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We aimed to investigate predictors for long-term survival of in-hospital patients with medical emergency team (MET) consultation with or without in-hospital cardiac arrest (IHCA) in Austria's largest medical center.Data of patients, who needed an intervention of a MET between 01/2014 and 03/2020 were reviewed for this retrospective analysis.In total, 708 MET calls were analyzed. The minimum follow-up was 7 months, the maximum 6.2 years. The main MET indications were circulatory failure (63%) followed by respiratory failure (27.1%), and bleeding events (3.5%). IHCA with subsequent cardiopulmonary resuscitation (CPR) was experienced by 425 (60%) patients. Of those, 274 (64%) reached return of spontaneous circulation (ROSC), and 221 (52%) survived the first 24-hours (median survival: 146 days) and 22.1% the first year. After adjustment for potential confounders, age (p0.001), time to ROSC (p0.001), a non-shockable rhythm (p=0.041), chronic kidney disease (CKD, p=0.041), peak lactate levels (p0.001), and C-reactive protein (p=0.001) were associated with long-term all-cause mortality in IHCA patients in Cox regression analysis. The 283 MET calls (40%) which were due to other reasons than IHCA were associated with a much better 24-hours (93%) and 1-year survival (61.8%). Beside age (p0.001), the main risk factors associated with mortality in MET patients without IHCA were comorbidities such as chronic obstructive pulmonary disease (COPD, p=0.008), CKD (p=0.001), pulmonary hypertension/chronic thromboembolic pulmonary hypertension (PH/CTEPH, p=0.024), and cancer (p=0.040).Patients triggering MET calls have an increased mortality, especially those with IHCA. Predictors of mortality comprise age, comorbidities, and cardiac arrest-related parameters. A better characterization of MET call populations and their outcome might help to improve clinical decision making.

Objective The slow spatial encoding of MRI has precluded its application to rapid physiologic motion in the past. The purpose of this study is to introduce a new fast acquisition method and to demonstrate feasibility of encoding rapid two-dimensional motion of human vocal folds with sub-millisecond resolution. Method In our previous work, we achieved high temporal resolution by applying a rapidly switched phase encoding gradient along the direction of motion. In this work, we extend phase encoding to the second image direction by using single-point imaging with rapid encoding (SPIRE) to image the two-dimensional vocal fold oscillation in the coronal view. Image data were gated using electroglottography (EGG) and motion corrected. An iterative reconstruction with a total variation (TV) constraint was used and the sequence was also simulated using a motion phantom. Results Dynamic images of the vocal folds during phonation at pitches of 150 and 165 Hz were acquired in two volunteers and the periodic motion of the vocal folds at a temporal resolution of about 600 µs was shown. The simulations emphasize the necessity of SPIRE for two-dimensional motion encoding. Discussion SPIRE is a new MRI method to image rapidly oscillating structures and for the first time provides dynamic images of the vocal folds oscillations in the coronal plane.

In this article, the spread of breathing air when playing wind instruments and singing was investigated and visualized using two methods: (1) schlieren imaging with a schlieren mirror and (2) background-oriented schlieren (BOS). These methods visualize airflow by visualizing density gradients in transparent media. The playing of professional woodwind and brass instrument players, as well as professional classical trained singers, were investigated to estimate the spread distances of the breathing air. For a better comparison and consistent measurement series, a single high and a single low note as well as an extract of a musical piece were investigated. Additionally, anemometry was used to determine the velocity of the spreading breathing air and the extent to which it was still quantifiable. The results presented in this article show there is no airflow escaping from the instruments, which is transported farther than 1.2 m into the room. However, differences in the various instruments have to be considered to assess properly the spread of the breathing air. The findings discussed below help to estimate the risk of cross-infection for wind instrument players and singers and to develop efficacious safety precautions, which is essential during critical health periods such as the current COVID-19 pandemic.

Aerosols are currently seen as one of the main transmission routes for SARS-CoV-2, but a comprehensive understanding of the processes and appropriate action/adaptation of protection concepts requires the exchange of information across interdisciplinary boundaries. Against this background, the Baden-Württemberg state government launched in October 2020 a multidisciplinary "Expert Group Aerosols" comprising engineers, natural scientists and medical professionals. In its statement, the group has compiled the current state of knowledge in all relevant disciplines in the context of airborne SARS-CoV-2 infection. In addition to the well-known hygiene and social distancing rules, the importance of the correct use of effective masks is emphasized. Furthermore, the necessity for dynamic and correct ventilation is pointed out and illustrated with ventilation intervals and periods for different scenarios as examples. The effectiveness of stationary or mobile cabin air filters as an important component in the protection concept is discussed. The first opinion of the expert group makes it clear that the existing hygiene and social distancing rules offer the best possible protection against SARS-CoV-2 infection only when correctly applied in combination.Aerosole werden gegenwärtig als einer der wesentlichen Übertragungswege für SARS-CoV-2 angesehen, doch ein umfassendes Verständnis der Prozesse und entsprechendes Handeln/Anpassen von Schutzkonzepten erfordert den Austausch von Informationen über interdisziplinäre Grenzen hinweg. Vor diesem Hintergrund hat die baden-württembergische Landesregierung Anfang Oktober 2020 einen multidisziplinären „Expertenkreis Aerosole“ aus Ingenieuren, Naturwissenschaftlern und Medizinern ins Leben gerufen. In seiner Stellungnahme hat der Kreis den aktuellen Kenntnisstand in allen relevanten Fachrichtungen im Kontext der luftübertragenen SARS-CoV-2 Infektion zusammengetragen. Darin wird neben den allseits bekannten Hygiene- und Abstandsregeln die Bedeutung des richtigen Tragens wirksamer Masken hervorgehoben und der Eigen- sowie Fremdschutz verschiedener Masken gegenübergestellt. Weiterhin wird auf die Notwendigkeit des dynamischen und richtigen Lüftens hingewiesen und es werden exemplarisch Lüftungsintervalle und -zeiträume für unterschiedliche Szenarien illustriert. Auf die Wirksamkeit stationärer oder mobiler Innenraumluftfilter als ein wichtiger Baustein im Schutzkonzept wird eingegangen. Die erste Stellungnahme des Expertenkreises macht deutlich, dass die bestehenden Hygiene- und Abstandsregeln (AHA+L) nur in ihrer Kombination und richtig angewandt, den bestmöglichen Schutz vor einer SARS-CoV-2 Infektion bieten.

Purpose In adults requiring treatment in an intensive care unit, probiotic therapy using Lactobacillus plantarum 299v may reduce nosocomial infection. The aim of this study was to determine whether early and sustained L. plantarum 299v therapy administered to adult ICU patients increased days alive and at home. Methods A multicentre, parallel group, placebo-controlled, randomised clinical trial was conducted. Adult patients within 48 h of intensive care admission and expected to require intensive care beyond the day after recruitment were eligible to participate. L plantarum 299v or placebo were administered immediately after enrolment and continued for 60 days. The primary outcome was days alive and out of hospital to Day 60 (DAOH60). Secondary outcomes included nosocomial infections. Results The median [interquartile range (IQR)] number of DAOH60 in the probiotic (n = 110) and placebo group (n = 108) was 49.5 (IQR 37.0–53.0) and 49.0 (IQR 43.8–53.0) respectively, between-group difference of 0.0 [95% confidence interval (CI) − 6.10 to 7.1, P = 0.55]. Nosocomial infection occurred in 8 (7.3%) and 5 (4.6%) of the probiotic and placebo group participants, respectively, odds ratio 1.62 (95% CI 0.51–5.10), P = 0.57. There were no serious, or probiotic-associated adverse events. Conclusion Early and sustained untargeted administration of probiotic therapy with Lactobacillus plantarum 299v to adult patients admitted to the ICU is safe, but not associated with improved patient outcomes. Electronic supplementary material The online version of this article (10.1007/s00134-020-06322-w) contains supplementary material, which is available to authorized users.

The sense of hearing is essential for human beings and their communication. One of the primary sources of human communication is the human voice. The ear conveys not only the content—what is said—but also the emotional content of what is spoken—how it is said. The communication of emotions through the human voice is based on musical parameters, the so-called prosodic elements. In order to acoustically express and perceive emotions and music correctly, everybody needs both the ear and the voice. Music-related physiological knowledge has increasingly found its way into instrumental and vocal pedagogy. Nowadays, with the help of dynamic MRI, stroboscopy, and high-speed glottography, it is possible to observe “at work” most of the organic systems inside the body that are involved in sound production. By means of modern audiometric measures, our current understanding of the hearing process is highly developed as well. Exposure to extreme sound pressure levels can lead to noise-induced hearing loss. Chronic noise trauma is defined as long-term exposure to ≥85 dB(A). Sound pressure levels in professional classical symphony orchestras are higher than this limit. The same is true for musicians who work in the rock/pop or light music sector. Preventive measures must be taken to obviate possible damage to hearing. Technical changes and organizational measures are mandatory; if this does not lead to a reduction of the weekly exposure levels to the range below 85 dB, the individual must wear hearing protection.

Operators of event locations are particularly affected by a pandemic. Resulting restrictions may cause uneconomical business. With previous models, only an incomplete quantitative risk assessments is possible, whereby no suitable restrictions can be derived. Hence, a mathematical and statistical model has been developed in order to link measurement data of substance dispersion in rooms with epidemiological data like incidences, reproduction numbers, vaccination rates and test qualities. This allows a first time overall assessment of airborne infection risks in large event locations. In these venues displacement ventilation concepts are often implemented. In this case simplified theoretical assumptions fail for the prediction of relevant airflows for infection processes. Thus, with locally resolving trace gas measurements and specific data of infection processes, individual risks can be computed more detailed. Via inclusion of many measurement positions, an assessment of entire event locations is possible. Embedding the overall model in a flexible application, daily updated epidemiological data allow latest calculations of expected new infections and individual risks of single visitors for a certain event. With this model, an instrument has been created that can help policymakers and operators to take appropriate measures and to check restrictions for their effect.

Resonance-strategies with respect to vocal registers, i.e., frequency-ranges of uniform, demarcated voice quality, for the highest part of the female voice are still not completely understood. The first and second vocal tract resonances usually determine vowels. If the fundamental frequency exceeds the vowel-shaping resonance frequencies of speech, vocal tract resonances are tuned to voice source partials. It has not yet been clarified if such tuning is applicable for the entire voice-range, particularly for the top pitches. We investigated professional sopranos who regularly sing pitches above C6 (1047 Hz). Dynamic three-dimensional (3D) magnetic resonance imaging was used to calculate resonances for pitches from C5 (523 Hz) to C7 (2093 Hz) with different vowel configurations ([a:], [i:], [u:]), and different contexts (scales or octave jumps). A spectral analysis and an acoustic analysis of 3D-printed vocal tract models were conducted. The results suggest that there is no exclusive register-defining resonance-strategy. The intersection of fundamental frequency and first vocal tract resonance was not found to necessarily indicate a register shift. The articulators and the vocal tract resonances were either kept without significant adjustments, or the fR1:fo-tuning, wherein the first vocal tract resonance enhances the fundamental frequency, was applied until F6 (1396 Hz). An fR2:fo-tuning was not observed.

In current voice research, there is a growing interest in semi-occluded vocal tract exercises and their contribution to an increased vocal efficiency. However, there are only few studies on the lasting effects.Eight vocally healthy subjects were asked to sustain a phonation at a comfortable loudness on the vowel /i/, with a Fundamental Frequency of 250 Hz (females) or 125 Hz (males). During phonation the subjects were simultaneously recorded with transnasal High Speed Videoendoscopy (HSV, 20,000fps), electroglottography, and audio signals. The subjects then performed a water resistance therapy (WRT) for 10 min (tube: 30 cm length, 5 cm below water surface, diameter 9 mm). Repeated measurements of sustained phonation were performed 0, 5, 10, 20, and 30 min after exercising. From the HSV material the Glottal Area Waveform (GAW) was segmented and GAW parameters were computed.There were strong inter-individual differences concerning the changes of different measures over time after WRT. In general, directly after WRT there was a lowering of the GAW derived Period Perturbation Quotient, a lowering of the Closing Quotient and an increase of the Sound Pressure Level (SPL) in comparison to the pre-intervention measurement. However, only 5 min post WRT there was no longer a clear difference compared to baseline results before WRT. Other values such as Open Quotients exhibited no evident changes by WRT at any timepoint.WRT showed strong inter-individual effects concerning the changes in the evaluated measures post-intervention. General tendencies of some measures directly after the intervention showed a brief effect of only a few minutes.

Introduction Vocal loading capacity is an important aspect of vocal health and is measured using standardized vocal loading tests. However, it remains unclear how vocal fold oscillation patterns are influenced by a standardized vocal loading task. Methods 21 (10 male, 11 female) vocally healthy subjects were analyzed concerning the dysphonia severity index (DSI) and high speed videolaryngoscopy (HSV) on the vowel /i/ at a comfortable pitch and loudness before and after a standardized vocal loading test (10 min standardized text reading, at a level higher than 80 dB (A) measured at 30 cm from the mouth). Results Changes in DSI were statistically significant, diminishing by 1.2 points after the vocal loading test, which was mainly caused by an increase of the minimum intensity. However, the pre-post comparison of HSV derived measures failed to show any statistically significant changes. Conclusion It seems necessary to analyze the effects of a standardized vocal loading test on vocal fold oscillation patterns with respect to softest phonation and phonation threshold pressure rather than comfortable pitch and loudness. Level of evidence 2c

Early prognostication in post-cardiac arrest (CA) patients remains challenging and biomarkers have evolved as helpful tools in risk assessment. The stress-response cytokine growth differentiation factor-15 (GDF-15) is dramatically up-regulated during various kinds of tissue injury and predicts outcome in many pathological conditions. We aimed to assess the predictive value of circulating GDF-15 in post-CA patients.This prospective observational study included 128 consecutive patients (median age 60.3 years, 75.8% male) with return of spontaneous circulation after in- or out-of-hospital CA who were treated at a tertiary university hospital. GDF-15 serum levels were determined at admission.A total of 52 patients (40.6%) died during the 6-month follow-up. Median GDF-15 levels were significantly lower in survivors (1601 ng/L (interquartile range: 1114-2983 ng/L) than in non-survivors (3172 ng/L (1927-8340 ng/L); p 0.001). GDF-15 levels were also significantly lower in patients with favourable neurological 6-month outcome (cerebral performance category (CPC) 1-2) than in those with poor neurological outcome (CPC 3-5; p 0.001). GDF-15 significantly predicted 6-month mortality in univariate Cox regression analysis (hazard ratio (HR) per 1-standard deviation increase 1.76 [95% confidence interval (CI) 1.35-2.31; p 0.001] and remained significant after multivariable adjustment (HR 1.57 [95% CI 1.19-2.07; p = 0.001]). Subgroup analysis revealed that the association between GDF-15 and 6-month outcome was present both in patients with in- and out-of-hospital CA.GDF-15 predicts poor survival and neurological outcome in post-CA patients. GDF-15 may reflect the extent of hypoxic injury to the brain and other organs and might help to improve early risk stratification after CA.

Breath control is an important factor for singing voice production, but pedagogic descriptions of how a beneficial movement pattern should be performed vary widely and the underlying physiological processes are not understood in detail. Differences in respiratory movements during singing might be related to the sex of the singer. To study sex-related differences in respiratory kinematics during phonation, 12 singers (six male and six female) trained in the Western classical singing tradition were imaged with dynamic magnetic resonance imaging. Singers were asked to sustain phonation at five different pitches and loudness conditions, and cross-sectional images of the lung were acquired. In each dynamic image frame the distances between anatomical landmarks were measured to quantify the movements of the respiratory apparatus. No major difference between male and female singers was found for the general respiratory kinematics of the thorax and the diaphragm during sustained phonation. However when compared to sole breathing, male singers significantly increased their thoracic movements for singing. This behavior could not be observed in female singers. The presented data support the hypothesis that professional singers follow sex-specific breathing strategies. This finding may be important in a pedagogical context where the biological sex of singer and student differ and should be further investigated in a larger cohort.

Postoperative atrial fibrillation (POAF) is a frequent complication after heart surgery and is associated with thromboembolic events, prolonged hospital stay, and adverse outcomes. Inflammation and fibrosis are involved in the pathogenesis of atrial fibrillation.The purpose of this study was to assess whether galectin-3, which reflects preexisting atrial fibrosis, has the potential to predict POAF and mortality after cardiac surgery.Four hundred seventy-five consecutive patients (mean age 67.4 ± 11.8 years; 336 (70.7%) male) undergoing elective heart surgery at the Medical University of Vienna were included in this prospective single-center cohort study. Galectin-3 plasma levels were assessed on the day before surgery.The 200 patients (42.1%) who developed POAF had significantly higher galectin-3 levels (9.60 ± 6.83 ng/mL vs 7.10 ± 3.54 ng/mL; P.001). Galectin-3 significantly predicted POAF in multivariable logistic regression analysis (adjusted odds ratio per 1-SD increase 1.44; 95% confidence interval 1.15-1.81; P = .002). During a median follow-up of 4.3 years (interquartile range 3.4-5.4 years), 72 patients (15.2%) died. Galectin-3 predicted all-cause mortality in multivariable Cox regression analysis (adjusted hazard ratio per 1-SD increase 1.56; 95% confidence interval 1.16-2.09; P = .003). Patients with the highest-risk galectin-3 levels according to classification and regression tree analysis (11.70 ng/mL) had a 3.3-fold higher risk of developing POAF and a 4.4-fold higher risk of dying than did patients with the lowest-risk levels (≤5.82 ng/mL).The profibrotic biomarker galectin-3 is an independent predictor of POAF and mortality after cardiac surgery. This finding highlights the role of the underlying arrhythmogenic substrate in the genesis of POAF. Galectin-3 may help to identify patients at risk of POAF and adverse outcome after cardiac surgery.

Introduction In addition to diagnosing acute myocardial infarction (MI), the electrocardiogram (ECG) may also predict the culprit coronary artery. We aimed to assess the diagnostic accuracy of ECG algorithms predicting the occluded vessel in inferior ST-segment elevation myocardial infarction (STEMI). Methods This retrospective cohort study included 300 consecutive patients with inferior STEMI undergoing acute coronary angiography. A new method based on the summation of ST-segment deviations in multiple leads from the first 12-lead-ECG was used to develop algorithms to discriminate between right coronary artery (RCA) and circumflex artery (CX) occlusion. Additionally, older algorithms were reassessed. Results The RCA was occluded in 235 patients (78%) and the CX in 65 (22%). ST-segment deviations differed significantly between RCA and CX occlusions in leads I, III, aVR, aVL, aVF and V1. ST-segment deviations in lead I showed the highest discriminatory ability of a single lead (area under the receiver operating curve (AUC): 0.77). The summation of multiple leads further increased the discriminatory ability ("III-II+aVF+aVR+V1": AUC=0.86; "III-II-I+aVF+V1": AUC=0.85). The best binary algorithm "III-II-I+aVF+V1>0.1 mV" classified 86% of cases correctly and was better than the best old algorithm (83.3%). The simpler algorithm "III+aVR+V1≥0.1mV" still predicted 85.0% correctly. All algorithms had higher sensitivities for RCA than for CX detection and performed better in right-dominant anatomy. Conclusions A new approach summating multiple ST-segment deviations generated ECG algorithms with higher diagnostic accuracy to predict the occluded vessel in inferior STEMI compared to previous studies. These algorithms may facilitate earlier risk stratification for patients at risk of post-infarct complications.

Boosted by the rapid development of multi-frequency multi-constellation Global Navigation Satellite Systems (GNSS), both high-precision Real-Time Kinematics (RTK) positioning and Precise Point Positioning (PPP) are more frequently performed under increasingly challenging conditions such as heavy canopy and urban canyons, where the GNSS observables measurement and the navigation messages decoding are severely affected by the multipath propagation phenomenon. The characteristics of this phenomenon are site-specific and cannot be easily modeled, which makes multipath remain a dominant error source in centimeter-level differential positioning. In addition, the increasing amount of ground wireless communication infrastructure results in interference-affected environments, which could significantly degrade both GNSS signal tracking and positioning capabilities. To provide high-quality GNSS measurements and positioning performance in challenging environments, advanced multipath and interference mitigation techniques are considered to be necessary. In the latest Leica GNSS technology, mitigation techniques for both error sources have been integrated: a novel multipath estimation and correction approach, the possibility to configure digital radio-frequency filters and the usage of High Dynamic Range (HDR) mode. Sophisticated algorithms are used to estimate multipath error and correct it in GNSS observations. In terms of interference mitigation, the so-called HDR mode removes distortions from the spectrum, working efficiently against wide-band and out-of-band interference generators (either intentional ones – jamming –, or interferences generated by normal operation of communication systems) by optimizing the Automatic Gain Control (AGC) to avoid losing GNSS-relevant signal content. Furthermore, programmable digital filters, such as bandpass and notch filters, are introduced to remove near-band and in-band interferences respectively. This paper assesses the benefits of the usage of multipath and interference mitigation techniques to GNSS signal tracking and RTK positioning. Based on representative data sets, the measurement domain analysis confirms that the new multipath estimation method significantly reduces the code multipath error by up to 60%, particularly in the lower frequency bands L5/E5 and E6/B3. The combined usage of HDR mode and digital filters – both in-band and out-of-band – adapts the power spectral density and allows for an enhanced GNSS signal tracking performance. The position domain analysis focuses on the improvements in availability, accuracy, and reliability of RTK survey scenarios. The results show that, under difficult conditions, applying advanced multipath estimation and interference mitigation techniques considerably improves the RTK fix availability and reduces the presence of large positioning errors caused by incorrect ambiguity fixes.

Vaccination is a significant preventive measure to contain the coronavirus disease-2019 (COVID-19) pandemic. Vaccination rates can provide useful information on the potential spread of infection in a given population. In this study, vaccination rates and attitudes towards vaccination in cultural sectors, specifically the music sector, have been investigated. In total, 4341 persons in four different areas, including visitors to performances of classical music and musicals, as well as professional and amateur musicians, have participated in this survey. Results show rates of 86% recovered from the COVID-19 virus or vaccinated at least once, with 54.5% fully vaccinated. These vaccination rates were considerably higher compared to the general population. An attitude of hesitation towards vaccination found in 6.4% of those sampled was half that of the general population. These findings drawn from a large sample indicate that in the field of music a high vaccination rate is to be found, as well as a low rejection rate of vaccination on the part of the audience and performers. The results can be used to provide insights into the vaccination status to be found at cultural events and, importantly, to assist in consideration of whether cultural events should be permitted to continue under pandemic circumstances.

The benefit of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and type 2 diabetes mellitus (T2DM) has been unequivocally proven in randomized, controlled trials. However, real-world evidence assessing the implementation of SGLT2i in clinical practice and their benefit in HF outside of highly selected study populations is limited. Patients with HF and T2DM admitted to the cardiology ward of the Medical University of Vienna between 01/2014 and 04/2020 were included in the present analysis. All first-time prescriptions of SGLT2i were identified. The outcome of interest was cardiovascular mortality. The median follow-up time was 2.3 years. Out of 812 patients with T2DM and HF (median age 70.4 [IQR 62.4–76.9] years; 70.3% males), 17.3% received an SGLT2i. The frequency of SGLT2i prescriptions significantly increased over the past 6 years (+ 36.6%, p

Respiratory kinematics are important for the regulation of voice production. Dynamic MRI is an excellent tool to study respiratory motion providing high-resolution cross-sectional images. Unfortunately, in clinical MRI systems images can only be acquired in a horizontal subject position, which does not take into account gravitational effects on the respiratory apparatus. To study the effect of body posture on respiratory kinematics during phonation, 8 singers were examined both in an open-configuration MRI with a rotatable gantry and a conventional horizontal MRI system. During dynamic MRI the subjects sang sustained tones at different pitches in both supine and upright body positions. Sagittal images of the respiratory system were obtained at 1–3 images per second, from which 6 anatomically defined distances were extracted to characterize its movements in the anterior, medium and posterior section of the diaphragm as well as the rip cage (diameter at the height of the 3rd and 5th rip) and the anterior–posterior position of the diaphragm cupola. Regardless of body position, singers maintained their general principles of respiratory kinematics with combined diaphragm and thorax muscle activation for breath support. This was achieved by expanding their chest an additional 20% during inspiration when singing in the supine position but not for sole breathing. The diaphragm was cranially displaced in supine position for both singing and breathing and its motion range increased. These results facilitate a more realistic extrapolation of research data obtained in a supine position.

(1) Objective: Teaching is a particularly voice-demanding occupation. Voice training provided during teachers’ education is often insufficient and thus teachers are at risk of developing voice disorders. Vocal demands during teaching are not only characterized by speaking for long durations but also by speaking in noisy environments. This provokes the so-called Lombard effect, which intuitively leads to an increase in voice intensity, pitch and phonation time in laboratory studies. However, this effect has not been thoroughly investigated in realistic teaching scenarios. (2) Methods: This study thus examined how 13 experienced, but vocally untrained, teachers behaved when reading in a noisy compared to quiet background environment. The quiet and noisy conditions were provided by a live audience either listening quietly or making noise by talking to each other. By using a portable voice accumulator, the fundamental frequency, sound pressure level of the voice and the noise as well as the phonation time were recorded in both conditions. (3) Results: The results showed that the teachers mainly responded according to the Lombard effect. In addition, analysis of phonation time revealed that they failed to increase inhalation time and appeared to lose articulation through the shortening of voiceless consonants in the noisy condition. (4) Conclusions: The teachers demonstrated vocally demanding behavior when speaking in the noisy condition, which can lead to vocal fatigue and cause dysphonia. The findings underline the necessity for specific voice training in teachers’ education, and the content of such training is discussed in light of the results.

Die Stimme ist ein unentbehrliches Werkzeug im Berufsalltag einer Lehrkraft. Ein Bewusstsein im Umgang mit der Stimme, die Uberzeugung, dass praventive Masnahmen fur die Gesunderhaltung der Stimme im Berufsalltag notwendig sind, sowie ein positives stimmliches Selbstkonzept sind entscheidende Voraussetzungen fur einen didaktisch wirksamen Einsatz der Stimme und fur deren Gesunderhaltung. Eine entsprechende Sensibilisierung sollte deshalb moglichst bereits im Studium erfolgen. In der vorliegenden Studie wurde untersucht, wie unterrichtspraktische Erfahrungen das stimmliche Selbstkonzept und die Einstellung zum praventiven Umgang mit der Stimme bei Lehramtsstudierenden beeinflussen. Hierfur wurden 258 Studierende des Lehramts vor und nach dem Praxissemester zu ihrer stimmlichen Gesundheit, ihrem stimmlichen Selbstkonzept und der Bedeutung der Stimme im Berufskontext befragt. Die Ergebnisse zeigen, dass das Praxissemester die Stimme stark beansprucht und zu einem deutlichen Zuwachs in der Selbstwahrnehmung der Stimme im Bereich des stimmlichen Selbstkonzepts und in der Bedeutung der Stimme fur den Lehrerberuf fuhrte. Erhebliche Unterschiede fanden sich zwischen den Studierenden, die wahrend des Praxissemesters ein Stimmproblem entwickelt hatten, und denjenigen ohne Stimmproblem. Insgesamt weisen die Ergebnisse das Praxissemester im Lehramtsstudium als einen geeigneten Zeitpunkt aus, zukunftige Lehrkrafte fur den Umgang mit der Stimme im Lehrerberuf zu sensibilisieren und fur praventive Moglichkeiten zu motivieren.

Blood urea nitrogen (BUN) has been shown to independently predict short- and intermediate-term outcomes in patients with acute myocardial infarction (AMI). We aimed to assess the additive predictive value of BUN beyond estimated glomerular filtration rate (eGFR) in AMI patients with an 8.6-year follow-up.This retrospective, observational single-centre study included 1332 consecutive AMI patients (median age 64 years, 58.4% male). BUN, creatinine and eGFR were determined at hospital admission.During a median follow-up of 8.6 years (interquartile range [IQR] 4.0-11.6), 408 patients (30.6%) experienced the study endpoint of cardiovascular mortality. BUN (median 17.0 mg/dL [IQR 13.5-22.7]) was a significant predictor of cardiovascular mortality in univariate Cox regression (hazard ratio (HR) per 1 standard deviation increase 2.10, 95% confidence interval [CI] 1.94-2.28, p .001). This association remained significant after multivariable adjustment for demographics, clinical variables and eGFR (adjusted HR 1.52 [CI 1.16-2.00, p = .003]). The association between BUN and outcome was more pronounced in patients with eGFR60 mL/min/1.73mCirculating BUN on admission is an independent predictor of long-term cardiovascular mortality in AMI patients and adds predictive power beyond eGFR. BUN reflects not only kidney function, but also acute haemodynamic and neurohumoral alterations during AMI, and may help to identify high-risk patients.

1.AbstractSince the Covid-19 virus spreads through airborne transmission, questions concerning the risk of spreading infectious droplets during singing and music making has arisen.To contribute to this question and to help clarify the possible risks, we analyzed 15 singing scenarios (1) qualitatively – by making airflows visible, while singing – and (2) quantitatively – by measuring air velocities at three distances (1m, 1.5m and 2m). Air movements were considered positive when lying above 0.1 m/s, which is the usual room air velocity in venue, such as the concert hall of the Bamberg Symphony, where our measurements with three professional singers (female classical style, male classic style, female popular music style) took place.Our findings highlight that high measurements for respiratory air velocity while singing are comparable to measurements of speaking and – by far – less than coughing. All measurements for singing stayed within a reach of 1.5m, while only direct voiceless blowing achieved measurements at the 2m sensor. Singing styles that use plosive sounds, i.e. using consonants more often as in rap, produced the highest air velocities of 0.17 m/s at the 1m sensor. Also, singing while wearing a facemask produces no air movements over 0.1 m/s.On the basis of our recent studies on measurements of airflows and air velocities of professional singers and wind instrument players, as well as further studies on CO□ measurements in room settings of music activities, we publish our results – in consideration of further up-to-date research – in our frequently updated risk assessment (first published in April 2020). On this behalf, we suggest 2m radial distances for singers, especially in choirs.

Background: After successful cardiopulmonary resuscitation (CPR) with return of spontaneous circulation (ROSC), many patients show signs of an overactive immune activation. Monocytes are a heterogeneous cell population that can be distinguished into three subsets. The aim of this prospective, observational study was to analyse whether monocyte subset distribution is associated with mortality at 6 months in patients after cardiac arrest (CA). Methods: We included 53 patients admitted to our medical intensive care unit (ICU) after CA. Blood was taken on admission and after 72 hours and monocyte subset distribution was analysed by flow cytometry and distinguished into classical monocytes (CD14++CD16-), intermediate monocytes (CD14++CD16+CCR2+) and non-classical monocytes (CD14+CD16++CCR2-). Results: Median age was 64.5 (interquartile range (IQR) 49.8-74.3) years and 75.5% were male. Six-month mortality was 50.9% and survival with good neurological outcome was 37.7%. Monocyte subset distribution upon admission to the ICU did not differ according to survival. However, patients who died within 6 months showed a more pronounced increase in the pro-inflammatory subset of intermediate monocytes (8.3% (3.8-14.6)% vs. 4.1% (1.5-8.2)%; p=0.025), and a decrease of classical monocytes (87.5% (79.9-89.0)% vs. 90.8% (85.9-92.7)%; p=0.036) 72 hours after admission. In addition, intermediate monocytes were predictive of outcome independent of time to ROSC and witnessed cardiac arrest, and correlated with the cerebral performance category (CPC)-score at 6 months (R=0.32; p=0.043). Discussion: Monocyte subset distribution is associated with outcome in patients surviving a CA. The activation of the innate immune system may play a significant role in CA patients.

Background After successful cardiopulmonary resuscitation with return of spontaneous circulation (ROSC), many patients show signs of an overactive immune activation. Monocytes are a heterogenous cell population that can be distinguished into three subsets. Purpose The aim of this prospective, observational study was to analyze whether monocyte subset distribution is associated with mortality at 6 months in patients after cardiac arrest. Methods We included 53 patients admitted to our medical ICU after cardiac arrest. Blood was taken on admission and monocyte subset distribution was analyzed by flow cytometry and distinguished into classical monocytes (CM; CD14++CD16-), intermediate monocytes (IM; CD14++CD16+CCR2+) and non-classical monocytes (NCM; CD14+CD16++CCR2-). Results Median age was 64.5 (IQR 49.8–74.3) years and 75.5% of patients were male. Mortality at 6 months was 50.9% and survival with good neurological outcome was 37.7%. Of interest, monocyte subset distribution upon admission to the ICU did not differ according to survival. However, patients that died within 6 months showed a strong increase in the pro-inflammatory subset of intermediate monocytes (8.3% (3.8–14.6)% vs. 4.1% (1.5–8.2)%; p=0.025), and a decrease of classical monocytes (87.5% (79.9–89.0)% vs. 90.8% (85.9–92.7)%; p=0.036) 72 hours after admission. In addition, intermediate monocytes were predictive of outcome independent of initial rhythm and time to ROSC and correlated with the CPC-score at 6 months (R=0.32; p=0.043). Discussion Monocyte subset distribution is associated with outcome in patients surviving a cardiac arrest. This suggests that activation of the innate immune system may play a significant role in patient outcome after cardiac arrest. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): FWF - Fonds zur Förderung der wissenschaftlichen Forschung

Contaminated aerosols in room air are one of the transmission routes of the coronavirus. The amount of contaminated aerosols in the room seems to play an important role for the infection risk. In rooms without technical air refreshing systems, the aerosol concentration can be reduced with simple natural ventilation activity. Instrumental and vocal lessons and rehearsals take place in closed indoor rooms. Therefore it is important to optimize the necessary ventilation activity in order to keep the infection risk for musicians low. Therefore, knowledge about the maximum duration of the lesson or rehearsal for ventilation intervals are necessary. In this study, carbon dioxide concentration (CO2) as an indicator of the indoor air quality (IAQ) was measured during 47 music lessons and rehearsals at a university of music including 141 persons. From these measurements, the air exchange rates of the rooms and the CO2 emission rates per person were extracted. The results show that the CO2 emission in musical activities can be assigned to light and moderate activities between 28 l/h and 39 l/h. Wind instruments had the highest CO2 emissions. Singers showed low CO2 emission rates comparable to the control group which only spoke and listened. Recommendations for the frequency of ventilation breaks were derived from empirical data and allow for an individual risk assessment of instrumental and vocal lessons and rehearsals depending on room size and number of musicians.

IntroductionThe effect of early and sustained administration of daily probiotic therapy on patients admitted to the intensive care unit (ICU) remains uncertain.Methods and analysisThe Restoration Of gut microflora in Critical Illness Trial (ROCIT) study is a multicentre, randomised, placebo-controlled, parallel-group, two-sided superiority trial that will enrol 220 patients in five ICUs. Adult patients who are within 48 hours of admission to an ICU and are expected to require intensive care beyond the next calendar day will be randomised in a 1:1 ratio to receive early and sustained Lactobacillus plantarum 299v probiotic therapy in addition to usual care or placebo in addition to usual care. The primary endpoint is days alive and out of hospital to day 60.Ethics and disseminationROCIT has been approved by the South Metropolitan Health Service Human Research Ethics Committee (ref: RGS00000004) and the St John of God Health Care Human Research Ethics Committee (ref: 1183). The trial results will be submitted for publication in a peer-reviewed journal.Trial registration numberAustralian and New Zealand Clinical Trials Registry (ANZCTR12617000783325); Pre-results.

Current guidelines suggest the use of epinephrine in patients with cardiac arrest (CA). However, evidence for increased survival in good neurological condition is lacking. In experimental settings, epinephrine-induced impairment of microvascular flow was shown. The aim of our study was to analyze the association between epinephrine treatment and intestinal injury in patients after CA.We have included 52 patients with return of spontaneous circulation (ROSC) after CA admitted to our medical intensive care unit (ICU). Blood was taken on admission and levels of circulating intestinal fatty acid binding protein (iFABP) were analyzed.Patients were 64 (49.8-73.8) years old and predominantly male (76.9%). After six months, 50% of patients died and 38.5% of patients had a cerebral performance category (CPC)-score of 1-2. iFABP levels were lower in survivors (234 IQR 90-399 pg/mL) as compared to non-survivors (283, IQR 86-11500 pg/mL; p 0.05). Plasma levels of iFABP were not associated with time to ROSC but correlated with epinephrine-dose (R = 0.32; p 0.05). 40% of patients receiving ≥3 mg of epinephrine as compared to 10.5% of patients treated with3 mg (p 0.05) developed iFABP plasma levels1500 pg/mL, which was associated with dramatically increased mortality (HR4.87, 95%CI 1.95-12.1; p 0.001). iFABP levels predicted mortality independent from time to ROSC and the disease severity score SAPS II. In contrast to mortality, iFABP plasma levels were not associated with neurological outcome.In this small, single centre study, cumulative dose of epinephrine used in cardiac arrest patients was associated with an increase in biomarker indicative of intestinal injury and 6-month mortality.

Background. Heart failure with reduced ejection fraction (HFrEF) constitutes a global health issue. While proinflammatory cytokines proved to have a pivotal role in the development and progression of HFrEF, less attention has been paid to the cellular immunity. Regulatory T lymphocytes (Tregs) seem to have an important role in the induction and maintenance of immune homeostasis. Therefore, we aimed to investigate the impact of Tregs on the outcome in HFrEF. Methods. We prospectively enrolled 112 patients with HFrEF and performed flow cytometry for cell phenotyping. Individuals were stratified in ischemic (iHFrEF, n=57) and nonischemic etiology (niHFrEF, n=55). Cox regression hazard analysis was used to assess the influence of Tregs on survival. Results. Comparing patients with iHFrEF to niHFrEF, we found a significantly lower fraction of Tregs within lymphocytes in the ischemic subgroup (0.42% vs. 0.56%; p=0.009). After a mean follow-up time of 4.5 years, 32 (28.6%) patients died due to cardiovascular causes. We found that Tregs were significantly associated with cardiovascular survival in the entire study cohort with an adjusted HR per one standard deviation (1-SD) of 0.60 (95% CI: 0.39-0.92; p=0.017). A significant inverse association of Tregs and cardiovascular mortality in patients with iHFrEF with an adj. HR per 1-SD of 0.59 (95% CI: 0.36-0.96; p=0.034) has been observed, while this association was not evident in the nonischemic subgroup (adj. HR per 1-SD of 0.62 (95% CI: 0.17-2.31); p=0.486). Conclusion. Our results indicate a potential influence of Tregs in the pathogenesis and progression of iHFrEF, fostering the implication of cellular immunity in iHFrEF pathophysiology and proving Tregs as a predictor for long-term survival among iHFrEF patients. A preview of this study has been presented at a meeting of the European Society of Cardiology earlier this year.

The chapter reflects the main clinical manifestations of voice disorders, the wide diversity and multiple sociocultural interrelations of which contrast with a consistent systematic order of aetiological or symptomatic categories. Instead, the compilation follows prevailing purposes to provide a useful overview for application in everyday practice. Functional dysphonias, psychosomatic voice dysfunction and singing voice disorders are closely related to each other but nevertheless require individual consideration regarding special diagnostic procedures as well as therapeutic or rehabilitative consequences, including occupational perspectives. Organic manifestations comprise benign lesions of the mucosa of the vocal folds, gastro-oesophageal reflux influences, central and peripheral neurogenic disorders and laryngeal sensory neuropathy. A section on hormone-related dysphonias is followed by a survey on gender vocology focused on the demands of male-to-female as well as female-to-male adaptation of transsexuals. Voice disorders in systematic diseases and also as consequences of environmental influences and allergy complete the chapter that includes paying attention to special aspects of the voices in childhood and adolescence and the elderly population. Malign lesions are not part of this chapter.

This historical review covers the scientific background of the discipline as reflected in documents from antiquity, the Renaissance, the seventeenth to the nineteenth centuries and the twentieth century up to present times.