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BACKGROUND The demographic change and an increasing multimorbidity of patients represent increasing challenges for the adequate prehospital treatment of emergency patients. The incorporation of supplementary telemedical concepts and systems can lead to an improved guideline-conform treatment. Beneficial evidence of telemedical procedures is only known for isolated disease patterns; however, no mobile telemedical concept exists which is suitable for use in the wide variety of different clinical situations. AIM This article presents a newly developed and evaluated total telemedical concept (TemRas) that encompasses organizational, medical and technical components. The use of intelligent and robust communication technology and the implementation of this add-on system allows the telemedical support of the rescue service for all emergencies. METHODS After development of the telemedical rescue assistance system, which includes organizational, medical and technical components, a telemedical centre and six ambulances in five different districts in North-Rhine Westphalia were equipped with this new tool. During the evaluation phase of 1 year in the routine emergency medical service the rate of complications as well as differences between urban and rural areas were analyzed with respect to different target parameters. RESULTS Between August 2012 and July 2013 a total of 401 teleconsultations were performed during emergency missions and 24 during secondary interhospital transfers. No complications due to teleconsultation were observed. The mean duration (±SD) of teleconsultations was longer in rural areas than in urban areas with 28.6±12.0 min vs. 25.5±11.1 min (p

Background Ceftaroline is a broad spectrum antibiotic used to treat complicated skin and soft tissues infections and community acquired pneumonia. To prevent emergence of resistant strains and conserve its effectiveness, ceftaroline prescription should be limited to specific recommended cases. Purpose The aim of this study was to evaluate proper use and effectiveness of ceftaroline in our establishment. Material and methods This was a retrospective study performed between January 2014 and December 2015. Patients who received ceftaroline and their biological and clinical data were collected by extraction from our prescription software (DXCARE and CLINISOFT). Seven items analysed the ‘correct use’ of ceftaroline: clinical setting, indication, referred germ, sensibility to other antibiotics, dosage, advice from an infectious disease and type of treatment (empiric, prophylactic or reassessed). Four items evaluated the ‘effectiveness’: treatment time, time for negative culture result, minimum inhibitory concentration (MIC) and healing of the infection. Results During the period, 13 patients received ceftaroline; 1 patient’s record was unusable. Prescriptions for ceftaroline were off-label in 83.3% (10/12, in the majority for osteo-articular infection), and 83.3% (10/12) of prescriptions were documented with identification of a methicillin resistant staphylococcal (once associated with Escherichia coli and another with Haemophilus parainfluenza ). Each time, germs were resistant to glycopeptides. Dosage was adapted to renal function for 83.3% of cases and the last 2 cases benefited from pharmaceutical intervention to obtain adequate posology. Advice from an infectiologist was given for each treatment initiation. Average and median treatment time were, respectively, 15.5 days and 10 days. Average time to culture negative result was 9.2 days, but was assessed for osteo-articular and not documented infections (7/12). Ceftaroline MIC was measured in 6 cases and was strictly below 1 mg/mL. All patients were cured of their infection, with a minimum step back 6 months. No adverse reactions were observed during the study. Conclusion This study showed important off-label use for ceftaroline but specialist advice was systematically requested due to the complexity of the patients. In all cases, patients were cured of their infection. Despite the off-label prescriptions, ceftaroline was used properly, with good therapeutic efficacy in our institution. A multicentre study should be performed to compare practices between several hospitals. No conflict of interest

International audience; Neonatal arterial ischemic stroke (NAIS) is a rare event that occurs in approximately one in 5000 term or close-to-term infants. Most affected infants will present with seizures. Although a well-recognized clinical entity, many questions remain regarding diagnosis, risk factors, treatment, and follow-up modalities. In the absence of a known pathophysiological mechanism and lack of evidence-based guidelines, only supportive care is currently provided. To address these issues, a French national committee set up by the French Neonatal Society (Société française de néonatologie) and the national referral center (Centre national de référence) for arterial ischemic stroke in children drew up guidelines based on an HAS (Haute Autorité de santé [HAS]; French national authority for health) methodology. The main findings and recommendations established by the study group are: (1) among the risk factors, male sex, primiparity, caesarean section, perinatal hypoxia, and fetal/neonatal infection (mainly bacterial meningitis) seem to be the most frequent. As for guidelines, the study group recommends the following: (1) the transfer of neonates with suspected NAIS to a neonatal intensive care unit with available equipment to establish a reliable diagnosis with MRI imaging and neurophysiological monitoring, preferably by continuous video EEG; (2) acute treatment of suspected infection or other life-threatening processes should be addressed immediately by the primary medical team. Persistent seizures should be treated with a loading dose of phenobarbital 20mg/kg i.v.; (3) MRI of the brain is considered optimal for the diagnosis of NAIS. Diffusion-weighted imaging with apparent diffusion coefficient is considered the most sensitive measure for identifying infarct in the neonatal brain. The location and extent of the lesions are best assessed between 2 and 4 days after the onset of stroke; (4) routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocysteinemia, the Lp(a) test, the MTHFR thermolabile variant should not be considered in neonates with NAIS. Testing for FV Leiden can be performed only in case of a documented family history of venous thromboembolic disease. Testing neonates for the presence of antiphospholipid antibodies should be considered only in case of clinical events arguing in favor of antiphospholipid syndrome in the mother; (5) unlike childhood arterial ischemic stroke, NAIS has a low 5-year recurrence rate (approximately 1 %), except in those children with congenital heart disease or multiple genetic thrombophilia. Therefore, initiation of anticoagulation or antithrombotic agents, including heparin products, is not recommended in the newborn without identifiable risk factors; (6) the study group recommends that in case of delayed motor milestones or early handedness, multidisciplinary rehabilitation is recommended as early as possible. Newborns should have physical therapy evaluation and ongoing outpatient follow-up. Given the risk of later-onset cognitive, language, and behavioral disabilities, neuropsychological testing in preschool and at school age is highly recommended.; L’accident vasculaire cérébral ischémique artériel néonatal (AVCian) est une pathologie rare. Afin d’actualiser les connaissances sur ce sujet, un groupe de travail multidisciplinaire s’est constitué sous l’égide de la Société française de néonatologie et le Centre national de référence de l’AVC de l’enfant afin de proposer des recommandations sur les facteurs de risque, les modalités de transfert et de prise en charge pré-hospitalière, les modalités diagnostiques et thérapeutiques, le traitement, le pronostic et la prise en charge à court et moyen terme. Ces recommandations ont été réalisées selon la méthodologie de la Haute autorité de santé et en fonctions des thématiques proposées par un comité d’experts. Les principales recommandations issues de ce travail sont : (1) l’orientation du patient vers une unité de réanimation ou de soins intensifs néonatals disposant d’une imagerie par résonance magnétique (IRM) facilement accessible et de la possibilité de réaliser une surveillance continue par électro-encéphalogramme ; (2) le phénobarbital est le médicament de première ligne pour le traitement des crises convulsives ; (3) l’IRM réalisée entre j2 et j4 après la survenue de l’AVCian est la meilleure technique pour confirmer le diagnostic et préciser son extension ; (4) un facteur biologique de risque thrombotique ne doit pas être systématiquement recherché après un AVCian, sauf en cas d’antécédent thrombotique veineux familial ; (5) un traitement thrombolytique n’est pas recommandé ; (6) une prise en charge rééducative précoce est recommandée en cas de déficience motrice évidente.

All biological risk factors that have been previously identified to increase the risk of thrombosis in adults, have also been studied in neonates with arterial Ischemic Stroke (NAIS), but most studies were retrospective and included relatively low numbers of affected children. We therefore could not suggest recommendations with a strong level of evidence and only expert proposals potentially useful for clinical practice will be presented in this text. Despite these limitations, the extensive analysis of published data supported that factor V Leiden (FVL) and increased levels of Lp(a) could be significant risk factors for NAIS. Importantly, these 2 risk factors cannot be considered as having provoked NAIS, and moreover, they do not influence the prognosis and the immediate treatment. However, since the FVL may have an impact for the prescription of a thromboprophylaxis when the neonate will become adult, to look for its presence in affected patients may be justified. For clinical practice, the following propositions can be applied: 1. Routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocystein or Lp(a) levels, MTHFR thermolabile variant, should not be considered in neonates with NAIS. 2. Testing for FV Leiden can be performed in case of documented family history of venous thromboembolic disease. 3. Testing neonates for the presence of antiphospholipid antibodies (APA) is mandatory in case of clinical events suggesting antiphospholipid syndrome in the mother (vascular thrombosis, and/or pregnancy morbidity). 4. Routine testing for thrombophilia is not proposed in both parents in case of early death of the neonate, apart from APA in the mother.

Background: The administration of histamine with iontophoresis is an alternative method to skin prick tests or intradermal injections. Skin reactions obtained with this method can be recorded with laser Doppler flowmetry (LDF) and previous studies with this method have shown histamine-induced laser Doppler changes in the wheal area. Objective: In order to compare the influence of two H1 receptor antagonists (cetirizine 10 mg vs. ebastine 10 mg) on the skin vascular responses to histamine introduced by iontophoresis, we designed a double-blind, randomized, two-period crossover trial in which 18 volunteers were randomized. Methods: Before and 2, 5 and 7 h after drug administration, iontophoresis (30 s, 1.4 mA/cm2) of histamine 10% was performed and followed by (1) monitoring of skin vascular responses with LDF at the administration site and at 1 cm from it, and (2) wheal and flare area measurements. Results: 2, 5 and 7 h after intake of the antihistaminic drug, there were significant differences between both drugs. Concerning LDF recordings, we noted at the histamine administration site an increase in perfusion unit (PU) values which is an effect known to be in proportion to the degree of inhibition of wheal reaction, and at 1 cm distal to the histamine administration site, there was a decrease in PU values. These changes were more marked under cetirizine. A greater suppressive effect of cetirizine on the wheal and flare reaction was consistently observed at all time points during the study, demonstrating its superior efficacy. Conclusion: We conclude that (1) cetirizine demonstrated a stronger antihistaminic effect compared to ebastine at all time points; (2) iontophoresis appears to be an appropriate method to study specific microvascular changes at the delivery site of histamine and hence to detect the earliest changes occurring at the site of agonist-antagonist competition in the skin.

SummaryObjectives: Demographic change, rising comorbidity and an increasing number of emer -gencies are the main challenges that emer -gency medical services (EMS) in several countries worldwide are facing. In order to improve quality in EMS, highly trained personnel and well-equipped ambulances are essential. However several studies have shown a deficiency in qualified EMS physicians. Telemedicine emerges as a complementary system in EMS that may provide expertise and improve quality of medical treatment on the scene. Hence our aim is to develop and test a specific teleconsultation system.Methods: During the development process several use cases were defined and technically specified by medical experts and en -gineers in the areas of: system administration, start-up of EMS assistance systems, audio communication, data transfer, routine tele-EMS physician activities and research capabilities. Upon completion, technical field tests were performed under realistic conditions to test system properties such as robustness, feasibility and usability, providing end-to-end measurements.Results: Six ambulances were equipped with telemedical facilities based on the results of the requirement analysis and 55 scenarios were tested under realistic conditions in one month. The results indicate that the developed system performed well in terms of usability and robustness. The major challenges were, as expected, mobile communication and data network availability. Third generation networks were only available in 76.4% of the cases. Although 3G (third generation), such as Universal Mobile Telecommunications System (UMTS), provides beneficial conditions for higher bandwidth, system performance for most features was also acceptable under adequate 2G (second generation) test conditions.Conclusions: An innovative concept for the use of telemedicine for medical consultations in EMS was developed. Organisational and technical aspects were considered and practical requirements specified. Since technical feasibility was demonstrated in these technical field tests, the next step would be to prove medical usefulness and technical robustness under real conditions in a clinical trial.

Scandinavian journal of trauma, resuscitation and emergency medicine : SJTREM 21, 54 (2013). doi:10.1186/1757-7241-21-54, Published by BioMed Central, London

Somatic coliphages, F-specific RNA bacteriophages, bacteriophages infecting Bacteroides fragilis , Escherichia coli and enterococci were counted in bathing waters in the late spring and summer. We tested fresh and marine bathing waters from North, South, East and West Europe expected to contain between 100 and 500 E. coli per 100 ml, although wider ranges were sometimes found. Bacteriophages were counted after concentration, since a preliminary study proved that this step was necessary to obtain positive counts. During monitoring, a first-line quality control with reference materials for bacteria and bacteriophages was performed by all the laboratories participating in the study. The same microbes were also counted in raw sewage samples from various areas in Europe, where the bacterial indicators and the three groups of bacteriophages were detected in roughly the same numbers. All groups of bacteriophages were detected in both fresh and marine bathing waters throughout Europe. Reliable and complete results from 147 samples showed that for log-transformed values, E. coli and bacteriophages were slightly correlated. However, the slope of the regression line changed according to E. coli concentration and the correlation diminished when this concentration was close to zero per 100 ml. The ratios between E. coli and phages in bathing waters differed significantly from those in sewage. The relative amounts of bacteriophages, mainly somatic coliphages and phages infecting Bact. fragilis RYC2056, increased in bathing waters with low E. coli concentration, especially in seawater samples containing E. coli per 100 ml. The relationship of bacteriophages with respect to enterococci paralleled that of bacteriophages with respect to E. coli . Somatic coliphages and bacteriophages infecting Bact. fragilis are useful to predict the presence of some pathogens with the same origin as present bacterial indicators but with higher survival rates.

(1938). Die Korrelation (Koppelung) Von Missbildungen, Erlautert Am Beispiel Der Akrocephalosyndaktylie. Acta Orthopaedica Scandinavica: Vol. 9, No. 4, pp. 235-316.

Scandinavian journal of trauma, resuscitation and emergency medicine 23(1), 31 (2015). doi:10.1186/s13049-015-0110-6, Published by BioMed Central, London