclusions: The severity of nerve injury after needle nerve perforation was related to the diameter of the applied cannula. However, no such difference exists for regional inflammation. Functional consequences of these findings need to be determined. Currently, small-diameter cannulae may be advisable for peripheral nerve blocks to minimize the risk of nerve injury in the case of nerve perforation.

Continuous peripheral nerve blocks offer the benefit of extended postoperative analgesia and accelerated functional recovery after major knee surgery. Conventional nerve localization is performed over a stimulating needle followed by blind insertion of the peripheral catheter. Correct catheter placement is confirmed by testing for satisfactory analgesia. Stimulating catheters offer the advantage of verifying correct placement close to the nerve during catheter placement. The aim of this randomized trial was to determine whether accurate catheter positioning under continuous stimulation accelerates the onset of sensory and motor block, improves the quality of postoperative analgesia, and enhances functional recovery. We compared femoral nerve catheters inserted under continuous stimulation with catheters that were placed using the conventional technique of blind advancement in 81 patients undergoing major knee surgery. Time of catheter placement was similar in both groups with 4 min (3/7.3; median, 25th/75th percentile) in the conventional group and 5 min (4/8.8) in the stimulating catheter group. In both groups, 42% of the catheters could be correctly placed (motor response of the patella with a current < or =0.5 mA) at first attempt. In 22 patients (58%) of the stimulating catheter group, the catheter had to be redirected 1-20 times, including 2 that could not be correctly placed within 20 min. The onset time of sensory and motor block was almost similar in both groups. There were no differences in the postoperative IV opioid consumption, and visual analog scale pain scores at rest and movement, or maximal bending and stretching of the knee joint during the 5 days after surgery. We conclude that with continuous femoral nerve blocks, blind catheter advancement is as effective as the stimulating catheter technique with respect to onset time of sensory and motor block as well as for postoperative pain reduction and functional outcome.