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Admission to an emergency department (ED) is challenging for older patients with cognitive dysfunction (PWCD). Targeted patient-oriented approaches to improve the care for PWCD are needed. The aim of this pilot study was to design and evaluate a program for volunteers to support PWCD in the ED. Volunteers (N = 9) first received a training and during the following six months (N = 90 shifts), they accompanied PWCD (N = 112) during their stay. Results showed that the training increased volunteers' knowledge and expertise, but not shift-related self-efficacy. The most frequent strategies applied were conversations, holding hands and touching, and providing food and drinks. After six months, volunteers reported a great sense of meaningfulness and felt that they were highly appreciated by the patients. ED nurses' sceptical attitudes towards the program decreased. The program is beneficial for PWCD, appears to be meaningful for volunteers and is appreciated by ED nurses.

mRNA-based host response signatures have been reported to improve sepsis diagnostics. Meanwhile, prognostic markers for the rapid and accurate prediction of severity in patients with suspected acute infections and sepsis remain an unmet need. IMX-SEV-2 is a 29-host-mRNA classifier designed to predict disease severity in patients with acute infection or sepsis.Validation of the host-mRNA infection severity classifier IMX-SEV-2.Prospective, observational, convenience cohort of emergency department (ED) patients with suspected acute infections.Whole blood RNA tubes were analyzed using independently trained and validated composite target genes (IMX-SEV-2). IMX-SEV-2-generated risk scores for severity were compared to the patient outcomes in-hospital mortality and 72-h multiorgan failure.Of the 312 eligible patients, 22 (7.1%) died in hospital and 58 (18.6%) experienced multiorgan failure within 72 h of presentation. For predicting in-hospital mortality, IMX-SEV-2 had a significantly higher area under the receiver operating characteristic (AUROC) of 0.84 [95% confidence intervals (CI), 0.76-0.93] compared to 0.76 (0.64-0.87) for lactate, 0.68 (0.57-0.79) for quick Sequential Organ Failure Assessment (qSOFA) and 0.75 (0.65-0.85) for National Early Warning Score 2 (NEWS2), ( P = 0.015, 0.001 and 0.013, respectively). For identifying and predicting 72-h multiorgan failure, the AUROC of IMX-SEV-2 was 0.76 (0.68-0.83), not significantly different from lactate (0.73, 0.65-0.81), qSOFA (0.77, 0.70-0.83) or NEWS2 (0.81, 0.75-0.86).The IMX-SEV-2 classifier showed a superior prediction of in-hospital mortality compared to biomarkers and clinical scores among ED patients with suspected infections. No improvement for predicting multiorgan failure was found compared to established scores or biomarkers. Identifying patients with a high risk of mortality or multiorgan failure may improve patient outcomes, resource utilization and guide therapy decision-making.

Zusammenfassung Hintergrund Die Sepsis ist eine häufige und lebensbedrohliche Komplikation einer akuten Infektion. In der Notfallmedizin hat sich zum Screening auf Sepsis der Quick Sequential-Organ-Failure-Assessment(qSOFA)-Score etabliert. Bereits mit der Einführung des Scores wurde dessen schwache Sensitivität kritisiert. Nun fordern aktuelle Leitlinien, den qSOFA-Score nicht mehr zum Screening auf Sepsis einzusetzen. Als eine Alternative wird der National Early Warning Score 2 (NEWS2) vorgeschlagen. Ziel der Arbeit In einer Subanalyse einer Kohorte von notfallmedizinischen Patient*innen soll die diagnostische Aussagekraft des qSOFA-Scores und des NEWS2 zur Erkennung einer Sepsis verglichen werden. Zusätzlich soll gezeigt werden, inwieweit mithilfe von abweichenden Vitalparametern bereits eine Risikoerhöhung für eine Sepsis ableitbar ist. Methodik Mittels AUROC (Area Under Receiver Operating Characteristics) und Odds Ratios wurden die Scores bzw. die Vitalparameter auf ihre Fähigkeit untersucht, septische Patient*innen zu erkennen. Ergebnisse Von 312 eingeschlossenen Patient*innen wurde bei 17,9 % eine Sepsis diagnostiziert. Der qSOFA-Score erkannte eine Sepsis mit einer AUROC von 0,77 (NEWS2 0,81). Für qSOFA fand sich eine Sensitivität von 57 % (Spezifität 83 %), für NEWS2 96 % (Spezifität 45 %). Die Analyse der einzelnen Vitalparameter zeigte, dass unter Patient*innen mit einer akuten Infektion eine Vigilanzminderung als deutliches Warnsignal für eine Sepsis zu werten ist. Diskussion In der Notfallmedizin sollte qSOFA nicht als alleiniges Tool für das Screening auf Sepsis verwendet werden. Bei Verdacht auf eine akute Infektion sollten grundsätzlich sämtliche Vitalparameter erfasst werden, um das Vorliegen einer akuten Organschädigung und somit einen septischen Krankheitsverlauf frühzeitig zu erkennen. Graphic abstract

Zusammenfassung Hintergrund In Deutschland gibt es bisher keine Gesundheitsberichterstattung zu sektorenübergreifenden Versorgungsverläufen im Kontext einer Notaufnahmeversorgung. Das Projekt INDEED (Inanspruchnahme und sektorenübergreifende Versorgungsmuster von Patienten in Notfallversorgungsstrukturen in Deutschland) erhebt Routinedaten aus 16 Notaufnahmen, die mit ambulanten Abrechnungsdaten der Jahre 2014 bis 2017 personenbezogen zusammengeführt werden. Ziel der Arbeit Die methodischen Herausforderungen der Planung der internen Zusammenführung von klinischen und administrativen Routinedaten aus Notaufnahmen in Deutschland bis zur finalen Datenextraktion werden hier gemeinsam mit Lösungsansätzen dargestellt. Methodik Die Auswahl der Notaufnahmedaten erfolgte in einem iterativen Prozess unter Berücksichtigung der Forschungsfragen, medizinischen Relevanz und angenommenen Datenverfügbarkeit. Nach einer Vorbereitungsphase zur Klärung der Rahmenbedingungen (u. a. Datenschutz, Ethik), zur Prüfung von Testdaten und ggf. Korrekturen, erfolgte die verschlüsselte und pseudonyme Datenausleitung. Ergebnisse Die Daten der 16 kooperierenden Notaufnahmen stammten in der Regel aus dem Notaufnahme- und dem Krankenhausinformationssystem. Die Datenlage war sehr heterogen. Nicht alle Variablen waren in jeder Notaufnahme verfügbar, da sie beispielsweise nicht standardisiert und digital vorlagen oder der Extraktionsaufwand als zu hoch bewertet wurde. Schlussfolgerung Relevante Daten aus Notaufnahmen liegen unterschiedlich strukturiert und in mehreren IT-Systemen vor. Die notwendige Bildung eines klinikübergreifenden vergleichbaren Datensatzes erfordert erhebliche Ressourcen auf Seiten der Kliniken sowie der datenaufbereitenden Stelle. Dies muss für zukünftige Projekte großzügig kalkuliert werden.

Coronavirus disease 2019 (COVID-19) is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Type I interferons are important in the defense of viral infections. Recently, neutralizing IgG auto-antibodies against type I interferons were found in patients with severe COVID-19 infection. Here, we analyzed expression of CD169/SIGLEC1, a well described downstream molecule in interferon signaling, and found increased monocytic CD169/SIGLEC1 expression levels in patients with mild, acute COVID-19, compared to patients with severe disease. We recommend further clinical studies to evaluate the value of CD169/SIGLEC1 expression in patients with COVID-19 with or without auto-antibodies against type I interferons.

Zusammenfassung Fragestellung Welche prädiktiven Faktoren lassen sich für die Gruppe der sog. Mehrfachnutzer (MFN; 4 und mehr Inanspruchnahmen einer Notaufnahme [NA] in den letzten 12 Monaten) finden? Sind Personen mit Migrationshintergrund häufiger in die Gruppe der MFN einzuordnen? Methodik Konsekutive Patienten, die von Juli 2017 bis Juli 2018 drei Klinik-NA in Berlin aufsuchten. Mittels Fragebogen Erfassung von Erkrankungen, Gründen für den NA-Besuch und sozioökonomischen Faktoren. Die Unterschiede zwischen Migranten (1. Generation), ihren Nachkommen (2. Generation) und Nichtmigranten wurden mithilfe der logistischen Regression bewertet. Ergebnisse 2339 Patienten konnten in die Auswertung einbezogen werden (Rücklaufrate 56 %), davon hatten 901 einen Migrationshintergrund. Bei jungen Frauen ( Schlussfolgerung MFN belasten das ohnehin zunehmende Patientenvolumen von NA. Sie stellen jedoch eine heterogene Patientengruppe dar, unter der Menschen mit Migrationshintergrund nicht häufiger vertreten sind. Weitere Untersuchungen sind erforderlich, um die Faktoren, die zu einer häufigen Inanspruchnahme führen, besser zu verstehen und wirksame Strategien zu entwickeln, um den komplexen Gesundheitsbedürfnissen von MFN gerecht zu werden.

Background In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. Methods Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). Results A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was − 14% [CI (− 11)–(− 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [− 16%; CI (− 13)–(− 19)], less urgent [− 18%; CI (− 12)–(− 22)] and non-admitted cases [− 17%; CI (− 13)–(− 20)] in particular during the second wave. During the entire observation period admissions for chest pain [− 13%; CI (− 21)–2], myocardial infarction [− 2%; CI (− 9)–11] and heart failure [− 2%; CI (− 10)–6] were less affected and remained comparable to the previous year. Conclusions ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies. Graphical abstract

Background Rational use of antibiotics (AB) and infection prevention and control (IPC) are key measures for reducing antimicrobial resistance (AMR) in healthcare. Nonetheless, transferring evidence into clinical practice in emergency medicine has proven difficult. The extent to which structural requirements for implementing AMR control exist in German emergency departments (ED) was determined in a survey. Methods Aspects of antimicrobial stewardship (AMS) and IPC implementation were surveyed within the German Association for Emergency Medicine (Deutsche Gesellschaft interdisziplinäre Notfall- und Akutmedizin e.V, DGINA) in 2018. Data were collected using an anonymous online questionnaire on ED characteristics, ED-based-link personnel for IPC and AMS, education and training, process monitoring and specific requirements for AMS and IPC as availability of AMR data and alcohol-based hand rub (AHR) consumption data. Data were analysed descriptively. Results 66 EDs with in median [interquartile range (IQR)] of 30,900 [23,000; 40,000] patient visits participated in the survey. EDs’ healthcare worker (HCW) received regular training on hand hygiene (HH) in 67% and on AMS in 20% of EDs. Surveillance of AHR consumption was performed by 73% EDs, surveillance of AB consumption by 64%. Regular audits on HH were performed in 39%. Training and audit activities, showed no significant variations according to EDs’ organizational characteristics. HCWs received immediate feedback of HH performance in 29%, in 23% a regular structured feedback of HH was provided. ED-based physicians with (1) specific IPC responsibilities and training were available in 61%, with (2) AMS training and responsibility in 15%. 83% had ED based IPC link nurses with precise IPC responsibilities in place. Essentially resistance data existed at the hospital level (74%) rather than at ED- or regional level (15% and 14% respectively). Conclusions Management of AMR varies in German EDs, especially in accordance to hospital size and level of emergency care. IPC seems to receive more attention than AMS. Our data indicate the need for more implementation of regular IPC and AMS training in connection with monitoring and feedback in German EDs.

In recent years, utilization of emergency departments (EDs) has increased continuously, both in Germany and internationally. Inappropriate use of EDs is believed to be partly responsible for this trend. The topic of doctor-patient interaction (DPI) has received little attention in research. However, successful DPI is not only important for adherence and treatment success, but also for the satisfaction of medical staff. This non-interventionl cross-sectional study attempts to identify factors influencing physicians' satisfaction with DPIs, with a particular focus on the appropriate utilization of EDs and verbal communication. We carried out tripartite data collection in three EDs of major referral hospitals in Berlin between July 2017 and July 2018. Migration experience, communication and language problems, level of education, and a large gap between physicians' and patients' perceived urgency regarding the utilization of EDs influence the quality of the doctor-patient relationships and interactions., In den letzten Jahren hat die Inanspruchnahme von klinischen Notaufnahmen (KNA) sowohl in Deutschland als auch international kontinuierlich zugenommen. Es wird angenommen, dass unangemessene Inanspruchnahmen von KNA mitverantwortlich für diesen Trend sind. Das Thema Arzt-Patient-Interaktion (API) ist in diesem Zusammenhang in der Forschung bisher wenig beachtet worden. Eine erfolgreiche API ist aber nicht nur für die Adhärenz und den Behandlungserfolg wichtig, sondern auch für die Zufriedenheit des medizinischen Personals. Im Rahmen einer nichtinterventionellen Querschnittsstudie wurden Einflussfaktoren auf die Zufriedenheit von Ärzten mit der API identifiziert, mit einem besonderen Fokus auf der angemessenen Nutzung von KNA und der verbalen Kommunikation. Zwischen Juli 2017 und Juli 2018 wurde in 3 großstädtischen KNA in Berlin eine dreigliedrige Datenerhebung durchgeführt. Migrationserfahrung, Kommunikations- und Sprachprobleme, Bildungsniveau und eine erhebliche Diskrepanz bei der wahrgenommenen Dringlichkeit der KNA-Inanspruchnahme beeinflussen die Qualität der Arzt-Patient-Beziehung und der Interaktion.

Supplemental Digital Content is available in the text., OBJECTIVES: The rapid diagnosis of acute infections and sepsis remains a serious challenge. As a result of limitations in current diagnostics, guidelines recommend early antimicrobials for suspected sepsis patients to improve outcomes at a cost to antimicrobial stewardship. We aimed to develop and prospectively validate a new, 29-messenger RNA blood-based host-response classifier Inflammatix Bacterial Viral Non-Infected version 2 (IMX-BVN-2) to determine the likelihood of bacterial and viral infections. DESIGN: Prospective observational study. SETTING: Emergency Department, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Germany. PATIENTS: Three hundred twelve adult patients presenting to the emergency department with suspected acute infections or sepsis with at least one vital sign change. INTERVENTIONS: None (observational study only). MEASUREMENTS AND MAIN RESULTS: Gene expression levels from extracted whole blood RNA was quantified on a NanoString nCounter SPRINT (NanoString Technologies, Seattle, WA). Two predicted probability scores for the presence of bacterial and viral infection were calculated using the IMX-BVN-2 neural network classifier, which was trained on an independent development set. The IMX-BVN-2 bacterial score showed an area under the receiver operating curve for adjudicated bacterial versus ruled out bacterial infection of 0.90 (95% CI, 0.85–0.95) compared with 0.89 (95% CI, 0.84–0.94) for procalcitonin with procalcitonin being used in the adjudication. The IMX-BVN-2 viral score area under the receiver operating curve for adjudicated versus ruled out viral infection was 0.83 (95% CI, 0.77–0.89). CONCLUSIONS: IMX-BVN-2 demonstrated accuracy for detecting both viral infections and bacterial infections. This shows the potential of host-response tests as a novel and practical approach for determining the causes of infections, which could improve patient outcomes while upholding antimicrobial stewardship.

BACKGROUND AND IMPORTANCE Differences between men and women visiting the emergency department (ED) with nonsurgical complaints have mostly been investigated in small, diagnosis-based subpopulations. OBJECTIVE This study investigated sex-differences in an unselected cohort of nonsurgical ED patients. DESIGN Secondary data of all patients attending two EDs of the Charite, Universitatsmedizin Berlin collected in the framework of their medical evaluation was reviewed. SETTINGS AND PARTICIPANTS Within a 1-year-period all 34 333 adult internal patients presenting to one of the two EDs were included and analysed. OUTCOMES MEASURE AND ANALYSES Sex-stratified descriptive analysis of the in-hospital course and outcome of the ED patients was performed as primary endpoint. Admission data, ED processes and diagnoses were analyzed as secondary endpoints. MAIN RESULTS A total of 51.2% of all patients were women. Women were slightly younger (median 56 years vs. men 58 years; P < 0.001) and presented more frequently with abdominal pain and headache. Men rather showed chest pain and dyspnea. Accordingly, women had more gastroenterological diseases; men were more often diagnosed with cardiological and pneumological diseases. Women were less frequently admitted for inpatient treatment [35.3 vs. men 43.7%; difference 8.4 percentage points (95% confidence interval (CI), 7.3-9.4)] and intensive care treatment [5.8 vs. men 9.0%; difference 3.2 percentage points (95% CI, 2.7-3.8)]. Inpatient-mortality did not show significant sex differences [4.6 women vs. 4.8% men; difference 0.2 percentage points (95% CI, -0.6 to 0.8)]. CONCLUSIONS There are significant differences in characteristics, symptoms, diagnoses and clinical course between men and women. Further investigations could identify causes and measures like sex-specific algorithms for ED-work processes.

BACKGROUND: In the emergency department (ED) setting, rapid testing for SARS-CoV-2 is likely associated with advantages to patients and healthcare workers, for example, enabling early but rationale use of limited isolation resources. Most recently, several SARS-CoV-2 rapid point-of-care antigen tests (AGTEST) became available. There is a growing need for data regarding their clinical utility and performance in the diagnosis of SARS-CoV-2 infection in the real life setting EDs. METHODS: We implemented AGTEST (here: Roche/SD Biosensor) in all four adult and the one paediatric EDs at Charité - Universitätsmedizin Berlin in our diagnostic testing strategy. Test indication was limited to symptomatic suspected COVID-19 patients. Detailed written instructions on who to test were distributed and testing personnel were trained in proper specimen collection and handling. In each suspected COVID-19 patient, two sequential deep oro-nasopharyngeal swabs were obtained for viral tests. The first swab was collected for nucleic acid testing through SARS-CoV-2 real-time reverse transcriptase (rt)-PCR diagnostic panel (PCRTEST) in the central laboratory. The second swab was collected to perform the AGTEST. Analysis of routine data was prospectively planned and data were retrieved from the medical records after the inclusion period in the adult or paediatric ED. Diagnostic performance was calculated using the PCRTEST as reference standard. False negative and false positive AGTEST results were analysed individually and compared with viral concentrations derived from the calibrated PCRTEST. RESULTS: We included n = 483 patients including n = 202 from the paediatric ED. N = 10 patients had to be excluded due to missing data and finally n = 473 patients were analysed. In the adult cohort, the sensitivity of the AGTEST was 75.3 (95%CI: 65.8/83.4)% and the specificity was 100 (95%CI: 98.4/100)% with a SARS-CoV-2 prevalence of 32.8%; the positive predictive value was 100 (95%CI: 95.7/100)% and the negative predictive value 89.2 (95%CI: 84.5/93.9)%. In the paediatric cohort, the sensitivity was 72.0 (95%CI: 53.3/86.7)%, the specificity was 99.4 (95%CI:97.3/99.9)% with a prevalence of 12.4%; the positive predictive value was 94.7 (95%CI: 78.3/99.7)% and the negative predictive value was 96.2 (95%CI:92.7/98.3)%. Thus, n = 22 adult and n = 7 paediatric patients showed false negative AGTEST results and only one false positive AGTEST occurred, in the paediatric cohort. Calculated viral concentrations from the rt-PCR lay between 3.16 and 9.51 log10 RNA copies/mL buffer. All false negative patients in the adult ED cohort, who had confirmed symptom onset at least seven days earlier had less than 5 × 105 RNA copies/mL buffer. CONCLUSIONS: We conclude that the use of AGTEST among symptomatic patients in the emergency setting is useful for the early identification of COVID-19, but patients who test negative require confirmation by PCRTEST and must stay isolated until this result becomes available. Adult patients with a false negative AGTEST and symptom onset at least one week earlier have typically a low SARS-CoV-2 RNA concentration and are likely no longer infectious.

The interaction of extracellular matrix (ECM) components with hepatic stellate cells (HSCs) is thought to perpetuate fibrosis by stimulating signaling pathways that drive HSC activation, survival and proliferation. Consequently, disrupting the interaction between ECM and HSCs is considered a therapeutical avenue although respective targets and underlying mechanisms remain to be established. Here we have interrogated the interaction between type VI collagen (CVI) and HSCs based on the observation that CVI is 10-fold upregulated during fibrosis, closely associates with HSCs in vivo and promotes cell proliferation and cell survival in cancer cell lines. We exposed primary rat HSCs and a rat hepatic stellate cell line (CFSC) to soluble CVI and determined the rate of proliferation, apoptosis and fibrogenesis in the absence of any additional growth factors. We find that CVI in nanomolar concentrations prevents serum starvation-induced apoptosis. This potent anti-apoptotic effect is accompanied by induction of proliferation and acquisition of a pronounced pro-fibrogenic phenotype characterized by increased α-smooth muscle actin, TGF-β, collagen type I and TIMP-1 expression and diminished proteolytic MMP-13 expression. The CVI-HSC interaction can be disrupted with the monomeric α2(VI) and α3(VI) chains and abrogates the activating CVI effects. Further, functional relevant α3(VI)—derived 30 amino acid peptides lead to near-complete inhibition of the CVI effect. In conclusion, CVI serves as a potent mitogen and activating factor for HSCs. The antagonistic effects of the CVI monomeric chains and peptides point to linear peptide sequences that prevent activation of CVI receptors which may allow a targeted antifibrotic therapy.

Die notfallmedizinische Versorgung wird in Deutschland zunehmend in Notfalleinheiten an Krankenhausern zentralisiert, und dieser Prozess wird durch die Ansiedlung von Bereitschaftspraxen der kassenarztlichen Vereinigungen (KV) an oder in den Krankenhausern beschleunigt. In diesen Notfallzentren steigen deswegen die Zahlen von Patienten mit geringer Gefahrdung als auch von Patienten mit lebensbedrohlichen Notfallen kontinuierlich an. Die Zentralisierung hat aber noch nicht dazu gefuhrt, dass die beiden Sektoren der Notfallversorgung ihre Versorgungsprozesse verlasslich verzahnen und aufeinander abstimmen. In dieser Situation ist die Patientensicherheit nur gewahrleistet, wenn sofort nach Eintreffen in einem Notfallzentrum eine Ersteinschatzung bezuglich der weiteren Behandlungsdringlichkeit erfolgt, die die Weiterversorgung strukturiert. Hierzu stehen im Krankenhaus pflegebasierte, strukturierte und validierte Ersteinschatzungssysteme zur Verfugung, die in diesem Positionspapier von der Deutschen Gesellschaft Interdisziplinare Notfall- und Akutmedizin (DGINA) zum Einsatz in den Notfallzentren empfohlen werden. Vergleichbare Ersteinschatzungstools existieren fur KV-Bereitschaftspraxen nicht, und die Krankenhausersteinschatzung ist auch nicht daraufhin evaluiert, ob sie eine Verweisung von Patienten in eine andere Notfallversorgungseinheit mit anderen Versorgungsprinzipien gefahrlos erlauben. Auf Basis dieser Ausgangslage fordert die DGINA in Bezug auf die Ersteinschatzung die Beachtung folgender 5 Punkte zur Erhaltung der Patientensicherheit in deutschen Notfallzentren.

In deutschen Notaufnahmen werden aktuell etwa 22 Mio. Patienten pro Jahr behandelt, ohne dass eine strukturierte Qualitatssicherung oder ein Qualitatsmanagement anhand nationaler Qualitatsindikatoren existiert. Ziel der vorliegenden Arbeit ist die Beschreibung der Ergebnisse einer erstmaligen standardisierten Bewertung von international etablierten Qualitatsindikatoren, welche potenziell in deutschen Notaufnahmen Anwendung finden konnten. Ausgehend von einer Literaturrecherche wurde eine Auswahl von 35 potenziellen Qualitatsindikatoren zu verschiedenen Prozessen einer Notaufnahme zunachst standardisiert mittels QUALIFY bewertet und in einem zweiten Durchgang interprofessionell diskutiert. Hierzu wurde eine 14-kopfige Arbeitsgruppe gebildet. Die Auswertung und Ergebnisdarstellung erfolgte fur beide Bewertungsmethoden mittels deskriptiver Statistik und Ergebniszusammenfassung. Der Vergleich beider Methoden wurde im Sinne einer Paralleltestubereinstimmung mittels Cronbach’s α ermittelt. Die Ergebnisse wurden zusatzlich in einem Indikatorregister angegeben. Bei 20 von 35 Qualitatsindikatoren wurden uberwiegend Starken in den zu bewertenden QUALIFY-Kriterien gesehen. Bei 11 Qualitatsindikatoren sah die Arbeitsgruppe Schwachen im Rahmen der Anwendung in deutschen Notaufnahmen. Die Ergebnisse der anonymen QUALIFY-Methode und diejenigen der offenen Diskussion waren zu 89 % kongruent (Cronbach’s α = 0,865). Durch die offene Diskussion wurden 46 % (16/35) der betrachteten Qualitatsindikatoren zusatzlich prazisiert und 20 % (7/35) wesentlich modifiziert. QUALIFY erlaubt eine schnelle und strukturierte Bewertung potenzieller Qualitatsindikatoren fur Notaufnahmen aus publizierten Versorgungsleitlinien bzw. einer Literaturrecherche und vermeidet einen Bias durch Beeinflussung der Experten untereinander. Die offene Diskussion ist zwar zeitaufwandiger, liefert als Ergebnis jedoch klar definierte und ausformulierte Kennzahlen fur ein Indikatorregister. Dabei zeigen beide Methoden einen hohen Grad an Ubereinstimmung. Vor der Implementierung der bewerteten Qualitatsindikatoren in standardisierte Qualitatssicherungsprogramme steht ihre wissenschaftliche Evaluation anhand nationaler Daten aus Notaufnahmen aus.

Zusammenfassung Ziel der Studie: Die Anzahl der Patienten in den Notaufnahmen der Krankenhäuser steigt stetig. Die Beweggründe der Patienten für die Inanspruchnahme von Notaufnahmen wurden in Deutschland bisher wenig untersucht und stützen sich vorwiegend auf Vermutungen. Durch direkte Befragung sollten daher die Gründe für die eigenständige Vorstellung von Notfallpatienten in Notaufnahmen untersucht werden. Methodik: An 2 Berliner Krankenhäusern der Maximalversorgung wurden 2 010 Patienten standardisiert innerhalb eines Zeitraums von 4 Wochen mithilfe eines Fragebogens anonym befragt. Dabei wurden nur Patienten einbezogen, die selbständig die Notaufnahme aufsuchten. Die Befragungsdaten wurden deskriptiv ausgewertet. Ergebnisse: Über 90% der Patienten betrachteten sich selbst als Notfall und drei Viertel gaben Schmerzen an. Die Mehrzahl der Patienten (57%) hatte zuvor versucht, während der regulären Praxisöffnungszeiten einen niedergelassenen Arzt zu erreichen. Die Patienten würden mehrheitlich (59%) Notfallstrukturen der KV nutzen, wenn sie vorhanden und bekannt wären. Allerdings kannten 55% der Befragten den KV-Notdienst nicht. Schlussfolgerung: Die Ergebnisse zeigen, dass ambulante Notfallstrukturen als zentrale Anlaufstellen an Notfallkrankenhäusern rund um die Uhr erforderlich sind. Die zukünftige Planung der Notfallversorgung muss daher sektorenübergreifend ausgerichtet sein. International bereits eingesetzte Instrumente zur Einbindung von integrierten Telefonzentralen, Ausweitung des ambulanten Angebots und Schaffung von Strukturen für weniger dringliche Fälle an oder in Krankenhäusern sollten im Sinne einer besseren Steuerung der Patientenströme auch in Deutschland implementiert werden.

BACKGROUND Agitation is common in geriatric patients with dementia (PWD) admitted to an emergency department (ED) and is associated with a higher risk of an unfavourable clinical course. Hence, monitoring of vital signs and enhanced movement is essential in these patients during their stay in the ED. Since PWD rarely tolerate fixed monitoring devices, non-contact monitoring systems might represent appropriate alternatives. OBJECTIVE To study the reliability of a non-contact monitoring system (NCMSys) and of a tent-like device (“Charité Dome”, ChD), aimed to shelter PWD from the busy ED-environment. Further, effects of the ChD on wellbeing and agitation of PWD will be measured. METHODS Both devices were attached to patient’s bed. Tests on technical reliability and other safety issues of the NCMSys and the ChD were performed at the iDoc-institute. A feasibility study evaluating the reliability of the NCMSys with and without the ChD was performed in the real-life setting of an ED and on a geriatric-gerontopsychiatric ward. Technical reliability and other safety issues were tested with six healthy volunteers. For the feasibility study 19 patients were included (ten males and nine females; mean age: 77.4 (55-93) years of which 14 were PWD. PWD inclusion criteria were age ≥55 years, a dementia diagnosis as well as a written consent (by patients themselves or by a custodian). Exclusion criteria were acute life-threatening situations and a missing consent. RESULTS Heart rate, changes in movement and sound emissions were measured reliably by the NCMSys, whereas patient movements affected respiratory rate measurements. The ChD did not impact patients’ vital signs or movements in our study setting. However, 53% of the PWD (7/13) and most of the patients without dementia (4/5) benefited from its use regarding their agitation and overall wellbeing. CONCLUSIONS NCMSys and ChD work reliably in the clinical setting and have positive effects on agitation and wellbeing. The results of this feasibility study encourages prospective studies with longer durations to further evaluate this concept for monitoring and prevention of agitation in PWD in the ED. CLINICALTRIAL ICTRP: “Charité-Dome-Study - DRKS00014737”

To assure adequate and efficient treatment in the emergency department (ED) despite increasing patient numbers, early risk stratification might be helpful for directing resource allocation. To determine whether routine clinical data can predict in-hospital mortality in nonsurgical ED patients and to specifically identify the best predictive parameters. This retrospective cohort study investigated 34,333 nonsurgical adult patients who attended one of the two participating EDs in Berlin, Germany, within 1 year. Routine clinical data were analysed for their potential to predict in-hospital mortality using logistic regression as well as classification and regression tree (CART) analysis. A validation dataset contained 35,646 patients of the following year. In-hospital mortality was 1.8 % (634/34,333). C-reactive protein (CRP) and red cell distribution width (RDW) were the best predictors of mortality. A model with nine predictors (CRP, RDW, age, potassium, sodium, WBC, platelets, RBC and creatinine) achieved an area under the receiver operating characteristic curve (AUROC) of 0.870 (95 % confidence interval, CI: 0.857–0.883). A three-marker model (CRP, RDW, age) resulted in an AUROC of 0.866 (95 % CI: 0.853–0.878). In the independent validation dataset the AUROC for this three-marker model was 0.837 (95 % CI: 0.825–0.850). CART analysis corroborated the importance of CRP and RDW, and a clinical algorithm for risk stratification was developed (Emergency Processes in Clinical Structures, EPICS score). Two different statistical procedures and independent validation revealed similar results, suggesting a combination of CRP and RDW as a score (EPICS score) for early identification of high-risk patients. This might be particularly helpful in overcrowded situations and where resources are limited. The suggested score should be validated and potentially adapted to diverse ED settings and patient populations in international multicentre trials.

Aus Notaufnahmen in Deutschland wird eine zunehmende Uberfullung berichtet, die die Prozesse belastet. Ziel der Studie ist es, Grunde fur die Uberfullung der Notaufnahmen sowie populationsbezogene Einflussfaktoren zu erfassen und so eine Datengrundlage fur evidenzbasierte Forschungs- und Losungsstrategien zu entwickeln. Dies ist eine „Mixed-methods“-Studie, die an zwei universitaren Notaufnahmen mit soziodemographisch unterschiedlichen Einzugsgebieten durchgefuhrt wurde (Notaufnahme Nord mit durchschnittlich niedrigem Sozialstatus der Bevolkerung und Notaufnahme Sud mit hoherem Sozialstatus). Die Methodik umfasst quantitative deskriptive Analysen eines Sekundardatensatzes von 34.333 Notfallpatienten und qualitative Fokusgruppeninterviews an beiden beteiligten Einrichtungen. Obwohl die Patienten der Notaufnahme Sud deutlich alter waren und haufiger stationar aufgenommen wurden, waren die Morbiditat und Krankenhausmortalitat der Notaufnahme Nord hoher. Die vom Personal genannten Grunde waren an beiden Einrichtungen sehr ahnlich und zeigten insbesondere externe und patientenbezogene Faktoren, die ein erhohtes Patientenaufkommen sowie einen erschwerten Patientenabfluss bedingen, auf. Es ergaben sich jedoch deutlich unterschiedliche Diskussionsschwerpunkte, die sich anhand der Patientenpopulation nachvollziehen lassen. In beiden Einrichtungen wurde ein erhohtes Mas an „Sicherheitsmedizin“ als Grund fur die Uberfullung genannt. Die wahrgenommenen Grunde fur die Uberfullung der Notaufnahmen liegen zu einem uberwiegenden Teil auserhalb des Einflussbereichs der Notaufnahmen und werden von den Charakteristika ihrer Patientenpopulation mit beeinflusst. Eine Losung des Problems erfordert daher Masnahmen, die uber Prozessoptimierungen in den Notaufnahmen selbst hinausgehen und im Sozial- bzw. dem Gesundheitssystem eingreifen.

Background & Aims In liver fibrosis, activated hepatic stellate cells (HSC) secrete excess extracellular matrix, thus, represent key targets for antifibrotic treatment strategies. Intermediate-conductance Ca2 + -activated K+-channels (KCa3.1) are expressed in non-excitable tissues affecting proliferation, migration and vascular resistance rendering KCa3.1 potential targets in liver fibrosis. So far, no information about KCa3.1 expression and their role in HSC exists. Aim was to quantify the KCa3.1 expression in HSC depending on HSC activation and investigation of antifibrotic properties of the specific KCa3.1 inhibitor TRAM-34 in vitro and in vivo. Methods KCa3.1 expression and functionality were studied in TGF-β1–activated HSC by quantitative real time PCR, western-blot and patch-clamp analysis respectively. Effects of TRAM-34 on HSC proliferation, cell cycle and fibrosis-related gene expression were assessed by [3H]-thymidine incorporation, FACS-analysis and RT-PCR respectively. In vivo, vascular resistance and KCa3.1 gene and protein expression were determined in bile duct ligated rats by in situ liver perfusion, Taqman PCR and immunohistochemistry respectively. Results Fibrotic tissues and TGF-β1-activated HSC exhibited higher KCa3.1-expressions than normal tissue and untreated cells. KCa3.1 inhibition with TRAM-34 reduced HSC proliferation by induction of cell cycle arrest and reduced TGF-β1-induced gene expression of collagen I, alpha-smooth muscle actin and TGF-β1 itself. Furthermore, TRAM-34 blocked TGF-β1-induced activation of TGF-β signalling in HSC. In vivo, TRAM-34 reduced the thromboxane agonist-induced portal perfusion pressure. Conclusion Inhibition of KCa3.1 with TRAM-34 downregulates fibrosis-associated gene expression in vitro, and reduces portal perfusion pressure in vivo. Thus, KCa3.1 may represent novel targets for the treatment of liver fibrosis.

Despite the success of elastography in grading hepatic fibrosis by stiffness related noninvasive markers the relationship between viscoelastic constants in the liver and tissue structure remains unclear. We therefore studied the mechanical properties of 16 human liver specimens with different degrees of fibrosis, inflammation and steatosis by wideband magnetic resonance elastography (MRE) and static indentation experiments providing the specimens׳ static Young׳s modulus (E), dynamic storage modulus (G') and dynamic loss modulus (G″). A frequency-independent shear modulus μ and a powerlaw exponent α were obtained by fitting G' and G″ using the two-parameter sprinpot model. The mechanical parameters were compared to the specimens׳ histology derived parameters such as degree of Fibrosis (F), inflammation score and fat score, amount of hydroxyproline (HYP) used for quantification of collagen, blood markers and presurgery in vivo function tests. The frequency averaged parameters G', G″ and μ were significantly correlated with F (G': R=0.762, G″: R=0.830; μ: R=0.744; all P

Purpose To assess induced oscillating volumetric strain as a biomarker for intrahepatic blood pressure abnormalities. Materials and Methods Harmonic vibrations of 25 and 50 Hz frequency were induced in the liver and measured by fast 3D vector field magnetic resonance elastography (MRE), followed by processing of the decomposed curl (shear) and divergence (compression) fields. After an initial study on an excised sheep liver, a group of 13 patients with hepatic hypertension were examined before and after implantation of a transjugular intrahepatic portosystemic shunt (TIPS). Results In the sheep liver specimen, volumetric strain decreased with excess portal pressure, whereas shear strain was not sensitive to portal pressure. In the patient cohort, volumetric strain was significantly higher after TIPS placement (P = 1.38·10−5), while neither shear strain nor the shear modulus were affected. Normalized changes in volumetric strain were significantly correlated with the hepatic venous pressure gradient (R2 = 0.7258, P = 6.95·10−5) and portal venous pressure (R2 = 0.5028, P = 0.0016). Conclusion These results indicate for the first time the sensitivity of volumetric strain to symptomatically high values of tissue pressure and motivate further developments in compression-sensitive MRE and poroelastography towards image-based and noninvasive markers of tissue pressure. J. Magn. Reson. Imaging 2014;39:298–306. © 2013 Wiley Periodicals, Inc.

The number of patients visiting emergency departments (ED) is steadily increasing. The cause for this rise in Germany is unclear and less examined. This study aimed to assess the reasons of walk-in patients to visit EDs by using a direct survey.During a period of 4 weeks, 2 010 walk-in patients were anonymously surveyed in 2 major Berlin hospitals using a standardized questionnaire. Descriptive statistics were used for data analysis.More than 90% of patients assessed themselves as an emergency and three-quarters of patients reported pain. The majority of patients (57%) tried to contact statutory health insurance (SHI) office-based physicians in advance and 59% of patients said they would make use of ambulatory emergency facilities if they were available and well established. However, 55% of patients were unaware of the emergency service of the association of SHI physicians.The results indicate that centralized ambulatory emergency facilities should be available 24/7 at hospitals with EDs. Therefore, future planning of emergency services should integrate providers of ambulatory and inpatient sector. International experience suggests that different instruments aiming at better coordination of care, such as integrated call centers, extended ambulatory services and facilities for less urgent cases located in or nearby hospitals with EDs should also be implemented in Germany.Die Anzahl der Patienten in den Notaufnahmen der Krankenhäuser steigt stetig. Die Beweggründe der Patienten für die Inanspruchnahme von Notaufnahmen wurden in Deutschland bisher wenig untersucht und stützen sich vorwiegend auf Vermutungen. Durch direkte Befragung sollten daher die Gründe für die eigenständige Vorstellung von Notfallpatienten in Notaufnahmen untersucht werden.An 2 Berliner Krankenhäusern der Maximalversorgung wurden 2 010 Patienten standardisiert innerhalb eines Zeitraums von 4 Wochen mithilfe eines Fragebogens anonym befragt. Dabei wurden nur Patienten einbezogen, die selbständig die Notaufnahme aufsuchten. Die Befragungsdaten wurden deskriptiv ausgewertet.Über 90% der Patienten betrachteten sich selbst als Notfall und drei Viertel gaben Schmerzen an. Die Mehrzahl der Patienten (57%) hatte zuvor versucht, während der regulären Praxisöffnungszeiten einen niedergelassenen Arzt zu erreichen. Die Patienten würden mehrheitlich (59%) Notfallstrukturen der KV nutzen, wenn sie vorhanden und bekannt wären. Allerdings kannten 55% der Befragten den KV-Notdienst nicht.Die Ergebnisse zeigen, dass ambulante Notfallstrukturen als zentrale Anlaufstellen an Notfallkrankenhäusern rund um die Uhr erforderlich sind. Die zukünftige Planung der Notfallversorgung muss daher sektorenübergreifend ausgerichtet sein. International bereits eingesetzte Instrumente zur Einbindung von integrierten Telefonzentralen, Ausweitung des ambulanten Angebots und Schaffung von Strukturen für weniger dringliche Fälle an oder in Krankenhäusern sollten im Sinne einer besseren Steuerung der Patientenströme auch in Deutschland implementiert werden.

BACKGROUND The development of liver graft disease is partially determined by individual genetic background. Interleukin 28B (IL28B) is strongly suspected to be involved in susceptibility for hepatitis C virus (HCV) infection, inflammation, and antiviral treatment response before and after liver transplantation (LT). Currently, the role of IL28B polymorphism (rs12979860) in the development of hepatocellular carcinoma (HCC) is unclear, and only limited data are available on the course of HCV recurrence. METHODS One hundred sixty-seven HCV-positive patients after LT were genotyped for IL28B (C→T; rs12979860). Sixty-one patients with histologically confirmed HCC in the explanted liver were compared with 106 patients without HCC regarding IL28B genotypes. Among patients with HCC, IL28B genotypes were correlated with tumor histology and pretransplant α-fetoprotein (AFP) levels. Furthermore, the role of IL28B polymorphism was evaluated regarding interferon-based treatment success and fibrosis progression after LT. RESULTS The prevalence of HCC in explanted livers was significantly higher among patients with TT genotype, suggesting a protective role of the C allele in HCC development (P=0.041). Median AFP level was closely to significance higher in the presence of T allele (P=0.052). Significant differences in IL28B genotype distribution were detected between AFP-negative and AFP-positive HCCs ( 15 μg/L; P=0.008). Although no impact could be observed regarding acute cellular rejection (P=0.940), T allele was significantly associated with antiviral therapy failure (P=0.028) and faster development of advanced fibrosis (P=0.017) after LT. CONCLUSION IL28B polymorphism seems to be involved in the development of HCV-induced HCC and in the course of HCV recurrence after LT. T allele may be regarded as a genetic risk factor for HCV-related carcinogenesis, posttransplant fibrosis progression, and antiviral therapy failure.

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide. Treatment options, especially in advanced tumor stages, are still limited. Inhibition of signaling cascades involved in the pathogenesis of HCC - such as NF-ĸB - offer a promising therapeutic approach. Aim of this study was to examine anti-neoplastic effects of (+)-episesamin which has been isolated from an anti-fibrotic extract of Lindera obtusiloba on human HCC cells with particular interest in activation of NF-κB. The human HCC cell lines HepG2, Huh-7 and SK-Hep1 were treated with (+)-episesamin. Beside measurement of proliferation, invasion and apoptosis, effects of (+)-episesamin on NF-κB-activity, VEGF secretion and enzymatic MMP-9 activity were determined. Anti-inflammatory effects were assessed by IL-6 ELISA using HCC cells and RAW264.7 macrophages. 10 μM (+)-episesamin reduced the proliferation of HCC cells by ~50%, suppressed invasion and induced apoptosis. DNA-binding ELISA experiments revealed that (+)-episesamin treated HCC cells showed a suppressed basal and TNFα-induced activation of NF-κB and a subsequent suppression of TNFα- and LPS-induced IL-6 production. Further, (+)-episesamin exhibited inhibitory effects on the enzymatic activity of recombinant MMP-9 and the secretion of MMP-9 and VEGF by HCC cells into their supernatants. Our findings show that anti-neoplastic effects of (+)-episesamin are mediated via suppressed activation of NF-κB which entails a decreased release of pro-inflammatory IL-6. In addition, (+)-episesamin inhibits MMP-9, which is strongly expressed in invasive HCC, and the production of proangiogenic VEGF. We conclude that (+)-episesamin has the potential to be further explored as a complementary treatment for HCC.

Fractionation of a 70% ethanolic extract from twigs of Lindera obtusiloba BLUME (Japanese spicebush, Tohaku) yielded fi ve fractions of different polarity. The antifi brotic activity within the chloroform phase was best assessed by an in vitro bioassay using rat hepatic stellate cell (HSC) proliferation and their autocrine transforming growth factor beta (TGF-β) expression as sensitive fi brosis-associated read out. Chromatography of the chloroform extract on Sephadex LH-20 or liquid-liquid extractions yielded a crystalline compound as an active principle, which was identifi ed from NMR and ESI-MS analyses, its melting point, and its optical rotation as (7S,7´R,8R,8´R)-3,4:3´,4´-bis(methylenedioxy)-7,9´:7´,9-diepoxy-lignane [(+)-episesamin]. X-Ray diffraction confi rmed the structure and provided, for the fi rst time, directly its absolute confi guration. (+)-Episesamin blocked proliferation and the profi brotic autocrine TGF-β expression HSC without signifi cant cytotoxicity.

Background: Development of end-stage liver and graft disease is suspected to be partially determined by the individual genetic background. Mannose-binding lectin (MBL) is an important immunomodulatory factor, which is supposed to be involved in complement activation and oncogenesis. Genetic polymorphisms of MBL-2 alter MBL functionality. The aim of our study was to determine the prevalence of MBL-2 polymorphism (rs7096206) in hepatitis C virus (HCV)-induced hepatocellular carcinoma (HCC) based on histological analysis of explanted livers in patients undergoing liver transplantation (LT). Methods: One hundred and seventy-seven patients, who underwent LT for HCV-induced liver disease, were genotyped for MBL-2 by TaqMan genotyping assay. Sixty-two patients with histologically confirmed HCC were compared with 115 patients without HCC. MBL-2 genotypes were corelated with the growth patern, tumour size and pretransplant α-fetoprotein (AFP) level of HCC patients. Results: The prevalence of GG/GC genotypes was significantly higher among HCC patients compared with tumour-free explanted livers (P=0.004; odds ratio 2.5; 1.3–4.8). GG/GC genotype group was significantly associated with the size of HCC (P=0.022), higher pretransplant AFP level (P=0.010) and bilobar tumour growth (P=0.038). Furthermore, CC genotype was found to be significantly more frequent in AFP-negative HCCs (P=0.002). Conclusion: Mannose-binding lectin-2 polymorphism seems to be involved in the development of pretransplant HCV-induced HCC and should be further investigated as potential risk factor for HCV-associated carcinogenesis.

Obesity, the related metabolic syndrome and associated liver diseases represent an epidemic problem and demand for effective therapeutic strategies. In this regard, natural compounds derived from Oriental medicine such as green tea polyphenols influencing adipogenesis attract growing attention. In Korea, an aqueous extract from the Japanese spice bush Lindera obtusiloba is traditionally used for treatment of inflammation and prevention of liver damage. We here investigated effects of the L. obtusiloba extract on cell growth, apoptosis, Wnt signaling and differentiation of (im)mature adipocytes using 3T3-L1, an established cell line for studying adipogenesis. L. obtusiloba extract reduced the de novo DNA synthesis of 3T3-L1 preadipocytes in a concentration dependent manner with an IC(50) of ∼135 μg/ml paralleled by induction of caspase 3/7 mediated apoptosis. Hormone-induced 3T3 L1 differentiation in the presence of L. obtusiloba extract resulted in a reduced accumulation of intracellular lipid droplets by 70%, in down-regulated expression of the adipogenesis-associated proteins glucose transporter-4 and vascular endothelial growth factor, in reduced secretion of the proadipogenic matrix metalloproteinase-2, and in dampened phosphorylation of the Wnt pathway effector protein β-catenin with subsequent diminished expression of the peroxisome proliferator-activated receptor-γ. Treatment of mature adipocytes with L. obtusiloba extract also significantly reduced intracellular lipid droplets. In addition to this strong interference of L. obtusiloba extract with adipogenesis, L. obtusiloba extract exerted anti-inflammatory effects. L. obtusiloba extract significantly attenuated lipopolysaccharide- and tumor necrosis factor α-induced secretion of IL-6 by preadipocytes, thus influencing insulin resistance and inflammatory state characterizing obesity. In conclusion, extracts of L. obtusiloba should be evaluated as a potential complementary treatment option for obesity associated with the metabolic syndrome.

To analyze the dynamics of the shear modulus of the liver to assess the optimal driving frequency and to determine the diagnostic accuracy of generalized frequency-independent elasticity cutoff values for staging hepatic fibrosis.This institutional review board-approved prospective study included 16 healthy volunteers and 72 patients with biopsy-proved liver fibrosis. After obtaining written informed consent, imaging was performed at 1.5-T by using a motion-sensitized echo-planar imaging sequence. Wave excitation was performed by an actuator introducing a superposition of four frequencies (25.0, 37.5, 50.0, 62.5 Hz) of shear waves. The elasticity µ value and the structure geometry parameter α were calculated by using the two-parameter springpot model. The performance of magnetic resonance (MR) elastography in staging liver fibrosis was assessed with area under the receiver operating characteristic curve (AUROC) analysis and Spearman correlation analysis.Elasticity increased with stage of fibrosis, with mean values as follows: for volunteers, 2.25 kPa ± 0.43 (standard deviation); stage F1, 2.61 kPa ± 0.43; stage F2, 3.00 kPa ± 0.63; stage F3, 3.86 kPa ± 0.61; and stage F4, 5.86 kPa ± 1.22. Frequency-independent cutoff values derived for fibrosis and AUROC values, respectively, were as follows: stage F1 or higher, 2.84 kPa and 0.9128; stage F2 or higher, 3.18 kPa and 0.9244; stage F3 or higher, 3.32 kPa and 0.9744; and equivalent to stage F4, 4.21 kPa and 0.9931. The geometry of the tissue (α value) did not correlate with fibrosis. Frequencies of 50.0 Hz and 62.5 Hz displayed the highest diagnostic accuracy.The diagnostic performance of multifrequency MR elastography in determining the degree of hepatic fibrosis increases with stage of fibrosis. Metrics obtained at the higher frequencies provide better diagnostic performance compared with the lower frequencies. Results of the AUROC analysis demonstrate the high accuracy of frequency-independent cutoff values for staging higher grades of hepatic fibrosis.

Thoraxschmerzen sind ein haufiger Grund, eine Notaufnahme aufzusuchen bzw. die Rettungsdienste zu alarmieren. Ein groser Anteil dieser Beschwerden ist kardial bedingt. Aufgrund der erheblichen Konsequenzen einer falschen Einschatzung, v. a. des akuten Koronarsyndroms (ACS), kommt der initialen Beurteilung eine hohe Bedeutung zu. Wesentlich dabei sind Anamnese, klinische Untersuchung, EKG (Elektrokardiogramm) und die Bestimmung von Biomarkern. Bereits in der Initialphase mussen aber auch nichtkardiale Ursachen wie Lungenarterienembolie (LAE), Aortendissektion oder gastrointestinale Ursachen bedacht werden. Bedeutung gewinnen die zur Risikostratifizierung bei ACS oder LAE eingesetzten Risikoscores. Insbesondere der GRACE(„global registry of acute coronary events“)- und der TIMI(„thrombolysis in myocardial infarction“)-Score sind mittlerweile fur das ACS gut validiert, sie wurden in die Leitlinien aufgenommen. Fur die Beurteilung einer LAE hat sich der Wells-Score etabliert. Letzterer sowie der GRACE- und der TIMI-Score sollten daher in Notaufnahmen vermehrt eingesetzt werden.

Die Ersteinschatzung eines Patienten, der die Notaufnahme einer Klinik aufsucht, ist von zentraler Bedeutung. Sie legt die Dringlichkeit, mit der ein Patient arztlich gesehen werden muss, sowie die anschliesenden Prozeduren und damit auch den Ressourcenverbrauch fest. Obwohl es sich bei Notaufnahmen um Hochrisikobereiche handelt, ist der Ersteinschatzungsprozess in vielen deutschen Kliniken wenig standardisiert. Durch Einsatz klinischer Triagesysteme, wie der Manchester Triage Scale, wird ein standardisierter Prozess vorgegeben, der vor allem bei vermehrtem Patientenaufkommen kritisch Kranke zielsicher und schnell identifizieren sowie in einem vorgegebenen Zeitrahmen einer Behandlung zufuhren soll. Die Datenlage, besonders hinsichtlich Zuverlassigkeit und Validitat, ist begrenzt und heterogen, wird aber zunehmend besser und stutzt damit die weitere Etablierung solcher Systeme als Instrumente des Risikomanagements auch in Deutschland. In den Studien wird aber auch evident, dass der zentrale Baustein eines gut funktionierenden Triagesystems das qualifizierte und klinisch erfahrene Personal einer Notaufnahme bleibt, ohne welches eine zuverlassige Ersteinschatzung nicht moglich ist.

PURPOSE: Recent magnetic resonance elastography (MRE) studies have reported the potential of this noninvasive method for diagnosing hepatic fibrosis based on the elastic properties of liver tissue. However, in many cases biological tissue responds to mechanical vibrations as a combined solid-liquid body causing MRE-derived elastic parameters to become functions of the applied vibration frequency. Therefore a multi-frequency MRE study of liver was performed and the potential of the method for separating healthy from fibrotic liver was investigated. The aim of this study was the increase of the accuracy of liver elastography by analyzing multi-frequency MRE examinations using the springpot model. MATERIALS AND METHODS: 18 healthy volunteers and 10 patients were examined by multi-frequency MRE of the liver in a frequency range between 25 Hz and 62.5 Hz. The liver was mechanically excited with four harmonic vibrations simultaneously. The measured dispersion of the complex modulus was analyzed using the springpot model which accounts for both elastic and viscous properties of a material with 2 independent parameters. RESULTS: The mechanical stimulation and the motion encoding according to the multi-frequency approach was implemented successfully. Significant differences (p < 0.05) were found in the hepatic viscoelasticities of normal livers. The separation of healthy volunteers and patients was achieved with a sensitivity and specificity of 80 and 100 %, respectively. CONCLUSION: Using the springpot model, multi-frequency MRE is sensitive to interindividual differences in the hepatic viscoelastic properties of healthy volunteers. The obtained accuracy of the technique in separating healthy from fibrotic livers opens the possibility of applying multi-frequency MRE as a noninvasive method for diagnosing liver fibrosis in the future.