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Background: The COVID-19 pandemic led to the implementation of drastic shutdown measures worldwide. While quarantine, self-isolation and shutdown laws helped to effectively contain and control the spread of SARS-CoV-2, the impact of COVID-19 shutdowns on trauma care in emergency departments (EDs) remains elusive., Methods: All ED patient records from the 35-day COVID-19 shutdown (SHUTDOWN) period were retrospectively compared to a calendar-matched control period in 2019 (CTRL) as well as to a pre (PRE)- and post (POST)-shutdown period in an academic Level I Trauma Center in Berlin, Germany. Total patient and orthopedic trauma cases and contacts as well as trauma causes and injury patterns were evaluated during respective periods regarding absolute numbers, incidence rate ratios (IRRs) and risk ratios (RRs)., Findings: Daily total patient cases (SHUTDOWN vs. CTRL, 106.94 vs. 167.54) and orthopedic trauma cases (SHUTDOWN vs. CTRL, 30.91 vs. 52.06) decreased during the SHUTDOWN compared to the CTRL period with IRRs of 0.64 and 0.59. While absolute numbers decreased for most trauma causes during the SHUTDOWN period, we observed increased incidence proportions of household injuries and bicycle accidents with RRs of 1.31 and 1.68 respectively. An RR of 2.41 was observed for injuries due to domestic violence. We further recorded increased incidence proportions of acute and regular substance abuse during the SHUTDOWN period with RRs of 1.63 and 3.22, respectively., Conclusions: While we observed a relevant decrease in total patient cases, relative proportions of specific trauma causes and injury patterns increased during the COVID-19 shutdown in Berlin, Germany. As government programs offered prompt financial aid during the pandemic to individuals and businesses, additional social support may be considered for vulnerable domestic environments., Competing Interests: The authors have declared that no competing interests exist.

Background: "Triage" means the primary assessment of a previously unknown patient with an acute health disorder, initially considered a medical emergency. The initial triage is part of the primary assessment, which also includes the registration of administrative data and patient's mode of arrival., Objectives: The aim of the work is to provide an overview of frequently used structured primary assessment tools and the underlying evidence for their use in the emergency room., Methods: Based on a systematic literature search in PubMed, 41 articles were selected according to predefined criteria., Results: The most frequently used primary assessment systems in Germany are the Emergency Severity Index (ESI) and the Manchester Triage System (MTS). Scientific evidence exists for the accuracy and reliability of the primary assessment with these instruments. However, there are no gold standards for measuring urgency, so that separate criteria must be defined. Sufficient data to determine a treatment sector or the necessary staffing levels are lacking., Conclusions: Structured primary assessment using formalized systems alone is inadequate to categorize the urgency of emergency and acute patients. In fact, a combination of different measures in an interprofessional team is required. Primary assessment systems and processes generally do not allow patients to be referred to downstream structures without a thorough medical examination.

Background: Coma of unknown etiology (CUE) is a major challenge in emergency medicine. CUE is caused by a wide variety of pathologies that require immediate and targeted treatment. However, there is little empirical data guiding rational and efficient management of CUE. We present a detailed investigation on the causes of CUE in patients presenting to the ED of a university hospital., Methods: One thousand twenty-seven consecutive ED patients with CUE were enrolled. Applying a retrospective observational study design, we analyzed all clinical, laboratory and imaging findings resulting from a standardized emergency work-up of each patient. Following a predefined protocol, we identified main and accessory coma-explaining pathologies and related these with (i.a.) GCS and in-hospital mortality., Results: On admission, 854 of the 1027 patients presented with persistent CUE. Their main diagnoses were classified into acute primary brain lesions (39%), primary brain pathologies without acute lesions (25%) and pathologies that affected the brain secondarily (36%). In-hospital mortality associated with persistent CUE amounted to 25%. 33% of patients with persistent CUE presented with more than one coma-explaining pathology. In 173 of the 1027 patients, CUE had already resolved on admission. However, these patients showed a spectrum of main diagnoses similar to persistent CUE and a significant in-hospital mortality of 5%., Conclusion: The data from our cohort show that the spectrum of conditions underlying CUE is broad and may include a surprisingly high number of coincidences of multiple coma-explaining pathologies. This finding has not been reported so far. Thus, significant pathologies may be masked by initial findings and only appear at the end of the diagnostic work-up. Furthermore, even transient CUE showed a significant mortality, thus rendering GCS cutoffs for selection of high- and low-risk patients questionable. Taken together, our data advocate for a standardized diagnostic work-up that should be triggered by the emergency symptom CUE and not by any suspected diagnosis. This standardized routine should always be completed - even when initial coma-explaining diagnoses may seem evident.

Objectives: To investigate the suitability of the German version of the Manchester Triage System (MTS) as a potential tool to redirect emergency department (ED) patients to general practitioner care. Such tools are currently being discussed in the context of reorganisation of emergency care in Germany., Design: Prospective cohort study., Setting: Single centre University Hospital Emergency Department., Participants: Adult, non-surgical ED patients., Exposure: A non-urgent triage category was defined as a green or blue triage category according to the German version of the MTS., Primary and Secondary Outcome Measures: Surrogate parameters for short-term risk (admission rate, diagnoses, length of hospital stay, admission to the intensive care unit, in-hospital and 30-day mortality) and long-term risk (1-year mortality)., Results: A total of 1122 people presenting to the ED participated in the study. Of these, 31.9% (n=358) received a non-urgent triage category and 68.1% (n=764) were urgent. Compared with non-urgent ED presentations, those with an urgent triage category were older (median age 60 vs 56 years, p=0.001), were more likely to require hospital admission (47.8% vs 29.6%) and had higher in-hospital mortality (1.6% vs 0.8%). There was no significant difference observed between non-urgent and urgent triage categories for 30-day mortality (1.2% [n=4] vs 2.2% [n=15]; p=0.285) or for 1-year mortality (7.9% [n=26] vs 10.5% [n=72]; p=0.190). Urgency was not a significant predictor of 1-year mortality in univariate (HR=1.35; 95% CI 0.87 to 2.12; p=0.185) and multivariate regression analyses (HR=1.20; 95% CI 0.77 to 1.89; p=0.420)., Conclusions: The results of this study suggest the German MTS is unsuitable to safely identify patients for redirection to non-ED based GP care., Trial Registration Number: U1111-1119-7564; Post-results., Competing Interests: Competing interests: This study was supported by Thermofisher Scientific. AS, JS, JF, MB, TL and MM report grants from Thermoficher Scientific, during the conduct of the study; grants from Roche Diagnostics, grants from Thermofisher Scientific, grants from Novartis, grants from Cardiorentis, grants from Governmental institutions, from Foundations, outside the submitted work. MM reports grants from Thermoficher Scientific, during the conduct of the study; grants and personal fees from Roche Diagnostics, grants and personal fees from Thermofisher Scientific, grants and personal fees from Novartis, grants from Cardiorentis, grants from Governmental institutions, grants from Foundations, personal fees from Bayer Healthcare, personal fees from Boehringer Ingelheim, personal fees from Daiichi Sankyo, personal fees from Astra Yeneca, outside the submitted work. FG, LH and FT have nothing to disclose., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Laboratory parameters in emergency medicine can be divided into 3 categories. Urgent obligatory parameters are necessary for immediate therapeutic decisions and must be available within 60 minutes. For these, testing in the emergency department (ED) as point-of-care-testing (POCT) should be considered. The second category are obligatory parameters which require diagnostic / therapeutic consequences in the emergency department, but are not necessary for immediate life-saving actions. Due to international consensus of a 4-hour length of stay target for ED, results should be available within this time. The third category are parameters which do not lead to immediate diagnostic or therapeutic consequences, but are important for process management and patient flow in the ED. They should therefore be available as emergency tests. POC-testing should be used for a limited number of very urgent parameters and should be organized as a satellite laboratory in cooperation with the central laboratory., (© Georg Thieme Verlag KG Stuttgart · New York.)

Quantified physical activity is an important parameter for evaluating the risk of the incidence of internal and musculoskeletal disorders. The objective of this study was to evaluate the physical activity of German Soldiers on duty and during leisure time with regard to individual determinants and to evaluate if factors associated with the risk of the incidence of internal or musculoskeletal disorders are of relevance for physical activity. For this purpose, we conducted activity measurements on 169 subjects. The accelerometer-based activity sensor was worn for 7 consecutive days. The number of steps taken was evaluated as an activity marker.We observed that a high body mass index and a large waist circumference were associated with a low activity level. Women were found to be more active than men, particularly during leisure time. Personnel under 25 years of age were more physically active than those between 25 and 50 years of age. Subjects with underlying musculoskeletal disorders were less active than those who had internal disorders or were healthy. Men and overweight people run a higher risk of developing musculoskeletal and internal disorders. Health promotion should focus on raising the physical activity level with the aim of exerting a positive influence on the associated risk factors.

Aims: Several polymorphisms of the melatonin receptor 1B gene (MTNR1B) have been shown to be associated with elevated fasting plasma glucose and impaired early insulin release. The aim of this study was to assess the effects of MTNR1B variants on traits related to the metabolic syndrome in the self-contained population of Sorbs from Germany. As comprehensive studies concerning the conservation of MTNR1B are lacking, we also evaluated natural selection in vertebrates and human populations at this locus., Methods: Five single nucleotide polymorphisms representing all blocks of linkage disequilibrium within and surrounding the MTNR1B locus were genotyped in 937 Sorbs for association analyses on metabolic traits related to Type 2 diabetes. The associations were assessed by regression analyses, the conservation between species was investigated with phylogenetic analysis by maximum likelihood (PAML). In addition, various tests of population genetic measures (e.g. fixation index, Tajima's D) were performed., Results: Previously reported association between MTNR1B variants (rs10830963, rs4753426) and oral glucose tolerance test-derived indices of β-cell function (homeostasis model assessment-B, P = 3.7 × 10⁻⁶ and P = 0.004, respectively), as well as insulin (fasting insulin: P=2×10⁻³ and P=0.02; 30-min insulin: P = 2.1 × 10⁻⁴ and P=0.03, respectively) and fasting glucose (rs10830963, P=1.2×10⁻⁶) parameters could be replicated in the present study. Phylogenetic analysis by maximum likelihood analyses showed that the gene was strongly conserved between species (ω=0.2583). Structures important for the receptor function are also conserved. On the lineage leading to human adaptive selection was present (ω=1.1030). Population genetic measures further indicated natural selection., Conclusions: Our data support the physiologic importance of MTNR1B in the context of glucose homeostasis and suggest evidence of selection at this locus., (© 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK.)

Maturity-onset diabetes of the young (MODY) is a genetically heterogeneous monogenic disorder characterized by autosomal dominant inheritance, onset usually before 25 yr of age, and abnormal pancreatic beta-cell function. Mutations in the hepatocyte nuclear factor(HNF)-4alpha/MODY1, glucokinase/MODY2, and HNF-1alpha/MODY3 genes can cause this form of diabetes. In contrast to the glucokinase and HNF-1alpha genes, mutations in the HNF-4alpha gene are a relatively uncommon cause of MODY, and our understanding of the MODY1 form of diabetes is based on studies of only a single family, the R-W pedigree. Here we report the identification of a second family with MODY1 and the first in which there has been a detailed characterization of hepatic function. The affected members of this family, Dresden-11, have inherited a nonsense mutation, R154X, in the HNF-4alpha gene, and are predicted to have reduced levels of this transcription factor in the tissues in which it is expressed, including pancreatic islets, liver, kidney, and intestine. Subjects with the R154X mutation exhibited a diminished insulin secretory response to oral glucose. HNF-4alpha plays a central role in tissue-specific regulation of gene expression in the liver, including the control of synthesis of proteins involved in cholesterol and lipoprotein metabolism and the coagulation cascade. Subjects with the R154X mutation, however, showed no abnormalities in lipid metabolism or coagulation except for a paradoxical 3.3-fold increase in serum lipoprotein(a) levels, nor was there any evidence of renal dysfunction in these subjects. The results suggest that MODY1 is primarily a disorder of beta-cell function.

The distribution of Chabertia (Ch.) ovina, Oesophagostomum (O.) venulosum and Trichuris spp. within the large intestine of naturally infected sheep in the dependence of worm counts and the presence of nematodes of other species or genera was evaluated. The large intestine was divided into 4 sections. More than 75% of Ch. ovina were found within the disk-like section of the colon independently from worm count and presence of nematodes of other species. O. venulosum and Trichuris spp. preferred the caecum and the first section of the colon up to the beginning of the disk-like section. In both, the share of worms recovered from the first section of the colon did increase with higher worm counts. The simultaneous presence of O. venulosum and Trichuris spp. had a significantly negative influence on the share of Trichuris spp. isolated from the caecum.

The relationship between the faecal egg count and the worm burden of the gastrointestinal tract of sheep was examined. Close relationships were found in strongyles, Trichostrongylidae (other than Nematodirus spp.), Nematodirus spp., Strongyloides papillosus, Chabertiidae and Trichuris spp.. Due to high percentage of false negative diagnosis from faecal examination, this relationship was in Nematodirus spp. and Trichuris spp. not as close as in the other nematodes. However, the results support the high diagnostic value of quantitative faecal examinations in sheep.