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In der Fachoffentlichkeit besteht Einigkeit, dass das Gesundheitspersonal weltweit schon in der Ausbildung auf eine sicherere Patientenversorgung vorbereitet werden muss. Wie kann das Themengebiet Patientensicherheit erfolgreich in die Curricula der Gesundheitsberufe integriert werden? Uberblick uber das Marburger Curriculum Patientensicherheit fur das praktische Jahr sowie uber weitere in der Literatur beschriebene Ansatze zur Lehre des Themengebiets Patientensicherheit Lehrinitiativen zur Patientensicherheit haben in den letzten Jahren zugenommen, sind aber weiterhin weder im deutschsprachigen noch im sonstigen europaischen Raum flachendeckend vorhanden. Bei ihrer Umsetzung kann das multiprofessionelle Mustercurriculum Patientensicherheit der Weltgesundheitsorganisation (WHO) als Leitfaden herangezogen werden. Eine vielversprechende aktuelle Entwicklung im Zusammenhang mit dem Erwerb und der Prufung der fur eine sichere Patientenversorgung notwendigen Kompetenzen stellt der Aufbau von interprofessionellen Ausbildungsstationen dar. Inzwischen gibt es klar beschriebene Strategien zur Integration des Themengebiets Patientensicherheit in die Curricula der Gesundheitsberufe. Auf dem Weg zu einer erfolgreichen, die notwendigen Kompetenzen und Verhaltensanderungen der Studierenden einbeziehenden Reform des Lehrplans bedarf es jedoch einer starken Unterstutzung seitens der Fuhrungskrafte in den Dekanaten und Lehrkrankenhausern.

BACKGROUND Increasing use of emergency departments (EDs) by patients with low urgency, combined with limited availability of medical staff, results in extended waiting times and delayed care. Technological approaches could possibly increase efficiency by providing urgency advice and symptom assessments. OBJECTIVE The purpose of this study is to evaluate the safety of urgency advice provided by a symptom assessment app, Ada, in an ED. METHODS The study was conducted at the interdisciplinary ED of Marburg University Hospital, with data collection performed between August 2019 and March 2020. This study had a single-center cross-sectional prospective observational design and included 378 patients. The app’s urgency recommendation was compared with an established triage concept (Manchester Triage System [MTS]), including patients from the lower 3 MTS categories only. For all patients who were undertriaged, an expert physician panel assessed the case to detect potential avoidable hazardous situations (AHSs). RESULTS Of 378 participants, 344 (91%) were triaged the same or more conservatively and 34 (8.9%) were undertriaged by the app. Of the 378 patients, 14 (3.7%) had received safe advice determined by the expert panel and 20 (5.3%) were considered to be potential AHS. Therefore, the assessment could be considered safe in 94.7% (358/378) of the patients when compared with the MTS assessment. From the 3 lowest MTS categories, 43.4% (164/378) of patients were not considered as emergency cases by the app, but could have been safely treated by a general practitioner or would not have required a physician consultation at all. CONCLUSIONS The app provided urgency advice after patient self-triage that has a high rate of safety, a rate of undertriage, and a rate of triage with potential to be an AHS, equivalent to telephone triage by health care professionals while still being more conservative than direct ED triage. A large proportion of patients in the ED were not considered as emergency cases, which could possibly relieve ED burden if used at home. Further research should be conducted in the at-home setting to evaluate this hypothesis. CLINICALTRIAL German Clinical Trial Registration DRKS00024909; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00024909

Background Increasing use of emergency departments (EDs) by patients with low urgency, combined with limited availability of medical staff, results in extended waiting times and delayed care. Technological approaches could possibly increase efficiency by providing urgency advice and symptom assessments. Objective The purpose of this study is to evaluate the safety of urgency advice provided by a symptom assessment app, Ada, in an ED. Methods The study was conducted at the interdisciplinary ED of Marburg University Hospital, with data collection performed between August 2019 and March 2020. This study had a single-center cross-sectional prospective observational design and included 378 patients. The app’s urgency recommendation was compared with an established triage concept (Manchester Triage System [MTS]), including patients from the lower 3 MTS categories only. For all patients who were undertriaged, an expert physician panel assessed the case to detect potential avoidable hazardous situations (AHSs). Results Of 378 participants, 344 (91%) were triaged the same or more conservatively and 34 (8.9%) were undertriaged by the app. Of the 378 patients, 14 (3.7%) had received safe advice determined by the expert panel and 20 (5.3%) were considered to be potential AHS. Therefore, the assessment could be considered safe in 94.7% (358/378) of the patients when compared with the MTS assessment. From the 3 lowest MTS categories, 43.4% (164/378) of patients were not considered as emergency cases by the app, but could have been safely treated by a general practitioner or would not have required a physician consultation at all. Conclusions The app provided urgency advice after patient self-triage that has a high rate of safety, a rate of undertriage, and a rate of triage with potential to be an AHS, equivalent to telephone triage by health care professionals while still being more conservative than direct ED triage. A large proportion of patients in the ED were not considered as emergency cases, which could possibly relieve ED burden if used at home. Further research should be conducted in the at-home setting to evaluate this hypothesis. Trial Registration German Clinical Trial Registration DRKS00024909; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00024909

Pandemic scenarios like SARS-Cov-2 require rapid information aggregation. In the age of eHealth and data-driven medicine, publicly available symptom tracking tools offer efficient and scalable means of collecting and analyzing large amounts of data. As a result, information gains can be communicated to front-line providers. We have developed such an application in less than a month and reached more than 500 thousand users within 48 hours. The dataset contains information on basic epidemiological parameters, symptoms, risk factors and details on previous exposure to a COVID-19 patient. Exploratory Data Analysis revealed different symptoms reported by users with confirmed contacts vs. no confirmed contacts. The symptom combination of anosmia, cough and fatigue was the most important feature to differentiate the groups, while single symptoms such as anosmia, cough or fatigue alone were not sufficient. A linear regression model from the literature using the same symptom combination as features was applied on all data. Predictions matched the regional distribution of confirmed cases closely across Germany, while also indicating that the number of cases in northern federal states might be higher than officially reported. In conclusion, we report that symptom combinations anosmia, fatigue and cough are most likely to indicate an acute SARS-CoV-2 infection.

Background Percutaneous mechanical circulatory devices are increasingly used in patients with cardiogenic shock (CS). As evidence from randomized studies comparing these devices are lacking, optimal choice of the device type is unclear. Here we aim to compare outcomes of patients with CS supported with either Impella or vaECMO. Methods Retrospective single-center analysis of patients with CS, from September 2014 to September 2019. Patients were assisted with either Impella 2.5/CP or vaECMO. Patients supported ultimately with both devices were analyzed according to the first device implanted. Primary outcomes were hospital and 6-month survival. Secondary endpoints were complications. Survival outcomes were compared using propensity-matched analysis to account for differences in baseline characteristics between both groups. Results A total of 423 patients were included (Impella, n = 300 and vaECMO, n = 123). Survival rates were similar in both groups (hospital survival: Impella 47.7% and vaECMO 37.3%, p = 0.07; 6-month survival Impella 45.7% and vaECMO 35.8%, p = 0.07). There was no significant difference in survival rates, even after adjustment for baseline differences (hospital survival: Impella 50.6% and vaECMO 38.6%, p = 0.16; 6-month survival Impella 45.8% and vaECMO 38.6%, p = 0.43). Access-site bleeding and leg ischemia occurred more frequently in patients with vaECMO (17% versus 7.3%, p = 0.004; 17% versus 7.7%, p = 0.008). Conclusions In this retrospective analysis of patients with CS, treatment with Impella 2.5/CP or vaECMO was associated with similar hospital and 6-month survival rates. Device-related access-site vascular complications occurred more frequently in the vaECMO group. A randomized trial is warranted to examine the effects of these devices on outcomes and to determine the optimal device choice in patients with CS.

Background The acute effect of supplemental oxygen during exercise has been shown to differ largely among patients with COPD. It is unknown what factors influence oxygen response. Methods In a randomized, single-blind fashion, 124 patients with COPD underwent one 6-min walk test on supplemental oxygen (6MWTO2) and one 6-min walk test on room air after a practice 6-min walk test. Both gases were delivered via standard nasal prongs (2 L/min). For analyses, patients were stratified on the basis of PaO2 values and compared: (1) 34 patients with resting hypoxemia (HYX); (2) 43 patients with exercise-induced hypoxemia (EIH); and (3) 31 patients with normoxemia (NOX). Results Oxygen supplementation resulted in an increase in the 6-min walk distance in the total cohort (27 ± 42 meters; P Conclusions In contrast to patients with NOX, patients with HYX and EIH generally benefit from supplemental oxygen by increasing exercise capacity. However, less than one-half of patients reached the threshold of clinically relevant improvements. These oxygen responders were characterized by significantly lower exercise capacity levels. Trial Registry ClinicalTrials.gov; No.: NCT00886639; URL: www.clinicaltrials.gov.

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.

Our aim was to compare the outcomes of Impella with extracorporeal life support (ECLS) in patients with post-cardiac arrest cardiogenic shock (CS) complicating acute myocardial infarction (AMI). This was a retrospective study of patients resuscitated from out of hospital cardiac arrest (OHCA) with post-cardiac arrest CS following AMI (May 2015 to May 2020). Patients were supported either with Impella 2.5/CP or ECLS. Outcomes were compared using propensity score-matched analysis to account for differences in baseline characteristics between groups. 159 patients were included (Impella, n = 105, ECLS, n = 54). Hospital and 12-month survival rates were comparable in the Impella and the ECLS groups (p = 0.16 and p = 0.3, respectively). After adjustment for baseline differences, both groups demonstrated comparable hospital and 12-month survival (p = 0.36 and p = 0.64, respectively). Impella patients had a significantly greater left ventricle ejection-fraction (LVEF) improvement at 96 h (p &lt, 0.01 vs. p = 0.44 in ECLS) and significantly fewer device-associated complications than ECLS patients (15.2% versus 35.2%, p &lt, 0.01 for relevant access site bleeding, 7.6% versus 20.4%, p = 0.04 for limb ischemia needing intervention). In subgroup analyses, Impella was associated with better survival in patients with lower-risk features (lactate &lt, 8.6 mmol/L, time from collapse to return of spontaneous circulation &lt, 28 min, vasoactive score &lt, 46 and Horowitz index &gt, 182). In conclusion, the use of Impella 2.5/CP or ECLS in post-cardiac arrest CS after AMI was associated with comparable adjusted hospital and 12-month survival. Impella patients had a greater LVEF improvement than ECLS patients. Device-related access-site complications occurred more frequently in patients with ECLS than Impella support.

Die Diagnosefindung ist die intellektuell herausforderndste Aufgabe des Arztes. Seltene Erkrankungen stellen hohe Anforderungen an die Differenzialdiagnose. Aufgrund der hohen Anzahl und Variabilitat der Symptomkomplexe konnen keinem Kliniker alle Entitaten bekannt sein. Spezifische Systeme zur Entscheidungsunterstutzung liefern in diesem Kontext bessere Ergebnisse als Standardsuchmaschinen. Die Systeme FindZebra, Phenomizer, Orphanet und Isabel werden hier pragnant vorgestellt, mitsamt Vorteilen und Limitationen. Zudem wird ein Ausblick auf Systeme im Bereich der sozialen Medien und Big-Data-Verfahren gegeben. Da die Zahl initialer Fehldiagnosen hoch ist und vor einer konfirmatorischen Diagnose lange Zeitraume verstreichen, konnten diese Werkzeuge die Diagnosestellung bei seltenen Erkrankungen verbessern.

Die Differenzialdiagnose ist zweifelsohne die wichtigste und intellektuell herausforderndste Aufgabe des Arztes. Fruhere Expertensysteme zur Unterstutzung konnten sich aufgrund der hohen Komplexitat nicht in der breiten Praxis etablieren. Auch war es schlichtweg unmoglich, das gesamte medizinische Wissen zu operationalisieren. Heutige Systeme prasentieren dem Anwender auf Grundlage der eingegebenen Symptome eine strukturierte Liste an moglichen Differenzialdiagnosen. Dies in Verbindung mit ansprechenden und intuitiven Benutzeroberflachen fuhrt zu einem steigenden Einsatz. Gerade die Innere Medizin profitiert aufgrund der Komplexitat der Symptome und hohen Anzahl der Diagnosen von dem Einsatz solcher Systeme. Durch unterstutzenden Einsatz kann die Geschwindigkeit der Diagnosefindung erhoht und Fehldiagnosen vermieden werden, wodurch insgesamt die Behandlungsqualitat gesteigert werden kann.

Im Zeitalter von E-Learning und exzellenten Online-Portalen konkurriert die klassische Vorlesung immer mehr mit ausgelagerten Lehr- und Lernstrukturen. Um daruber hinaus die Studierenden fur wichtige, aber prufungstechnisch untergeordnete Lehrinhalte (wie der Beschaftigung mit seltenen Erkrankungen) zu begeistern, bedarf es spezieller Hilfsmittel. In diesem Kapitel beschreiben wir, wie wir mithilfe der bei Studierenden beliebten US-amerikanischen Fernsehserie „Dr. House“ eine durchaus erfolgreiche Lehrveranstaltung zum Thema „seltene Erkrankungen“ initiierten. Diese Lehrveranstaltung fand dabei nicht nur reges Interesse bei Studenten und Studentinnen, sondern auch bei den Medien. In der Folge fuhrte dieses Seminar sogar zur Grundung eines Zentrums fur unerkannte und seltene Erkrankungen, ein Vorgang, der in der bundesdeutschen Universitatsgeschichte einmalig sein durfte.

Im Juli 2015 ist die uberarbeitete Version der S3-Leitlinie „Nichtinvasive Beatmung als Therapie der akuten respiratorischen Insuffizienz“ verabschiedet worden. Federfuhrend bei der Erstellung war die Deutsche Gesellschaft fur Pneumologie und Beatmungsmedizin, unterstutzt durch 11 weitere Fachgesellschaften wie der Deutschen Gesellschaft fur Anasthesiologie und Intensivmedizin (DGAI) oder der Deutschen Gesellschaft fur Neurologie (DGN).

Seltene und unerkannte Erkrankungen stellen oft eine intellektuelle Herausforderung dar. Manche prasentieren sich mit wegweisenden Symptomen, meist ist jedoch eine sehr sorgfaltige und ausfuhrliche Diagnostik innerhalb eines systematischen Vorgehens notig, das sich nicht prinzipiell vom ublichen diagnostischen Vorgehen unterscheidet, jedoch haufig sehr viel langer dauert. Auch fur seltene Erkrankungen gilt, dass eine sorgfaltige Anamnese und korperliche Untersuchung oft die entscheidenden Schritte der Diagnostik sind. Das Labor kann vor allem fur seltene internistisch-rheumatologische Erkrankungen wegweisend sein. Haben sich bei den bisherigen Untersuchungsschritten keine wegweisenden Hinweise ergeben, konnen invasivere Verfahren notwendig werden. Ein systematisches, diagnostisches Vorgehen ist bei den meisten seltenen Erkrankungen essentiell. Teambesprechungen in Anlehnung an Strukturen der bewahrten Tumorboards sind ein optimales Mittel, um komplexe Patientenfalle effektiv anzugehen. Was einem Arzt unter okonomischen Bedingungen, aber auch vom systematischen differentialdiagnostischen Denken her ein Graus ist, ist zur Diagnosestellung bei seltenen Erkrankungen in manchen Fallen doch zielfuhrend: die Schrotschuss-Diagnostik. Im DRG-Zeitalter ist sie auch fur Klinken schwierig, da sie in der Regel nicht kostendeckend durchgefuhrt werden kann. Andererseits hilft eine endlich gefundene Diagnose nicht nur dem Patienten, sondern auch den Kostentragern, weitere arztliche Untersuchungen oder gar Krankenhausaufenthalte zu vermeiden.

ObjectiveVasodilators are used with caution in patients with chronic obstructive pulmonary disease (COPD). We have developed a device for percutaneous arteriovenous shunt creation in the iliac region to increase cardiac output and oxygen delivery for patients with COPD. Although this device does not cause significant blood pressure changes in normotensive patients with COPD, we hypothesized that arteriovenous shunt creation might cause vasodilator effects in hypertensive patients because of a reduction in vascular resistance.MethodsTwenty-four patients with COPD and hypertension enrolled in an open label study of arteriovenous shunt creation for COPD. We performed cardiac catheterization at baseline and again 3 to 6 months after the procedure. As a safety measure we also recorded office blood pressure at baseline and again after 3, 6, 9, and 12 months.ResultsThe procedure increased oxygen delivery (1.1-1.4 L.min−1) and cardiac output (6-8.2 L.min−1) (P < .001) and lowered both the systemic vascular resistance (P < .001) and the pulmonary vascular resistance (P < .01). After 12 months, however, the average systolic blood pressure was reduced from 145 to 132 mm Hg (P < .0001), and the average diastolic blood pressure was reduced from 86 to 67 mm Hg (P < .0001).ConclusionsPercutaneous iliac arteriovenous fistula creation for COPD causes a significant and persistent lowering of blood pressure in patients with co-existing hypertension.

Background Most endurance training programs rely on continuous or interval cycling. Objective Aim of this study was to determine the feasibility of these training modalities during treadmill walking. Methods 42 COPD patients (FEV 1 : 37±14% pred.) were enrolled in this prospective, randomized 4-arm study. Patients were randomized to one of four treadmill walking programs (a 15 sessions). Training modalities consisted of 2 constant walking speed groups (MIC group walking speed [WS]: 60% from mean baseline 6-minute walking test [6MWT] speed/ HIT group WS: 120% from mean 6MWT speed for 1 min alternating with 1 min of rest) and 2 symptom orientated groups (MIC-Borg group [BG]/ HIT-BG) where WS was adjusted to dyspnea scores of 4-6 on a 10 point Borg scale (BS). Total walking time was increased from 10 up to 32 minutes in all groups. Dyspnea, leg fatigue, heart rate (HR) and oxygen saturation (SpO 2 ) were recorded during each session. Results Levels of dyspnea (BS: MIC: 4.3±1.4 vs. MIC-BG: 4.1±1.1, p=n.s. and HIT: 3.6±1.0 vs. HIT-BG: 3.7±0.9, p=n.s.) and leg fatigue (BS: MIC: 2.6±1.7 vs. MIC-BG: 3.2±1.2, p=n.s. and HIT: 2.5±1.4 vs. HIT-BG: 1.7±1.0 p=n.s.) were comparable during exercise. Also mean SpO 2 and HR were comparable. MIC-BG had markedly, but not significantly less unintended breaks (n) during training than MIC group (0.8±2 vs. 13±20) and trained at a higher walking speed (p=0.02) than predicted. In all groups no adverse events were observed. Conclusion It seems that all 4 treadmill-based walking training modalities are feasible and safe for patients with severe COPD.

The acute effect of supplemental oxygen during exercise has been shown to differ largely among patients with COPD. It is unknown what factors influence oxygen response.In a randomized, single-blind fashion, 124 patients with COPD underwent one 6-min walk test on supplemental oxygen (6MWTOxygen supplementation resulted in an increase in the 6-min walk distance in the total cohort (27 ± 42 meters; P .001) and in the subgroups of HYX (37 ± 40 meters; P .001) and EIH (28 ± 44 meters; P .001) but not in the NOX subgroup (15 ± 43 meters; P = .065). Forty-two percent of patients with HYX and 47% of patients with EIH improved their 6-min walk distance to a clinically relevant extent (≥ 30 meters) by using oxygen. These oxygen responders were characterized by significantly lower 6-min walk distance using room air compared with patients without a relevant response (306 ± 106 meters vs 358 ± 113 meters; P .05). Although oxygen saturation was significantly higher during 6MWTIn contrast to patients with NOX, patients with HYX and EIH generally benefit from supplemental oxygen by increasing exercise capacity. However, less than one-half of patients reached the threshold of clinically relevant improvements. These oxygen responders were characterized by significantly lower exercise capacity levels.ClinicalTrials.gov; No.: NCT00886639; URL: www.clinicaltrials.gov.

Background Little is known about the characteristics of patients seeking help from dedicated centers for undiagnosed and rare diseases. However, information about their demographics, symptoms, prior diagnoses and medical specialty is crucial to optimize these centers’ processes and infrastructure. Methods Using a questionnaire, structured information from 522 adult patients contacting a center for undiagnosed and rare diseases was obtained. The information included basic sociodemographic data (age, gender, insurance status), previous hospital admissions, primary symptoms of complaint and previously determined diagnosis. Results The majority of patients completing the questionnaire were female, 300 (57 %) vs. 222 men (43 %). The median age was 52 years (range 18–92). More than half, 309 (59 %), of our patients had never been admitted to a university hospital. Common diagnoses included other soft tissue disorders, not classified elsewhere (ICD M79, n = 63, 15.3 %), somatoform disorders (ICD F45, n = 51, 12.3 %) and other polyneuropathies (ICD G62, n=36, 8.7 %). The most frequent symptoms were general weakness (n = 180, 36.6 %) followed by arthralgia (n = 124, 25.2 %) and abdominal discomfort (n = 113, 23.0 %). The majority of patients had either internal medicine (81.3 %) and/or neurologic (37.6 %) health problems. Conclusions Pain-associated diagnoses and the typical “unexplained” medical conditions (chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome) are frequent among people contacting a center dedicated to undiagnosed diseases. The chief symptoms are mostly unspecific. An interdisciplinary organizational approach involving mainly internal medicine, neurology and psychiatry/psychosomatic care is needed.

The field of COPD has faced several new and interesting developments in the past year. Predictions based on the updated BODE index match observed mortality better than before. Several studies suggest a susceptibility phenotype: frequent inflammatory symptoms like chronic cough and sputum production are associated with more exacerbations per year. Since exacerbations frequently lead to hospitalization and increase mortality, there is a necessity to use all means to reduce exacerbation frequency in COPD patients. The phosphodiesterase-4-inhibitor Romflumilast is a new medication to lower the frequency of exacerbations. Another expansion of therapeutic options in COPD is the first once-daily, long acting inhaled beta-2-agonist Indacaterol. After 12 weeks treatment, FEV 1 was significantly improved compared to placebo. New data show a strong association between adherence to inhaler-therapy and mortality. However, mortality was also decreased with adherence to placebo. This gives strong evidence for a “healthy adherer effect”. Non-medication strategies such as lung volume reduction surgery, new endoscopic techniques, and noninvasive ventilation are described elsewhere in this issue. A unique new approach in COPD-therapy is the implantation of an arteriovenous fistula with left-to-right shunt. The shunt increases mixed venous oxygen content and cardiac output. The fistula is created in the iliofemoral region by a minimally invasive approach whereby an anastomotic vascular clip device is deployed. At this time, this therapy is exclusively available within controlled studies.

Die Entwicklungen neuer Medien und leistungsstarker Internetverbindungen machen auch vor dem Horsaal nicht halt. Die klassische Vorlesung steht in direkter Konkurrenz mit den neuen Medien, die zum Teil hervorragend illustrierte und animierte Lehrvideos und Clips zur Verfugung stellen. Um Studenten wieder in den Horsaal zu locken, ist es erforderlich, attraktive Lehrangebote zur Verfugung zu stellen. Dabei kann man, wie wir in dem folgenden Beitrag zeigen werden, durchaus populare Fernsehserien sinnvoll fur die Lehre nutzen. Dies wird von den Studenten mit grosem Interesse angenommen und ermoglicht uns, die studentische Ausbildung auch im Bereich sehr seltener Erkrankungen voranzubringen. The development of new media and high-performance Internet connections do not stop in front of the auditorium. The classic teaching course is in direct competition with the new media that provide some excellent illustrated and animated educational videos and clips. In order to bring students back into the classroom, it is mandatory to make teaching more attractive. One can, as we shall show in the following contribution, use popular television series for successful teaching. This approach is accepted by the students with great interest and allows us to teach our students also in the field of rare diseases.

Study Objectives: To examine the prevalence and clinical significance of sleep-disordered breathing in patients with implantable cardioverter defibrillators (ICD). Methods and Results: Overnight sleep studies were performed in 129 ICD recipients who had no history of sleep apnea. The mean left ventricular ejection fraction (LVEF) was 29 ± 11%. Mild, moderate, and severe sleep apnea was diagnosed in the presence of an apnea/hypopnea index (AHI) of 5–15/h, 15.1–30/h, and >30/h, respectively. No sleep apnea was present in 49 patients (38%), 57 (44%) had central sleep apnea (CSA), and 23 patients (18%) had obstructive sleep apnea (OSA). Mild, moderate, and severe sleep apnea were present in 25%, 31%, and 44% of patients with CSA, compared with 52%, 22%, and 26% of patients with OSA (P < 0.05). LVEF was similar in patients with versus without OSA or CSA. Patients with CSA were significantly older and had a higher prevalence of ischemic cardiomyopathy than patients without sleep apnea. Conclusions: Previously undiagnosed CSA is common in ICD recipients. Severely disordered breathing during sleep was more prevalent among patients with CSA than patients with OSA. This prospective, observational study will examine the long-term clinical significance of sleep-disordered breathing in ICD recipients.

Background: Expiratory pressure relief continuous positive airway pressure (pressure relief CPAP, C-Flex®) is known to be as effective in the treatment of obstructive sleep apnea (OSA) as conventional CPAP while improving overall patients’ adherence. However, the effects of C-Flex on ventilation during sleep have not been studied yet. Objective: This study investigates the effects of pressure relief CPAP on respiratory parameters and possible inspiratory flow limitation with increased difference between inspiratory and expiratory pressure compared with conventional CPAP. Methods: In total, 24 patients were investigated both during conventional CPAP and during three C-Flex pressure relief settings in randomized order during rapid-eye-movement (REM) and non-REM (NREM) sleep. Airflow was monitored with a pneumotachograph; inspiratory flow limitation was assessed by analyzing airflow and esophageal pressure swings. Results: Using higher C-Flex gains, expiratory time decreased in favor of the inspiratory duty cycle while there was no significant change in tidal volume. Analysis of inspiratory flow limitation showed no significant difference between conventional CPAP and the C-Flex gains studied. Conclusions: The increase in the inspiratory duty cycle with C-Flex might either indicate an increase in the work of breathing or a decrease in the work of breathing due to a lower peak end-expiratory pressure and consecutive alleviation of passive expiration. Both treatments appeared equivalent regarding the occurrence of inspiratory flow limitation.

Objectives The occurrence of mask leakages during the administration of nasal continuous positive airway pressure (CPAP) therapy for treating obstructive sleep apnoea syndrome (OSAS) leads to decreased compliance. Because of exhalation valves, all mask systems have a predefined amount of systematic mask leakage, thereby complicating measurement of any additional spontaneous leakage occurring during the night. In fact, relatively few studies have investigated the impact and amount of mask leakage in patients using CPAP.

Background: Supplemental oxygen (O 2 ) improves exercise capacity, oxygenation and dyspnea in patients with hypoxemic chronic obstructive pulmonary disease (COPD). Evidence regarding the effect of O 2 in normoxemic COPD patients or comparing its effects in normoxemic and hypoxemic patients is still scarce. Objective: The aim of our study was to investigate the effect of O 2 in patients with (LTOT) and without indication for long term oxygen therapy (nonLTOT). Methods: 124 COPD patients underwent two 6-minute walking tests (day 2+3) after a pretest (day 1). One test was performed using O 2 and the other using compressed room air in randomized order and a single-blinded fashion. Results: O 2 resulted in a significant increase in 6MWD (+26m, p 2 seems to be the individual level of exercise performance (6MWD) at baseline (r=-0.337, p Comparing LTOT- and nonLTOT-patients, we found that LTOT-patients benefit more from O 2 regarding the walking distance (+33m vs. +15m, p 2 -level (+7.0 vs. +3.4 percentage points, p 2 only when suffering from severe airflow obstruction (r=-0.257, p Discussion: O 2 improves 6MWD, oxygenation and dyspnea in normoxemic and hypoxemic COPD-patients. However, these short-term effects were more pronounced in patients with indication for LTOT than in those without. NonLTOT-patients suffering from severe airflow obstruction or severe exercise-induced dyspnea seem to show a relevant benefit from O 2 .

Question of the study Compliance with nasal continuous positive airway pressure (nCPAP) treatment may be reduced due to difficulties when exhaling against a positive pressure. A recently introduced CPAP system therefore lowers the expiratory pressure proportional to the patient's airflow. To evaluate the theoretical concern that this might induce, flow limitations during inspiration, we measured the occurrence of flow limitation during sleep.

The term ‘sleep attack’ is used in patients with Parkinson's disease (PD) to designate a sudden onset of sleep (SOS) without any prior sleepiness. Clinically, sleep attacks can be distinguished from unintended sleep episodes, i.e. SOS with prior sleepiness. This study aimed to assess the prevalence of SOS and to identify its predictors in patients with sleep-disordered breathing (SDB). A total of 114 consecutive patients with the clinical suspicion of obstructive sleep apnoea syndrome (OSAS) and a respiratory disturbance index (RDI) of >5/h were examined using a questionnaire and polysomnography (PSG). Altogether 57.7% reported SOS, with 5.2% of the total population describing exclusively sleep attacks. SOS was observed in both patients with obstructive sleep apnoea-hypopnoea (OSAH) or increased upper airway resistance (UAR). Increased scores on the Epworth Sleepiness Scale (ESS) were the best predictor of SOS. Logistic regression showed a possible association of SOS with a low PLMS index, while no definite effect was observed for other PSG parameters. Our data show that SDB is frequently associated with SOS. Future studies should address in more detail whether SDB patients with sleep attacks pose an increased accident risk.

Background— There is increasing evidence that obstructive sleep apnea (OSA) is an independent risk factor for arterial hypertension. Because there are no controlled studies showing a substantial effect of nasal continuous positive airway pressure (nCPAP) therapy on hypertension in OSA, the impact of treatment on cardiovascular sequelae has been questioned altogether. Therefore, we studied the effect of nCPAP on arterial hypertension in patients with OSA. Methods and Results— Sixty consecutive patients with moderate to severe OSA were randomly assigned to either effective or subtherapeutic nCPAP for 9 weeks on average. Nocturnal polysomnography and continuous noninvasive blood pressure recording for 19 hours was performed before and with treatment. Thirty two patients, 16 in each group, completed the study. Apneas and hypopneas were reduced by ≈95% and 50% in the therapeutic and subtherapeutic groups, respectively. Mean arterial blood pressure decreased by 9.9±11.4 mm Hg with effective nCPAP treatment, whereas no relevant change occurred with subtherapeutic nCPAP ( P =0.01). Mean, diastolic, and systolic blood pressures all decreased significantly by ≈10 mm Hg, both at night and during the day. Conclusions— Effective nCPAP treatment in patients with moderate to severe OSA leads to a substantial reduction in both day and night arterial blood pressure. The fact that a 50% reduction in the apnea-hypopnea index did not result in a decrease in blood pressure emphasizes the importance of highly effective treatment. The drop in mean blood pressure by 10 mm Hg would be predicted to reduce coronary heart disease event risk by 37% and stroke risk by 56%.