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Force-displacement measurements and macrosections are commonly used methods to validate numerical models of clinching processes. However, these ex-situ methods often lead to springback of elastic deformations and crack-closing after unloading. In contrast, the in-situ computed tomography (CT) can provide three-dimensional images of the clinching point under loading conditions. So far, the quantity of elastic springback that causes measuring deviations between in- and ex-situ measurements is not determined. In this paper, a method is described to quantitatively compare the results of in-situ CT, ex-situ CT and CT scans of cut specimens, which are prepared for macrosectioning, among each other. The method is applied to a single-lap shear test of two clinched aluminum sheets. Here, the test is conducted to specific process steps, then the specimen is CT scanned in-situ (during loading) and ex-situ (after unloading). Subsequently, the specimens are cut for macrosectioning and CT scanned. Finally, the outer contours and the interfaces of cross section images are determined by digital image analysis and the deviations over the clinching point between ex- and in-situ methods are calculated.

Access to large, annotated samples represents a considerable challenge for training accurate deep-learning models in medical imaging. Although at present transfer learning from pre-trained models can help with cases lacking data, this limits design choices and generally results in the use of unnecessarily large models. Here we propose a self-supervised training scheme for obtaining high-quality, pre-trained networks from unlabelled, cross-modal medical imaging data, which will allow the creation of accurate and efficient models. We demonstrate the utility of the scheme by accurately predicting retinal thickness measurements based on optical coherence tomography from simple infrared fundus images. Subsequently, learned representations outperformed advanced classifiers on a separate diabetic retinopathy classification task in a scenario of scarce training data. Our cross-modal, three-stage scheme effectively replaced 26,343 diabetic retinopathy annotations with 1,009 semantic segmentations on optical coherence tomography and reached the same classification accuracy using only 25% of fundus images, without any drawbacks, since optical coherence tomography is not required for predictions. We expect this concept to apply to other multimodal clinical imaging, health records and genomics data, and to corresponding sample-starved learning problems. The thickness of the retina is an important medical indicator for diabetic retinopathy. Holmberg and colleagues present a self-supervised deep-learning method that uses cross-modal data to predict retinal thickness maps from easily obtainable fundus images.

As most COVID-19 patients only receive thoracic CT scans, but body composition, which is relevant to detect sarcopenia, is determined in abdominal scans, this study aimed to investigate the relationship between thoracic and abdominal CT body composition parameters in a cohort of COVID-19 patients. This retrospective study included n = 46 SARS-CoV-2-positive patients who received CT scans of the thorax and abdomen due to severe disease progression. The subcutaneous fat area (SF), the skeletal muscle area (SMA), and the muscle radiodensity attenuation (MRA) were measured at the level of the twelfth thoracic (T12) and the third lumbar (L3) vertebra. Necessity of invasive mechanical ventilation (IMV), length of stay, or time to death (TTD) were noted. For statistics correlation, multivariable linear, logistic, and Cox regression analyses were employed. Correlation was excellent for the SF (r = 0.96) between T12 and L3, and good for the respective SMA (r = 0.80) and MRA (r = 0.82) values. With adjustment (adj.) for sex, age, and body-mass-index the variability of SF (adj. r2 = 0.93; adj. mean difference = 1.24 [95% confidence interval (95% CI) 1.02–1.45]), of the SMA (adj. r2 = 0.76; 2.59 [95% CI 1.92–3.26]), and of the MRA (adj. r2 = 0.67; 0.67 [95% CI 0.45–0.88]) at L3 was well explained by the respective values at T12. There was no relevant influence of the SF, MRA, or SMA on the clinical outcome. If only thoracic CT scans are available, CT body composition values at T12 can be used to predict abdominal fat and muscle parameters, by which sarcopenia and obesity can be assessed.

The working group “Analyses in Biological Materials” of the Permanent Senate Commission for the Investigation of Health Hazards of Chemical Compounds in the Work Area developed and validated the presented biomonitoring method. This analytical method permits the determination of tobacco‐specific nitrosamines (TSNA) in urine using liquid chromatography‐tandem mass spectrometry (LC‐MS/MS). The parameters in question are N‐nitrosoanabasine (NAB), N‐nitrosoanatabine (NAT), N‐nitrosonornicotine (NNN) and 4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol (NNAL). NNAL is a metabolite of 4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanone (NNK). Due to its sensitivity, this method is suitable for the detection of the aforementioned analytes in the urine of smokers. NNAL can also be quantified in the urine of passive smokers. The analytes NAB, NAT, NNN and NNAL are present in urine in both free and glucuronidated forms. For the determination of the total TSNA level in urine, the glucuronides are cleaved by enzymatic hydrolysis and then the analytes are isolated and concentrated using solid phase extraction (SPE). Two sorbent materials are used for sample preparation via SPE, first a material based on molecularly imprinted polymers and then a mixed‐mode cation exchange polymer. Analysis is performed by LC‐MS/MS. Deuterated internal standards are used for calibration. Calibration standards are prepared in pooled urine obtained from non‐smokers and are processed in the same way as the samples to be analysed.

The working group “Analyses in Biological Materials” of the Permanent Senate Commission for the Investigation of Health Hazards of Chemical Compounds in the Work Area developed and validated the presented biomonitoring method. This analytical method permits the determination of tobacco‐specific nitrosamines (TSNA) in urine using liquid chromatography‐tandem mass spectrometry (LC‐MS/MS). The parameters in question are N‐nitrosoanabasine (NAB), N‐nitrosoanatabine (NAT), N‐nitrosonornicotine (NNN) and 4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanol (NNAL). NNAL is a metabolite of 4‐(methylnitrosamino)‐1‐(3‐pyridyl)‐1‐butanone (NNK). Due to its sensitivity, this method is suitable for the detection of the aforementioned analytes in the urine of smokers. NNAL can also be quantified in the urine of passive smokers. The analytes NAB, NAT, NNN and NNAL are present in urine in both free and glucuronidated forms. For the determination of the total TSNA level in urine, the glucuronides are cleaved by enzymatic hydrolysis and then the analytes are isolated and concentrated using solid phase extraction (SPE). Two sorbent materials are used for sample preparation via SPE, first a material based on molecularly imprinted polymers and then a mixed‐mode cation exchange polymer. Analysis is performed by LC‐MS/MS. Deuterated internal standards are used for calibration. Calibration standards are prepared in pooled urine obtained from non‐smokers and are processed in the same way as the samples to be analysed.

In Germany there are regional driving bans on older diesel vehicles without SCR catalytic converters if the limit values for nitrogen dioxide (NO

Since 2005, invasive long-term ventilation in Germany has increased significantly from around 1000 to 20 000 patients in Germany. Due to complex home care, the health care system incurs additional costs of around 4 billion euros per year. In addition, in the last 2 - 3 years more tracheostomized patients have been discharged home without ventilation (usually after stroke), and they receive the same complex home care. These patients have almost never been given the chance of a professional weaning trial by a weaning center. They are discharged from hospitals directly into the care. As a result, the quality of care is significantly worse than traditional care with structured discharge management via a weaning center. The solutions are difficult to find due to the interface problems between inpatient and outpatient care and the different organizational structures with different delivery systems. Possible solutions are shown, but most of them require a change in the law.

In Deutschland sind die Kosten im Gesundheitswesen gedeckelt, d. h. Mehrausgaben in einem Bereich fuhren zu Defiziten in anderen Bereichen. Deswegen ist es sinnvoll, in der arztlichen Arbeit kluge Entscheidungen zu treffen. Dazu gehoren auch wirtschaftliche Uberlegungen. Diese verbessern nicht nur die Gesundheitsversorgung als Ganzes, sondern fuhren auch dazu, dass eigene Ressourcen fur andere Tatigkeiten frei werden. In der Medizin allgemein sowie in der Pneumologie gibt es viele Bereiche, in denen eine Uber- und Fehlversorgung vorliegen. Eine Reduktion unnotiger Diagnostik und Therapie hilft auch dem Patienten, da sich Komplikationen durch ggf. riskante Folgeuntersuchungen und Nebenwirkungen vermeiden lassen.Die Uberversorgung wird begunstigt durch die oft unzulassige Verallgemeinerung (Induktion) von randomisierten kontrollierten Studien (RCT) in Leitlinien, deren Resultate an sich nur fur den eingeschlossenen Patientenkreis gelten. Dieser unterscheidet sich haufig von der klinischen Realitat. Viel zu selten werden Auslassversuche bei Medikamenten durchgefuhrt („n-of-1 trial“). In dem Artikel werden Beispiele fur die Therapieoptimierung des Asthma bronchiale, der COPD, der Intensivmedizin und des Lungenkarzinoms genannt.

Die nicht-invasive Beatmung (NIV) ist in der klinischen Medizin weit verbreitet und hat mittlerweile einen hohen Stellenwert im klinischen Alltag erlangt. Der Einsatz der NIV reduziert die Intensiv- und Krankenhausaufenthaltsdauer sowie die Mortalitat von Patienten mit akutem hyperkapnischen Atemversagen. Patienten mit akuter respiratorischer Insuffizienz im Rahmen eines Lungenodems sollten neben den notwendigen kardiologischen Interventionen mit CPAP oder NIV behandelt werden. Bei anderen Formen des akuten hypoxamischen Atemversagens wird empfohlen, den Einsatz der NIV auf lediglich mildes ARDS zu begrenzen, da eine NIV bei schweren Formen mit hoheren Raten von Therapieversagen und Mortalitat assoziiert ist. Im Weaning von invasiver Beatmung reduziert die NIV die Reintubationsraten im Wesentlichen bei hyperkapnischen Patienten. Eine verzogerte Intubation bei Auftreten eines NIV-Versagens fuhrt zu einem Anstieg der Mortalitat und sollte deshalb vermieden werden. Bei entsprechendem Monitoring auf der Intensivstation kann die NIV auch bei padiatrischen Patienten mit akuter respiratorischer Insuffizienz erfolgreich eingesetzt werden. Weiterhin kann im Rahmen der Palliativmedizin die NIV hilfreich bei der Reduktion von Dyspnoe und Verbesserung von Lebensqualitat sein. Ziel des Updates dieser Leitlinie ist es, unter Berucksichtigung der zunehmenden aktuellen wissenschaftlichen Evidenz, sowohl die Vorteile als auch die Limitationen der NIV in der Behandlung der akuten respiratorischen Insuffizienz in der taglichen klinischen Praxis und bei verschiedenen Indikationen aufzuzeigen.

Numerous studies have shown that exacerbation rates in COPD can be significantly reduced by long acting beta-2-agonists (LABA), long acting anticholinergic agents (LAMA) and inhaled steroids (ICS). Elaborate and extensive investigations however failed to prove that the reduction in exacerbation rates leads to life prolongation. As opposed to this, numerous studies have shown a reduction in life expectancy with increasing number and severity of exacerbations.This review aimed at comparing these studies and to elaborate the relevance and reduction of exacerbations rates by LABA, LAMA and ICS application through effect size calculation by means of Cohens' d. These studies display a common pattern. The reduction of exacerbation rates is only being achieved for less severe exacerbations (Cohens' d max. 0.21). For more severe exacerbations and for the comparison of different substances Cohens' d remains below 0.1, indicating that the effect of the medications is practically irrelevant. The impact of LABA's, LAMA's and ICS on exacerbation rates in COPD patients is obviously overrated.Durch zahlreiche Studien ist belegt, dass inhalative, langwirksame Beta-2-Mimetika (LABA) und Anticholinergika (LAMA) sowie Steroide (ICS) die Exazerbationsrate bei COPD signifikant reduzieren. Allerdings konnte auch in aufwendigen und länger dauernden Studien nicht gezeigt werden, dass diese Reduktion der Exazerbation auch die Lebenserwartung reduziert. Im Gegensatz dazu zeigen zahlreiche Studien, dass die Lebenserwartung mit zunehmender Schwere und Häufigkeit der Exazerbation vermindert wird.In dieser Übersicht werden diese Studien gegenübergestellt und die Relevanz der Reduktion der Exazerbationsraten durch LABA, LAMA und ICS durch Bewertung ihrer Effektstärke mittels Cohen’s d bewertet. Dabei zeigt sich in den Studien ein gleiches Muster. Die Reduktion der Exazerbationsrate zeigt nur bei den geringen Schweregraden einen kleinen Effekt (Cohen’s d max. 0,21). Bei Exazerbation mit höherem Schweregrad und bei Vergleich der Substanzen untereinander fällt Cohen’s d unter 0,1, was zeigt, dass die Wirkung der Medikamente klinisch praktisch bedeutungslos ist. Die Wirkung von LABA, LAMA und ICS auf die Exazerbationsrate bei COPD ist deutlich überschätzt.

Aim Choking in children is a feared condition, which potentially can deteriorate to hypoxic cardiac arrest and death. Fast recognition and immediate initiation of basic life support (BLS)1, primary back blows and abdominal thrusts given by bystanders and secondary activation of the Emergency Medical System (EMS) are vital for the survival. Methods The Region of Southern Denmark has a tiered response with prehospital emergency physicians to supplement the ambulance service. EMS physicians register all contacts in a database. We reviewed the database for all children below the age of 5 years who suffered from choking in 2009 to 2014. Results From 70.289 total contacts 4.857 contacts was with children less than 5 years. In this group 98 children suffered from choking. In 78% BLS had resolved the obstructing foreign body before arrival of EMS services. Seventeen children had successful treatment with BLS by ambulance personal. Five children required advanced airway management and one child required cardiopulmonary resuscitation. No deaths were registered. None of the children with near fatal choking had any comorbidity prior to incident. Conclusion Choking in children is an uncommon emergency with only 0,14% of all contacts. We found like others2 that BLS solves most cases before arrival of EMS. This demonstrates the importance of immediate initiation of BLS and keeping the chain of survival as a concept. Death to choking is rare among small children. Near fatal choking resolves with skills and routine in advanced airway management and advanced life support. References Maconochie IK, Bingham R, Eich C, Lopez-Herce J4, Rodriguez-Nunez A, Rajka T, Van de Voorde P, Zideman DA, Biarent D: European Resuscitation Council Guidelines for Resuscitation 2015: Section 6. Paediatric life support. Resuscitation. 2015Oct;95:223–48. Vilke GM, Smith AM, Ray LU, Steen PJ, Murrin PA, Chan TC: Airway obstruction in children aged less than 5 years: the prehospital experience. Prehosp Emerg Care2004, 8:196–199. Conflict of interest None declared. Funding None declared.