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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.

Zusammenfassung Hintergrund Zur frühzeitigen Entscheidung in zukünftigen „Integrierten Notfallzentren“, ob eine ambulante oder innerklinische Versorgung indiziert ist, wäre es hilfreich, ein System zu haben, mit dem die Identifizierung von Patienten mit ambulanter Behandlungsindikation möglich ist. In dieser Studie untersuchten wir, ob das Manchester Triage System (MTS) dafür geeignet ist, Patienten zu erkennen, die sicher der ambulanten medizinischen Versorgung zugeteilt werden können. Methode Notaufnahmepatienten der „blauen“ MTS-Dringlichkeitsstufe wurden auf den Endpunkt „stationäre Aufnahme“ untersucht und mit der nächsthöheren MTS-Kategorie „grün“ verglichen. In einem zweiten Schritt wurde die „blaue“ Dringlichkeitsstufe auf die häufigsten gemeinsamen Kriterien untersucht, die zur stationären Aufnahme führten. Ergebnisse Nach Ausschluss von Patienten, die durch den Rettungsdienst oder nach vorherigem Arztbesuch vorstellig wurden, war die Rate der stationären Aufnahmen in der blauen Dringlichkeitsstufe signifikant niedriger als in der grünen Kategorie (10,8 % vs. 29,0 %). Die Rate konnte durch die Etablierung einer Untergruppe mit den zusätzlichen Ausschlusskriterien chronische Erkrankung und Wiedervorstellung nach vorheriger stationärer Behandlung auf 0,9 % gesenkt werden. (CEReCo-blue-Gruppe: Chronic Disorder (C), Emergency Medical Service (E), Readmission (R), Prior Medical Consultation (Co)). Schlussfolgerung Die blaue MTS-Dringlichkeitsstufe scheint zur Selektion von Patienten mit ambulanter Behandlungsindikation nicht geeignet zu sein. Wir schlagen die Einführung einer Untergruppe, der sog. CEReCo-blue-Gruppe vor, die für die Selektion dieser Patientengruppe hilfreich sein könnte.

The use of Antigen point of care tests (AgPOCT) might be an essential tool to fight the coronavirus disease 2019 (COVID‐19) pandemic. Manufacturer information indicates a specificity of about 95% and there is a growing interest to use these tests area‐wide. Therefore, it is necessary to clarify whether AgPOCT can be used safely for “rule‐in” (detection of positive patients) and for “rule‐out” (valid negative testing). Two thousand three hundred and seventy‐five patients received polymerase chain reaction (PCR) testing and AgPOCT for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) regardless of symptoms. The positive predictive value of symptomatic and asymptomatic patients was compared with a cut‐off threshold cycle (C t) value of ≤30 and in total. Five hundrded and fifty‐one patients tested positive for the SARS‐CoV‐2 virus by PCR, of whom 35.2% presented without symptoms. In all patients, regardless of their symptoms or C t values, a sensitivity of 68.9% and a specificity of 99.6% were calculated for AgPOCT. In patients with C t values ≤30, a sensitivity of 80.5% (95% confidence interval: ±1.62) and a specificity of 99.6% were shown for all tests (symptomatic/asymptomatic). Highly infectious patients (C t ≤ 20), regardless of symptoms, were reliably detected by the AgPOCT. In infectious patients with C t values ≤30, the test has a sensitivity of about 80% regardless of COVID‐19 typical symptoms, which is apparently less than the 96.52% specificity indicated by the manufacturer. Relevant improvement in test sensitivity by querying the patients who are symptomatic and asymptomatic is also not feasible. We strongly suggest that we critically question the use of AgPOCT for “rule‐out,” as they only provide a supposed safety.

Aim of the study For out-of-hospital-cardiac-arrest (OHCA) due to ventricular fibrillation (VF) guidelines recommend early defibrillation followed by chest compressions for two minutes before analyzing shock success. If rhythm analysis reveals VF again, it is obscure whether VF persisted or reoccurred within the two-minutes-cycle of chest compressions after successful defibrillation. We investigated the time of VF-recurrence in OHCA. Methods We examined all cases of OHCA presenting with initial VF rhythm at arrival of ALS-ambulance (Marburg-Biedenkopf-County, 246.648 inhabitants) from January 2014 to March 2018. Three independent investigators analyzed corpuls3® ECG-recordings. We included ECG-data from CPR-beginning until four minutes after the third shock. VF termination was defined as the absence of a VF-waveform within 5 s of shock delivery. VF recurrence was defined as the presence of a VF-waveform in the interval 5 s post shock delivery. Results We included 185 shocks in 82 patients. 74.1% (n = 137) of all shocks terminated VF, but VF recurred in 81% (n = 111). The median (IQR) time of VF-recurrences was 27 s (13.5 s/80.5 s) after shock. 51.4% (n = 57) of VF-recurrence occurred 5–30 s after shock, 13.5% (n = 15) VF-recurrence occurred 31−60 s after shock, 21.6% (n = 24) of VF-recurrence occurred 61–120 s after shock, 13.5% (n = 15) of VF-recurrence occurred 121–240 s after shock. Conclusions Although VF was terminated by defibrillation in 74.1%, VF recurred in 81% subsequent to the chest compression interval. Thus, VF reappears frequently and early. It is unclear to which extend chest compressions influence VF-relapse. Further studies need to re-evaluate the algorithm, timing of antiarrhythmic therapy or novel defibrillation strategies to minimize refibrillation during shockable OHCA.

The maintenance of oral health is important for the health of hospitalized pediatric patients, the relationship between oral health and systemic disease. The habits and values ​​acquired for the night were related to the habits and values ​​of the mothers, and the knowledge and level of health of the mother can influence the behavior and the attitudes towards the health and to the own son. Understand maternal practices and care with the oral health of their children at the time of hospitalization. It was a qualitative and quantitative research that analyzed the data referring to the practices and the maternal care with oral hygiene of children of both sexes. 61% of hospitalized children were 0 to 3 years old, 51% of mothers rated their child's oral health as good, 25% regular, 17% optimum, 5% bad and 2% bad. Faced with this, there is a presence of the doctor in the hospitalization environment by most of the mothers reported during the time when there is no contact with the oral health professional and without information on how to avoid oral problems. In addition, they questioned that their children are very hated during the hospitalization period.

Introdução: Traqueobroncomegalia ou síndrome de Mounier-Kuhn é uma doença rara, observada principalmente em homens de meia idade antes da 5ª década de vida, caracterizada por atrofia ou ausência das fibras elásticas ou da musculatura lisa da parede da traquéia e dos brônquios principais, determinando dilatação dessas estruturas. Acredita-se que a fraqueza do tecido conjuntivo, associada à inalação de poluentes aéreos e fumaça de cigarro, sejam os principais fatores no desenvolvimento desta síndrome. O diagnóstico pode ser ocasional em indivíduos assintomáticos, contudo cursa frequentemente com infeções respiratórias de repetição e bronquiectasias. Descrição: A.H.A.G., 65 anos, masculino, solteiro, branco. Relatava tosse crônica com aumento da frequência há 10 dias associado a um aumento de expectoração, no momento, esverdeado. Queixava-se também de febre irregular diária não termometrada, dispneia aos mínimos esforços, e sudorese noturna. Paciente menciona diagnóstico de bronquiectasia, porém sem adesão ao acompanhamento ambulatorial de pneumologia no HRT desde 2015. Conclusão: A síndrome de Mounier-Kuhn se caracteriza pelo aumento do diâmetro da traqueia e dos brônquios principais associado a redução do clearence mucociliar, o que leva o indivíduo a desenvolver infecções respiratórias com frequência. O diagnóstico é feito por TC de tórax. O tratamento só é realizado nos sintomáticos, objetivando tratar o fator desencadeante da descompensação.

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 Current ESC guidelines for non-ST-segment elevation myocardial infarction suggest the utilization of echocardiography in patients with inconclusive initial electrocardiography and cardiac enzymes. Besides detection of alternative pathologies associated with chest pain, echocardiography can screen for wall motion abnormalities (WMA) as sign of myocardial necrosis. Purpose We evaluated the ability of the assessment of regional WMA, detected via transthoracic echocardiography, to predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Methods In this prospective single-centre observational cohort study, we included consecutive patients presenting to the emergency department of our University Hospital with acute chest pain, suggestive of an acute coronary syndrome, between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, hemodynamic instability, or known coronary artery disease were excluded. As part of initial workup, patients received bedside echocardiography for the assessment of regional WMA by a dedicated study physician, blinded to all patients' characteristics. The primary endpoint was defined as the presence of culprit lesions as detected in subsequent invasive coronary angiography, requiring coronary revascularization therapy. Logistic regression analysis was performed in different models adjusted for traditional cardiovascular risk factors, cardiac biomarkers as well as established risk scores. Area under the receiver operating characteristics curve (AUC) was calculated to assess a potential improvement in the prediction of culprit lesions. Results Overall, 657 patients (age 58.06±18.04 years, 53% male) were included in our study. WMA were detected in 76 patients (11.6%). Patients with WMA were older (66.92±13.85 vs. 56.90±18.21 years, p Conclusion WMA strongly and independently predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Our results suggest that routine bedside echocardiography for assessment of WMA in emergency department may improve diagnostic algorithms in suspected acute coronary syndrome. Funding Acknowledgement Type of funding sources: None.

Embora o acometimento do nervo fibular seja uma das neuropatias mais comuns nos membros inferiores, a lesão bilateral ainda é pouco citada na literatura. Apresentamos uma mulher jovem com doença de nervo fibular comum pouco tempo após a descompressão cirúrgica bem sucedida no membro contralateral. O principal achado é o déficit motor, com a típica marcha escarvante. A eletroneuromiografia continua sendo a propedêutica ideal, considerando atualmente novas modalidades em estudo. Mesmo que em diferentes apresentações, até o momento, a descompressão cirúrgica do nervo fibular parece ser a modalidade terapêutica de melhor resultado.

Introdução: O conhecimento, as percepções e atitudes sobre saúde bucal expressas pelas figuras maternas são importantes e merecem atenção. O planejamento de ações e a compreensão dos valores, atitudes e crenças em saúde são fenômenos sociais e biológicos vividos culturalmente. A educação em saúde bucal no ambiente domiciliar é uma opção promissora para o processo educativo devido à facilidade de aprendizagem por parte das crianças. Objetivo: Verificar o conhecimento das mães sobre saúde bucal na infância, observando as práticas e cuidados domiciliares estabelecidos por essas mulheres com a saúde oral de seu filho. Método: Foi uma pesquisa qualitativa e quantitativa que analisou os dados relacionados às práticas e cuidados maternos domiciliares com a higiene bucal de crianças, internadas num Hospital no Distrito Federal – DF. Resultados: Revelou-se 98% das mães responderam que seus filhos têm os dentes limpos quando estão em casa e 2% responderam que não. Obteve-se que 67% das mães executam os procedimentos de higienização bucal domiciliar em seus filhos, 15% é a própria criança. Através da pesquisa obteve-se que 53% das crianças já visitaram o dentista pelo menos uma vez na vida e 47% nunca foram ao dentista. Conclusão: Com o estudo proposto foi possível observar que apesar do grande percentual de crianças nunca terem ido ao dentista existe uma grande adesão às práticas de limpeza bucais domiciliares, sendo a mãe a principal figura familiar responsável pelos cuidados com seu filho. Descritores: Percepção social; Relações mãe-filho; Saúde bucal; Conhecimentos, atitudes e prática em saúde.

Die Therapie nach Herz-Kreislauf-Stillstand ist uber die letzten Jahre deutlich komplexer und interdisziplinarer geworden. Dabei muss der klinisch tatige Intensiv- und Notfallmediziner nicht nur die unmittelbare Versorgung und Akutdiagnostik durchfuhren, sondern auch die neurologische Prognoseerstellung planen. Es sollen von fuhrenden Experten im Gebiet die unterschiedlichen, wichtigsten Schritte vorgestellt werden unter Berucksichtigung der Interdisziplinaritat und der aktuell gultigen Leitlinien. Es wurde auf eine knappe, praxisorientierte Darstellung geachtet. Der Praxisleitfaden enthalt alle wichtigen Schritte von der Akutversorgung bis hin zur neurologischen Prognoseerstellung, die relevant sind fur den klinisch tatigen Intensivmediziner.

Hutchinson–Gilford progeria syndrome (HGPS) is a rare, premature ageing syndrome in children. HGPS is normally caused by a mutation in the LMNA gene, encoding nuclear lamin A. The classical mutation in HGPS leads to the production of a toxic truncated version of lamin A, progerin, which retains a farnesyl group. Farnesyltransferase inhibitors (FTI), pravastatin and zoledronic acid have been used in clinical trials to target the mevalonate pathway in HGPS patients to inhibit farnesylation of progerin, in order to reduce its toxicity. Some other compounds that have been suggested as treatments include rapamycin, IGF1 and N-acetyl cysteine (NAC). We have analysed the distribution of prelamin A, lamin A, lamin A/C, progerin, lamin B1 and B2 in nuclei of HGPS cells before and after treatments with these drugs, an FTI and a geranylgeranyltransferase inhibitor (GGTI) and FTI with pravastatin and zoledronic acid in combination. Confirming other studies prelamin A, lamin A, progerin and lamin B2 staining was different between control and HGPS fibroblasts. The drugs that reduced progerin staining were FTI, pravastatin, zoledronic acid and rapamycin. However, drugs affecting the mevalonate pathway increased prelamin A, with only FTI reducing internal prelamin A foci. The distribution of lamin A in HGPS cells was improved with treatments of FTI, pravastatin and FTI + GGTI. All treatments reduced the number of cells displaying internal speckles of lamin A/C and lamin B2. Drugs targeting the mevalonate pathway worked best for progerin reduction, with zoledronic acid removing internal progerin speckles. Rapamycin and NAC, which impact on the MTOR pathway, both reduced both pools of progerin without increasing prelamin A in HGPS cell nuclei. Electronic supplementary material The online version of this article (10.1007/s10522-019-09807-4) contains supplementary material, which is available to authorized users.

Investigations of the educational implications of children's exposure to air pollutants at school are crucial to enhance our understanding of the hazards for children. Most of the existing literature is based on studies performed in North America and Europe. Further investigation is required in low- and middle-income countries, where there are important challenges related to public health, transportation, environment, and education sector. In response, in this present study, we studied the association between proximity of schools to roads and the academic achievement of the students in the Federal District, Brazil. We accessed academic achievement data at the student level. The data consist of 256 schools (all the public schools in the FD) and a total of 344,175 students (all the students enrolled in the public schools in the FD in 2017–2020). We analyzed the association between the length of all roads within buffers around schools and student-level academic performance using mixed-effects regression models. After adjustments for several covariates, the results of the primary analysis indicate that the presence of roads surrounding schools is negatively associated with student-level academic performance in the FD. This association varies significantly depending on the buffer size surrounding schools. We found that the highest effects occur in the first buffer, with 250 m. While in the first buffer we estimated that an increase of 1 km of length of roads around schools was associated with a statistically significant decrease of 0.011 (95%CI: 0.008; 0.013) points in students' grades (students' academic performance varies from 0 to 10), in the buffer of 1 km we found a decrease of 0.002 (95%CI: 0.002; 0.002) points in the student-level academic performance. Findings from our investigation provide support for the creation of effective health, educational and urban planning policies for local intervention in the FD. This is essential to improve the environmental quality surrounding schools to protect children from exposure to environmental hazards.

Background Birth defects are a major cause of poor health outcomes during both childhood and adulthood. A growing body of evidence demonstrated associations between air pollution exposure during pregnancy and birth defects. To date, there is no study looking at birth defects and exposure to wildfire-related air pollution, which is suggested as a type of air pollution source with high toxicity for reproductive health. Objective Our study addresses this gap by examining the association between birth defects and wildfire smoke exposure in Brazil between 2001 and 2018. Based on known differences of impacts of wildfires across different regions of Brazil, we hypothesized differences in risks of birth defects for different regions. Methods We used a logistic regression model to estimate the odds ratios (ORs) for individual birth defects (12 categories) associated with wildfire exposure during each trimester of pregnancy. Results Among the 16,825,497 birth records in our study population, there were a total of 7595 infants born in Brazil between 2001 and 2018 with birth defects in any of the selected categories. After adjusting for several confounders in the primary analysis, we found statistically significant OR for three birth defects, including cleft lip/cleft palate [OR: 1.007 (95% CI: 1.001; 1.013)] during the second trimester of exposure, congenital anomalies of the respiratory system [OR: 1.013 (95% CI: 1.002; 1.023)] in the second trimester of exposure, and congenital anomalies of the nervous system [OR: 1.002 (95% CI: 1.001; 1.003)] during the first trimester of exposure for the regions South, North, and Midwest, respectively. Significance Our results suggest that maternal exposure to wildfire smoke during pregnancy may increase the risk of an infant being born with some congenital anomaly. Considering that birth defects are associated with long-term disability, impacting families and the healthcare system (e.g., healthcare costs), our findings should be of great concern to the public health community. Impact statement Our study focused on the association between maternal exposure to wildfire smoke in Brazil during pregnancy and the risk of an infant being born with congenital anomalies, which presents serious public health and environmental challenges.

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/ p = 0.07). Overall, 21% of patients survived to hospital discharge (POCT 30% vs no POCT 16%, p = 0.01, Φ = 0.16). Conclusions Using a POCT analyser in pre-hospital resuscitation allows rapid detection of pathological acid–base imbalances and potassium concentrations and often leads to specific interventions on scene and could improve the probability of survival.

Background The amount of epicardial adipose tissue (EAT) is associated with prevalent and incident myocardial infarction. However, clinical studies, specifically designed to determine, how the assessment of EAT can affect patient management, are lacking. Within Epicardial adipose tissue thickness PredIcts obstructive Coronary artery disease in Acute Coronary Syndrome patients (EPIC-ACS) study we tested the hypothesis that EAT quantification improves the prediction of the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Methods In this observational cohort study, we prospectively included consecutive patients 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, hemodynamic instability, or known coronary artery disease were excluded. As part of the initial workup, bedside echocardiography for quantification of EAT thickness was performed by a dedicated study physician, blinded to all patients' characteristics. Treating physicians remained unaware of the results of the EAT assessment. The primary endpoint was defined as presence of a culprit lesion, as detected in subsequent invasive coronary angiography within 90 days after initial presentation. Logistic regression analysis was performed in different models adjusted for traditional cardiovascular risk factors, cardiac biomarkers as well as established cardiovascular risk scores. Results Overall, 657 patients (mean age 58.06±18.04 years, 53% male) were included in our study. Patients reaching the primary endpoint had significantly more EAT than patients without culprit lesions (7.90±2.56mm vs. 3.96±1.91mm, p Conclusion EAT strongly and independently predicts the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Our results suggest that the bedside echocardiographic assessment including the quantification of EAT may improve diagnostic algorithms of patients with acute chest pain. Funding Acknowledgement Type of funding sources: None. Distribution of EAT thickness

Background Cerebrovascular bypass surgical procedures require highly developed dexterity and refined bimanual technical skills. To attain such a level of prowess, neurosurgeons and residents have traditionally relied on “flat” models (without depth of field), such as chicken wings, live rats, silicone vessels, and other materials that stray far from the reality of the operating room, albeit more accessible. We have explored the use of a hybrid ex vivo simulator that takes advantage of the availability of placenta vessels and retains the complexity of surgery performed on a human skull to create a more realistic method for the development of cerebrovascular bypass surgical skills. Methods Twelve ex vivo simulators were constructed using 3 human placentas and 1 synthetic human skull for each. Face, content, construct, and concurrent validity were assessed by 12 neurosurgeons (6 trained vascular surgeons and 6 general neurosurgeons) and compared with those of other bypass models. Results The fidelity grade was ranked as low (Linkert scale score, 1–2), medium (score, 3), and high (score, 4–5). The face and content validity of the model showed high fidelity to superficial temporal artery–middle cerebral artery bypass surgery. Construct validity showed that cerebrovascular neurosurgeons had better performance, and concurrent validity highlighted that all surgical steps were present. Conclusion The simulator was found to have strong face and content, construct, and concurrent validity for microsurgical cerebrovascular training, allowing for simulation of all surgical steps of the bypass procedure. The hybrid simulator seems to be a promising method for shortening the bypass surgery learning curve. However, more studies are required to evaluate the predictive validity of the model.

Zusammenfassung Einleitung Wenig ist bisher bekannt über die optimale Ersteinschätzung fußläufiger Patienten mit Verdacht auf COVID-19-Infektion oder bereits bestätigter Infektion. Insbesondere der zu erwartende Massenanfall von Erkrankten verlangt nach einer raschen, effizienten und sicheren Unterscheidung zwischen ambulanter Therapieführung, stationärer Überwachung und ggf. Intensivtherapie. Methode Wir präsentieren das in der Universitätsmedizin Essen (UME) entwickelte und verwendete Modell einer möglichst sicheren und effizienten Triage außerhalb des Katastrophenfalls. Das beschriebene Modell der UME ist eine Kombination aus klinischer Einschätzung durch Vitalparameter und Manchester-Triage-Skala (MTS), optional ergänzt durch POCT-Labor, EKG, CT-Pulmonalisangiografie, SARS-CoV-2-PCR sowie ausführlichere Labordiagnostik. Es erfolgte eine Validierung anhand von 100 konsekutiven Patienten. 3 konkrete Patientenbeispiele verdeutlichen das Modell. Ergebnisse Im Rahmen des Regelbetriebs ergab sich in den ersten 2 Wochen eine gute Trennschärfe zwischen stationär behandlungsbedürftigen und ambulanten Patienten. 16 Patienten wurden primär stationär aufgenommen. Bei den 84 initial „ambulant“ klassifizierten Patienten kam es zu 7 Wiedervorstellungen binnen 14 Tagen, 3 hiervon aus anderen Gründen. Eine Patientin musste hierbei aufgrund von progredienter Dyspnoe stationär aufgenommen werden. Fazit Das vorgestellte Triage-Modell bewährt sich in der Praxis, wobei weitere Anpassungen je nach Erfahrung und Patientenanfall vorgesehen sind.

To evaluate the economic and operational effects of implementing a shorted diagnostic pathway during influenza epidemics. This retrospective study used emergency department (ED) data from the 2014/2015 influenza season. Alere i influenza A & B rapid molecular diagnostic test (RDT) was compared with the polymerase chain reaction (PCR) pathway. Differences in room occupancy time in the ED and inpatient ward and cost differences were calculated for the 14-week influenza season. The process flow was more streamlined with the RDT pathway, and the necessary isolation time in the ED was 9 h lower than for PCR. The difference in the ED examination room occupancy time was 2.9 h per patient on a weekday and 4 h per patient on a weekend day, and the difference in the inpatient room occupancy time was 2 h per patient on a weekday and 3 h per patient on a weekend day. Extrapolated time differences across the influenza season were projected to be 2733 h in the ED examination room occupancy and 1440 h in inpatient room occupancy. In patients with a negative diagnosis, the RDT was also estimated to reduce the total diagnostic costs by 41.52 € per patient compared with PCR. The total cost difference was projected to be 31,892 € across a 14-week influenza season. The improved process and earlier diagnosis with the RDT pathway compared with conventional PCR resulted in considerable savings in ED, inpatient room occupancy time and cost across the influenza season.

Der Rettungsdienst wird haufig zu Patienten mit kurzzeitiger Bewusstseinsstorung als Warnsymptom einer Vielzahl von auch lebensbedrohlichen Situationen gerufen. Dabei muss zwischen dem kurzzeitigen Bewusstseinsverlust („transient loss of consciousness“, TLOC) und dem Begriff Synkope unterschieden werden, der fur eine kardiovaskulare Ursache vorbehalten ist. Die Erstversorgung im Rettungsdienst erfolgt nach Eigensicherung gemas dem ABCDE-Schema einschlieslich 12-Kanal-EKG. Wesentliche Risikofaktoren, die eine klinische Uberwachung und Abklarung auch bei unauffalligen Vitalwerten zwingend erfordern, sind das Auftreten im Liegen oder unter Belastung, Palpitationen, Herzvorerkrankungen und Pathologien im EKG. Eine ambulante Versorgung im Rettungsdienst kann nur bei zuvor gesunden Patienten ohne Risikofaktoren oder sturzbedingte Verletzungen bei unauffalligen Befunden und plausiblem Orthostaseereignis erfolgen. Alle andern Patienten sollten unter Monitoruberwachung einer Notaufnahme zugefuhrt werden.

Die extrakorporale kardiopulmonale Reanimation („extracorporeal cardiopulmonary resuscitation“, eCPR) kann als Rettungsversuch fur hoch selektierte Patienten mit refraktarem Herz-Kreislauf-Stillstand und potenziell reversibler Atiologie erwogen werden. Aktuell fehlen randomisiert-kontrollierte Studien zur eCPR und es existieren keine validen Pradiktoren fur Nutzen und Risiko, die bei der Indikationsstellung hilfreich sein konnten. Die bisherigen Selektionskriterien und Ablaufe sind klinikspezifisch und ein (nationaler) standardisierter Algorithmus fehlt. Das vorliegende Konsensuspapier bietet basierend auf einer konsentierten Expertenmeinung den Vorschlag fur ein standardisiertes Vorgehen bei eCPR.

To compare survival outcomes of Impella support and medical treatment in patients with post-cardiac arrest cardiogenic shock related to acute myocardial infarction (AMI).Retrospective single center study of patients resuscitated from out of hospital cardiac arrest (OHCA) due to AMI with post-cardiac arrest cardiogenic shock between September 2014 and September 2016. Patients were either assisted with Impella or received medical treatment only. Survival outcomes were compared using propensity score-matched analysis to account for differences in baseline characteristics between both groups.A total of 90 consecutive patients with post-cardiac arrest shock due to AMI were included; 27 patients in the Impella group and 63 patients in the medical treatment group. Patients with Impella support had a longer duration of low-flow time (29.54 ± 10.21 versus 17.57 ± 8.3 min, p 0.001), higher lactate levels on admission (4.75 [IQR 3.8-11] versus 3.6 [IQR 2.6-3.9] mmol/L, p = 0.03) and lower baseline systolic LVEF (25% [IQR 25-35] versus 45% [IQR 35-51.25], p 0.001) as compared to patients without circulatory support. After propensity score matching, patients with Impella support had a significantly higher survival to hospital discharge (65% versus 20%, p = 0.01) and 6-months survival (60% versus 20%, p = 0.02).The results from our study suggest that Impella support is associated with significantly better survival to hospital discharge and at 6 months compared to medical treatment in OHCA patients admitted with post-cardiac arrest cardiogenic shock and AMI.

Introdução: A trombose venosa cerebral é uma entidade de grande importância na clínica neurológica. Consiste de evento de grande morbidade e mortalidade, sendo potencialmente recuperável se diagnosticada precocemente. É uma condição rara, constituindo menos de 1% dos acidentes vasculares. A transformação hemorrágica é uma complicação preditora deprognóstico desfavorável. O manejo desta patologia é de alta complexidade e demanda tratamento agressivo. Objetivo: revisar a literatura sobre esta patologia e relatar um caso clinico para exemplificar o beneficio do junto ao tratamento precoce. Conclusão: A trombose dos seios da dura-mater é entidade patológica de grande importância, e sua etiologia deve ser amplamente pesquisada para o tratamento adequado e prevenção secundária.

Introdução: A radiculopatia, causada pelo Loop da artéria vertebral, é uma entidade rara, tendo como uma das opções de tratamento a descompressão cirúrgica do forame vertebral. Objetivo: Revisar literatura e demonstrar técnica cirúrgica empregada em uma paciente de 50 anos, a qual não obteve melhora com tratamento conservador. Conclusão: Um método indicado, quando o paciente não apresenta melhora com o método conservador, é a descompressão cirúrgica.

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.

Two performance studies were conducted to investigate the effects of 3 different sources of Cu on production parameters of piglets. A total of 256 piglets weaned at 24 ± 2 d were randomly allocated into 4 treatments with 10 or 8 replicates per treatment of 4 or 3 piglets per pen in Exp. 1 and 2, respectively. The experimental period was divided into 3 feeding phases: Phase 1 (24 to 35 d), Phase 2 (36 to 49 d), and Phase 3 (50 to 70 d). Treatments included a Control group (fed 10 mg/kg of Cu from CuSO4), a group fed 160 mg/kg of either CuSO4 (CuSO4-160) or tri-basic copper chloride (TBCC), and a group fed Cu methionine hydroxy analogue chelated (Cu-MHAC) at 150, 80, and 50 mg/kg in Phases 1, 2, and 3, respectively. The methionine value of Cu-MHAC was accounted during diet formulation to achieve the same levels of methionine across treatments. Phases 1 and 2 diets contained 2,200 and 1,500 ppm of ZnO, respectively; and antibiotics were used as growth promoters. Performance parameters were analyzed as completely randomized block design, in which each experiment was considered as a block. In trial 2, blood serum and mucosal samples, from the fundic region of the stomach, were collected from 1 piglet per replicate at day 70 and tested for serum growth hormone levels (GH) and ghrelin mRNA expression, respectively. The contrast between Cu-MHAC vs. CuSO4-160 + TBCC showed that piglets fed Cu-MHAC exhibited better feed conversion ratio (FCR) in all feeding phases compared with feeding inorganic Cu (P < 0.05). Overall, feeding Cu-MHAC improved body weight (BW), BW gain, feed intake (FI), and FCR vs. Control diet fed piglets; yet, it improved BW and FCR vs. TBCC fed piglets, and improved BW, BW gain, and FI vs. CuSO4-160 fed piglets (P < 0.05). Feeding TBCC promoted similar performance than feeding CuSO4-160, regardless of age (P > 0.05). Both ghrelin expression and growth hormone serum levels were significantly increased by feeding Cu-MHAC vs. Control diet fed animals (P < 0.01). Feeding CuSO4-160 upregulated ghrelin expression vs. Control (P < 0.01) while GH serum levels and ghrelin expression did no change by feeding TBCC compared with Control diet fed animals (P > 0.05). It was concluded that feeding Cu-MHAC at the levels tested herein can improve growth performance of piglets beyond feeding 160 ppm of either CuSO4 or TBCC, which may be partially explained by the increased expression of ghrelin and GH serum levels.

Im Jahr 2014 haben wir unser Marburg Cardiac Arrest Center (MCAC) nach 2-jahriger Pilotphase offiziell eroffnet. Ziel war es, eine konzernierte Bundelung aller Ressourcen in der Versorgung von reanimierten Patienten vorzunehmen. Es bedeutete, Hurden zu uberwinden und Uberzeugungsarbeit zu leisten, denn es fuhlten sich einige berufen, diese Patienten auch versorgen zu konnen. Dies ist allerdings ein groses Problem an deutschen Kliniken, denn obwohl in Deutschland nach praklinischem Herz-Kreislauf-Stillstand etwa 40 % der Falle erfolgreich durch den Rettungsdienst in die Krankenhauser gebracht werden, versterben mit Spontankreislauf (ROSC; return of spontaneous circulation) dann die deutliche Mehrzahl dieser schwer erkrankten Patienten in der Klinik, sodass zumeist nur ein Drittel der primar erfolgreich Reanimierten lebend aus der Klinik entlassen werden konnen. Die Grunde fur den innerklinischen Tod basieren ganz uberwiegend auf einem erneuten kardialen Versagen, einer irreversiblen zerebralen Hypoxie sowie unklaren innerklinischen Versorgungskompetenzen, die in dieser Notfallsituation zu einer Verzogerung der kausalen Therapie fuhren. Die Etablierung einer spezialisierten klinischen Versorgungsstruktur in Form eines Cardiac Arrest Centers stellt hier einen neuen Weg dar, die Versorgung reanimierter Patienten zu optimieren.

In den letzten Jahren sind die Techniken zur Uberwachung und Befunderhebung immer weiter ausgereift. Von einfachen Untersuchungen, wie der Erhebung des Blutzuckers bis hin zu komplexen wie der Bestimmung von Gerinnungsparametern konnen jetzt viele Untersuchungen in unmittelbarer Nahe zum Patienten erfolgen. Die rasche Verfugbarkeit von Ergebnissen kann dabei zu unmittelbaren Konsequenzen in der Diagnosefindung und Therapieentscheidung fuhren. Die Diagnostik direkt am Patientenbett ist Dank vieler mobiler Analysatoren mittlerweile auch auserhalb der Klinik im Rettungsdienst moglich. Eine Standarduntersuchung in der Intensiv- und Notfallmedizin, welche auch zunehmend in der Praklinik eingesetzt wird, ist die Blutgasanalyse. Durch die Feststellung der Blutgase konnen respiratorische Insuffizienzen differenziert und die Beatmung optimiert werden. Bei instabilen oder reanimationspflichtigen Patienten kann die Blutgasanalyse zur Ursachenfindungen genutzt werden und gleichzeitig entsprechende Therapien beinhalten.

INTRODUCTION: The aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe.METHODS: This was an international, pr ...

Successful Balloon Angioplasty with Low-pressure Balloon on Early Transplant Renal Artery Stenosis at Postoperative Day 7 Doo Youp Kim, M.D., Hyun Do Jung, M.D., Jin Ho Lee, M.D., Han Sae Kim, M.D., Dong Yeol Lee, M.D., Joon Seok Oh, M.D., Seong Min Kim, M.D., Yong Hun Sin, M.D., Joong Kyung Kim, M.D., Kill Huh, M.D., Jong Hyun Park, M.D. and Gyu Sik Jung, M.D. Departments of Nephrology, General Surgery, Bong Seng Memorial Hospital, Department of Radiology, Kosin University Gospel Hospital, Busan, Korea

The purpose of this study was to assess the levels of available phosphorus (AP) in the diet of growing pigs selected for lean deposition on the hematological, biochemical, and bone performance parameters. A total of 64 commercial hybrid pigs (32 castrated males and 32 females; mean initial weight: 23.31±2.4kg; age: 55-90 days) were used. Animals were distributed into a randomized block design with four treatments, eight replicates, and two animals (one male and one female) per experimental unit. The treatments consisted of a basal diet and another three diets, which were obtained by supplementing the basal diet with dicalcium phosphate replacing the inert phosphate, resulting in four diets with 0.100, 0.180, 0.260, and 0.340% of available phosphorus. The levels of available phosphorus quadratically influenced the daily weight gain, feed consumption, and feed conversion, which increased up to the estimated levels 0.331; 0.330, and 0.302% of available phosphorus. Levels of phosphorus showed no influence on the hematological parameters, which remained within the reference values. Levels of available phosphorus increased linearly the ash and phosphorus contents in the metacarpal bone and decreased linearly the alkaline phosphatase activity. Levels of available phosphorus (0.331 and 0.302%, corresponding to a daily intake of 5.73 and 5.18g d-1) provided respectively the best results for weight gain and feed conversion in pigs with high genetic potential, without change in hematological parameters. RESUMO: O objetivo deste estudo foi avaliar níveis de fósforo disponível em rações para suínos em crescimento, selecionados para deposição de carne, sobre os parâmetros de desempenho, hematológico, bioquímico e ósseo. Foram usados 64 suínos híbridos comerciais (32 machos castrados e 32 fêmeas; peso médio inicial: 23,31±2,4 kg; idade: 55-90 dias). Os animais foram distribuídos em blocos casualizados com quatro tratamentos, oito repetições e dois animais (um macho e uma fêmea) por unidade experimental. Os tratamentos consistiram em uma ração basal e em outras três rações, obtidas pela suplementação da ração basal com fosfato bicálcico em substituição ao inerte, resultando em quatro rações com 0,100, 0,180, 0,260, 0,340% de fósforo disponível. Os níveis de fósforo disponível influenciaram de forma quadrática o ganho de peso diário, o consumo de ração e a conversão alimentar, que aumentaram até o nível estimado de 0,331, 0,330 e 0,302% de fósforo disponível, respectivamente. Não houve influência dos níveis de fósforo sobre os parâmetros hematológicos que permaneceram dentro dos valores de referência. Os níveis de fósforo disponível influenciaram de forma linear crescente os teores de cinzas e fósforo no metacarpo dos animais e, de forma decrescente, a atividade da fosfatase alcalina. Os níveis de fósforo disponível, de 0,331 e 0,302%, correspondentes ao consumo diário de 5,73 e 5,18g d-1, proporcionaram, respectivamente, os melhores resultados de ganho de peso e conversão alimentar em suínos de alto potencial genético, sem alterações nos parâmetros hematológicos.

Extracorporeal cardiopulmonary resuscitation (eCPR) may be considered as a rescue attempt for highly selected patients with refractory cardiac arrest and potentially reversible etiology. Currently there are no randomized, controlled studies on eCPR, and valid predictors of benefit and outcome which might guide the indication for eCPR are lacking. Currently selection criteria and procedures differ across hospitals and standardized algorithms are lacking. Based on expert opinion, the present consensus statement provides a proposal for a standardized treatment algorithm for eCPR.

Objective.To assess monocytic expression and ratio of angiotensin and endothelin receptors in systemic sclerosis (SSc) and their functional relevance.Methods.Receptor expression was measured by flow cytometry. Chemokine ligand 18 (CCL18) concentration in supernatants of peripheral blood mononuclear cells stimulated with immunoglobulin G was measured by ELISA.Results.Monocytes of patients with SSc presented an increased angiotensin II Type 1 receptor (AT1R)/AT2R ratio compared with those of healthy donors. Patients with lung fibrosis and patients with high modified Rodnan skin score showed a reduced endothelin 1 Type A receptor (ETAR)/ETBR ratio. High AT1R/AT2R, but low ETAR/ETBR ratios corresponded to higher CCL18 secretion.Conclusion.Altered angiotensin and endothelin receptor ratios observed in SSc influence autoantibody-mediated effects such as secretion of profibrotic CCL18.

The application of ambient ionization mass spectrometry such as paper spray ionisation (PSI) is a fast, powerful, and simple method to analyze designer drugs directly on the surface of blotters. PSI-MS does not require nebulizing gas and heating temperature as well as complex protocols for sample preparation. Herein, it was possible to identify and elucidate the chemical structure of designer drugs using tandem mass spectrometry experiments from a triangular blotter. Substances such as lysergic acid diethylamide (LSD), and five new designer drugs (2,5-dimethoxy-4-chloroamphetamine (DOC), 2,5-dimethoxy-4-bromoamphetamine (DOB), 25C-NBOMe, 25B-NBOMe, and 25I-NBOMe) were characterized by PSI-MS. The PSI(+)-MS and PSI(+)-MS/MS data confirmed the assignments of the designer drugs and fragmentation mechanisms have been proposed. From losses of 17 Da (NH3), which is typical of primary amines, the CID results suggest the presence of isomers in the chemical composition of the NBOMe class. Additionally, the data were compared to those of ultra-high-resolution mass spectroscopy (positive-ion electrospray ionization coupled with Fourier transform ion cyclotron mass spectrometry, ESI(+)FT-ICR MS).

Avaliou-se o efeito de quatro niveis de inclusao (0; 450; 900 e 1.350g T-1) do cloridrato de ractopamina, sobre o ganho de peso, a conversao alimentar, o consumo de materia seca, as caracteristicas de carcaca e a qualidade de carne de bovinos machos castrados em confinamento. Foram utilizados 40 bovinos da raca Nelore, com idade media de 26 meses e peso medio inicial de 423,4±2,7kg, em um delineamento experimental em blocos casualizados, com quatro tratamentos e dez repeticoes. A dieta foi fixada obedecendo-se razao volumoso:concentrado de 75,3:24,7 na materia seca. Observou-se efeito linear positivo da inclusao da ractopamina sobre o ganho de peso diario e efeito linear negativo sobre a conversao alimentar, com destaque para as melhorias com o aumento da inclusao do cloridrato de ractopamina. Em relacao as caracteristicas de carcaca, observou-se o efeito linear negativo para a espessura de gordura e nao foram observadas diferencas quanto ao peso da carcaca quente; rendimento de carcaca; area, largura e profundidade de area de olho de lombo do musculo Longissimus dorsi, e cortes nobres. Em relacao ao consumo de materia seca, a comparacao dos tratamentos demonstrou que a ractopamina nao influencia negativamente no consumo, o que evidencia seu efeito positivo no desempenho animal. O uso do cloridrato de ractopamina melhora o desempenho e diminui a quantidade de gordura superficial na carcaca de bovinos machos nelore em confinamento.

A toxoplasmose e uma doenca causada pelo protozoario Toxoplasma gondii e e a principal causa de lesao com efeito de massa no sistema nervoso central (SNC) em pacientes imunodeprimidos, causando sintomas neurologicos significativos. Em pacientes imunocompetentes, a evolucao clinica da toxoplasmose e habitualmente benigna e a infeccao e, na maioria das vezes, assintomatica. O diagnostico da neurotoxoplasmose e presuntivo, baseado nos achados de tomografia computadorizada (TC) ou de ressonância magnetica (RM), e em casos inconclusivos, pode-se utilizar a biopsia cerebral estereotaxica. O paciente relatado apresentava lesoes sugestivas de neurotoxoplasmose na RM de encefalo, porem era imunocompetente, e a sorologia para neurotoxoplasmose era negativa para o IgM. Foi submetido entao a biopsia estereotaxica como extensao de propedeutica. O presente trabalho visa, a partir do relato de um caso raro, discutir sobre as formas de diagnostico e tratamento de uma infeccao em paciente previamente sadio, cuja evolucao foi benigna devido ao diagnostico e tratamento precoces.

OBJECTIVE: To compare the interlaminar and transforaminal block techniques with regard to the state of pain and presence or absence of complications.METHOD: This was a randomized double-blind prospective study of descriptive and comparative nature, on 40 patients of both sexes who presented lumbar sciatic pain due to central-lateral or foraminal disk hernias. The patients had failed to respond to 20 physiotherapy sessions, but did not present instability, as diagnosed in dynamic radiographic examinations. The type of block to be used was determined by means of a draw: transforaminal (group 1; 20 patients) or interlaminar (group 2; 20 patients).RESULTS: Forty patients were evaluated (17 males), with a mean age of 49 years. There was a significant improvement in the state of pain in all patients who underwent radicular block using both techniques, although the transforaminal technique presented better results than the interlaminar technique.CONCLUSION: Both techniques were effective for pain relief and presented low complication rates, but the transforaminal technique was more effective than the interlaminar technique. OBJETIVO: comparar a técnica de bloqueio interlaminar com a de bloqueio transforaminal, quanto ao quadro álgico e à presença ou não de complicações.MÉTODO: estudo prospectivo, de caráter descritivo e comparativo, duplo-cego e randomizado, em que são sujeitos 40 pacientes, de ambos os sexos, portadores de lombociatalgia por hérnia de disco, do tipo centro-lateral ou foraminal, sem resposta a 20 sessões de fisioterapia e sem instabilidade, diagnosticada em exame de radiografia dinâmica. O tipo de bloqueio, transforaminal (grupo 1) ou interlaminar (grupo 2), a ser feito foi determinado por meio de sorteio e constituiu 20 pacientes do grupo 1 e 20 do grupo 2.RESULTADOS: foram avaliados 40 pacientes, 17 do sexo masculino, média de 49 anos, nos quais houve melhoria significativa do quadro álgico em todos os submetidos ao bloqueio radicular em ambas as técnicas, embora a técnica transforaminal apresentasse melhores resultados quando comparada com a interlaminar.CONCLUSÃO: ambas as técnicas são eficazes no alívio da dor e apresentam baixa taxa de complicação, mas a transforaminal foi mais eficaz do que a interlaminar.