Surface Energy and Wetting Behavior of Dolomite in the Presence of Carboxylic Acid-Based Deep Eutectic Solvents.

This study endeavors to apply experimental and theoretical analyses to assess the viability of wettability alteration for two carboxylic acid-based deep eutectic solvents (DESs). To prepare these chemicals, oxalic acid and citric acid were used as hydrogen bond donors mixed with choline chloride as the hydrogen bond acceptor in an equimolar ratio. In the theoretical part, dolomite and crude oil were characterized using a three-phase setup. Then, the adhesion propensity of brines/crude oil toward dolomite was evaluated by calculating the work of adhesion. Contact angle and interfacial tension measurements were conducted in the experimental part to investigate the impact of chemicals on brine-crude oil and brine-rock interactions. Results revealed that the oxalic acid-based DES outperformed the citric acid-based DES in terms of interfacial tension reduction. In addition, choline chloride/oxalic acid (1:1) could effectively restore the wettability of the dolomite sample to its original state with a wettability alteration index of 82%. Theoretical calculations also confirmed the wettability alteration potential of DESs. Finally, a correlation was proposed to predict the contact angle of brine on the dolomite surface in the presence of crude oil using surface-energy components of brine, crude oil, and dolomite.

[Interdisciplinary neurovascular networks: state of the art]. / Interdisziplinäre neurovaskuläre Netzwerke: eine Standortbestimmung.

BACKGROUND: In order to treat the complete spectrum of neurovascular diseases at a high level of quality, which goes beyond the purely acute treatment of stroke, the German Stroke Society (DSG) together with the German Societies for Neurosurgery and Neuroradiology developed a certification procedure for neurovascular networks (NVN). Structurally, a NVN consists of a coordinating center with at least three neurovascular network partners with a certified stroke unit. From 2018 to 2020 a total of 15 NVN have so far been audited and certified according to this new standard. OBJECTIVE: How efficient are the NVN? Are high standards maintained? MATERIAL AND METHODS: The reports of the audits were analyzed. The data were taken from the period 2017-2019. RESULTS: The 15 NVN treated a total of 86,510 stroke patients in the years examined and were networked with a total of 107 partner clinics, which were situated an average of 25 km from the coordinating center and transferred a total of 2726 patients. The coordinating centers performed 2463 thrombectomies and treated 2383 patients with nontraumatic intracerebral bleeding. In 712 patients with acute aneurysmatic subarachnoid hemorrhages endovascular treatment was carried out and clipping in 401. The audit was successful in the majority of the NVN. CONCLUSION: The certification process of NVN has been successfully established and the audits proved to be a useful instrument for quality control and improvement. The 15 NVN are highly efficient and treat more than one quarter of stroke patients in German stroke units.

[Structures of endovascular recanalization in Germany : Cross-sectional survey of certified stroke units 2016-2018]. / Strukturen der endovaskulären Rekanalisation in Deutschland : Querschnittserhebung in zertifizierten Stroke-Units 2016 bis 2018.

In this cross-sectional study data from 299 certified stroke units (SU) in Germany were analyzed from January 2016 to December 2018 and included comprehensive stroke centers (CSC 34%), local SU (62%), and telemedical SU (4%). In a total of 2487 SU monitor beds, 251,539 cases of stroke treatment were documented. The number of monitor beds (10.8 vs. 7.2) and stroke cases per year (1143 vs. 708) were significantly higher in CSC than in local SU. A total of 9251 endovascular recanalization (ER) procedures were performed annually by 475 interventionalists. The overall rate of ER was 3.7% of all stroke cases, including intracerebral hemorrhage (ICH) and transient ischemic attacks (TIA). A total of 124 of the SUs (41.5%) had a 24/7 ER structure in which 55% of all stroke treatments and 96% of all ERs were carried out. In the vast majority of CSC the ER structure was robust (≥4 interventionalists, 52%) or acceptable (3 interventionalists, 27%). In contrast, the majority of local SU (88%) had to transfer patients for ER over average distances of 40 km (range 1-160 km). Overall, the ER structures in Germany between 2016 and 2018 could be described as good to very good.

[Ability to drive with cerebrovascular diseases : Position paper of the German societies DGNB, DGN, DGNC, DGNR, DSG and GNP]. / Fahreignung bei Hirngefäßerkrankungen : Positionspapier der DGNB, DGN, DGNC, DGNR, DSG und GNP.

The regulations for ability to drive with cerebrovascular diseases in the German Driving License Regulations (Fahrerlaubnisverordnung, FeV) and German Guidelines for the Evaluation of Driving Ability of the Federal Highway Research Institute (BASt) are not up to date with the current medical knowledge and are not consistent with comparable regulations regarding cardiovascular diseases. This is particularly true for the assessment of future risks for a sudden loss of control during driving. The present position paper of six medical and neuropsychological societies in Germany presents the current conditions for the assessment of driving ability of patients a cerebrovascular diesease and recommends an estimation of the ability to drive founded on the current state of scientific knowledge. It addresses the following: 1. Physical and mental functional limitations and the possibilities for compensation, which if necessary enable a fitness to drive under conditions or within limits, including the importance of behavioral or personality changes and cognitive deficiencies that interfere with safety. 2. The potential danger due to a sudden loss of control as a result of a transient ischemic attack (TIA) new stroke event, or another cardiovascular event while driving. A summary in the form of a table provides physicians and expert assessors with assistance for the most important cerebrovascular diseases.

[Neurointensive care in Germany : Results of an inspection of intensive care units]. / Neurointensivmedizin in Deutschland : Ergebnisse einer Begehung von Intensivstationen.

BACKGROUND: The situation of neurointensive care in Germany is unclear. OBJECTIVES: An inspection of neurointensive wards should help to clarify the situation. MATERIALS AND METHODS: On the occasion of stroke unit certification audits, 320 intensive care units (39 independent neurological and 20 neurosurgical, 6 combined neurological/neurosurgical, 253 interdisciplinary intensive wards) were inspected. RESULTS: On the 39 neurological and the 20 neurosurgical intensive care units, a physician with intensive care specialization was available in 92% and 100% of units, respectively, and a physician with authorization for intensive care training was available in 74% and 80% of units, respectively. A whole day shiftwork existed in 59% and 55% of units, respectively. On the interdisciplinary wards a physician with intensive care specialization was available in 76% and a physician with authorization for intensive care training was available in 52% of units. A whole day shiftwork existed in 64% of units. A full-time neurological/neurosurgical presence during business hours was found only in 18% of units. CONCLUSIONS: The neurological/neurosurgical presence and the opportunities for intensive care training on the interdisciplinary wards are not sufficient. There is an urgent need for improvement.

[Diagnostic and treatment standards for cerebral sinus venous thrombosis : Results of an online survey of German stroke units]. / Diagnose- und Behandlungsstandards der zerebralen Sinus­/Venenthrombose : Ergebnisse einer Onlineumfrage an deutschen Stroke-Units.

BACKGROUND AND PURPOSE: The aim of this survey was to characterize the current diagnostic and therapeutic strategies for thrombosis of the cerebral sinus and veins (CVT) performed in German stroke units (SU). METHODS: Between September 2015 and January 2016 all clinical heads of certified SUs in Germany were invited to participate in a standardized online survey. The survey concentrated on the basic characteristics of SUs, diagnostic and therapeutic procedures and was made anonymous if so desired. Frequencies were expressed as percentages and differences between regional stroke units (RSU) and supraregional (i. e. comprehensive) SUs (SRSU) were compared with the χ2-test or Fisher's test RESULTS: A total of 107 SU heads participated (response rate 42.8%) and 55.1% of these were RSUs. In 77.2% the diagnosis is made by magnetic resonance imaging angiography (MR-A, RSU 81.1% vs. SRSU 72.3%; p = 0.29). Of the SUs 79.1% determined d­dimer if CVT is suspected (79.3% vs. 78.7%; p = 0.94) and 88.5% carried out screening for thrombophilia (89.5% vs. 87.2%; p = 0.72). Intravenous unfractionated heparin (67.2% vs. 70.2%; p = 0.74) or subcutaneous low molecular weight heparin (32.8% vs. 29.8%; p = 0.74) are first line therapy in all SUs. Invasive procedures, such as hypothermia (3.7% vs. 10.6%; p = 0.25), hemicraniectomy (26% vs. 63.9%; p = 0.0001), endovascular techniques (11.1% vs. 40.4%; p = 0.0007) and systemic thrombolysis (5.5% vs. 10.6%; p = 0.47) are performed more frequently in SRSUs. Of the SUs 18.5% already use new oral anticoagulants (10.7% vs. 27.7%; p = 0.027). Most of the SUs organize a follow-up visit (70.9% vs. 76.6%; p = 0.52) with a MRI (94.2% vs. 91.1%; p = 0.7) within the first 6 months. CONCLUSION: The survey revealed substantial homogeneity between RSUs and SRSUs and standards are mostly in line with the guidelines. Non-established procedures, such as invasive therapeutic procedures and the administration of new oral anticoagulants were used significantly more often in SRSUs.

[Consideration of guidelines, recommendations and quality indicators for treatment of stroke in the dataset "Emergency Department" of DIVI]. / Berücksichtigung von Leitlinien, Empfehlungen und Qualitätsindikatoren zur Schlaganfalltherapie im Datensatz Notaufnahme der DIVI.

BACKGROUND: The dataset "Emergency Department" of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) has been developed during several expert meetings. Its goal is an all-encompassing documentation of the early clinical treatment of patients in emergency departments. Using the example of the index disease acute ischemic stroke (stroke), the aim was to analyze how far this approach has been fulfilled. MATERIAL AND METHODS: In this study German, European and US American guidelines were used to analyze the extent of coverage of the datasets on current emergency department guidelines and recommendations from professional societies. In addition, it was examined whether the dataset includes recommended quality indicators (QI) for quality management (QM) and in a third step it was examined to what extent national provisions for billing are included. In each case a differentiation was made whether the respective rationale was primary, i.e. directly apparent or whether it was merely secondarily depicted by expertise. In the evaluation an additional differentiation was made between the level of recommendations and further quality relevant criteria. RESULTS: The modular design of the emergency department dataset comprising 676 data fields is briefly described. A total of 401 individual fields, divided into basic documentation, monitoring and specific neurological documentation of the treatment of stroke patients were considered. For 247 data fields a rationale was found. Partially overlapping, 78.9 % of 214 medical recommendations in 3 guidelines and 85.8 % of the 106 identified quality indicators were primarily covered. Of the 67 requirements for billing of performance of services, 55.5 % are primarily part of the emergency department dataset. Through appropriate expertise and documentation by a board certified neurologist, the results can be improved to almost 100 %. CONCLUSION: The index disease stroke illustrates that the emergency department dataset of the DIVI covers medical guidelines, especially 100 % of the German guidelines with a grade of recommendation. All necessary information to document the specialized stroke treatment procedure in the German diagnosis-related groups (DRG) system is also covered. The dataset is also suitable as a documentation tool of quality management, for example, to participate in the registry of the German Stroke Society (ADSR). Best results are obtained if the dataset is applied by a physician specialized in the treatment of patients with stroke (e.g. board certified neurologist). Finally the results show that changes in medical guidelines and recommendations for quality management as well as billing-relevant content should be implemented in the development of datasets for documentation to avoid duplicate documentation.

[Revised certification criteria for regional and national stroke units in Germany]. / Aktualisierte Zertifizierungskriterien für regionale und überregionale Stroke-Units in Deutschland.

The revised criteria for regional and national German stroke units (SU) defined by the SU commission of the German Stroke Society come into effect on 1 July 2015. Due to the already high level of quality, various aspects only needed minor adjustments and definitions; therefore, the majority of minimum structural standards were carried forward. For medical personnel thresholds for when staff further recruitment is necessary were defined for the first time. The current evidence for endovascular thrombectomy (ET) resulted in enhanced standards for acute brain vessel imaging, network formation and timely transport between regional and national SUs with and without ET capability. It further confirmed certification criteria for national SUs that have been valid since 2012: at least two neurointerventionalists as staff members enabling ET on a 24/7 basis. Diagnostic of atrial fibrillation (AF) has been newly implemented following current evidence and internal audits on an annual basis have now become obligatory. Overall, activities to ensure and improve quality must not only be restricted to the minimally required criteria of SU certification but should also incorporate recommendations of the SU commission. The continuous further development of German SU in recent years underlines the importance of the certification procedure as a guarantee of a minimum standard and as the driving force of sustainable quality improvements.

[FEES for neurogenic dysphagia: training curriculum of the German Society of Neurology and the German Stroke Society]. / FEES für neurogene Dysphagien : Ausbildungscurriculum der Deutschen Gesellschaft für Neurologie und Deutschen Schlaganfall-Gesellschaft.

Neurogenic dysphagia is one of the most frequent and prognostically relevant neurological deficits in a variety of disorders, such as stroke, parkinsonism and advanced neuromuscular diseases. Flexible endoscopic evaluation of swallowing (FEES) is now probably the most frequently used tool for objective dysphagia assessment in Germany. It allows evaluation of the efficacy and safety of swallowing, determination of appropriate feeding strategies and assessment of the efficacy of different swallowing manoeuvres. The literature furthermore indicates that FEES is a safe and well-tolerated procedure. In spite of the huge demand for qualified dysphagia diagnostics in neurology, a systematic FEES education has yet not been established. The structured training curriculum presented in this article aims to close this gap and intends to enforce a robust and qualified FEES service. As management of neurogenic dysphagia is not confined to neurologists, this educational program is applicable to other clinicians and speech language therapists with expertise in dysphagia as well.

[FEES in the stroke unit: recommendations for implementation in the clinical routine]. / FEES auf der Stroke-Unit : Empfehlungen zur Umsetzung im klinischen Alltag.

Dysphagia occurs in about 50 % of patients with acute stroke, is strongly related to early complications, such as aspiration pneumonia and is a major cause of increased morbidity and mortality in acute stroke. Flexible endoscopic evaluation of swallowing (FEES) has proven to be an easy to use, non-invasive tool for assessment of dysphagia in acute stroke, significantly adding accuracy to the clinical evaluation of dysphagia. With respect to the growing use of FEES in German stroke units this article summarizes recommendations for implementation and execution.A 3-step process is recommended to acquire the relevant knowledge and skills for carrying out FEES. After a systematic training (first step), swallowing endoscopy should be done under close supervision (second step) which is then followed by independent practice coupled with indirect supervision (third step). In principle, FEES should adopt a team approach involving both neurologists and speech language pathologists (SLP) or alternatively speech therapists. The allocation of responsibilities between these two professions should be kept flexible and should be adjusted to the individual level of education. Reducing the role of the SLP to mere assistance work in particular should be avoided. To enhance interprofessional communication and to allow for a smooth and efficient workflow, endoscopic grading of stroke-related dysphagia should adopt a standardized score that also includes protective and rehabilitative measures as well as nutritional recommendations. A major task for the future is to develop an educational curriculum for FEES that takes the specific needs of stroke unit care into account and is applicable to both physicians and SLPs.

[Regional and national stroke units in Germany: amended certification criteria]. / Regionale und überregionale Stroke-Units in Deutschland : Aktualisierte Zertifizierungskriterien.

Stroke units (SU) have been certified for many years by the German Stroke Society (DSG) and the German Stroke Aid Foundation (SDSH). Since 2009 this is now undertaken in the third generation by the LGA InterCert of the Technical Surveillance Society of Rhineland (TÜV Rheinland). This article presents the amended certification criteria which came into effect in 2012. Many criteria and definitions could be further defined and specified and residual grey areas and fields of conflict could be reduced. For the first time a distinction has been made between the minimum requirements relevant for certification and additional recommendations by the SU Commission of the DSG. In this manner the authors are aiming to motivate SU operators not just to align quality assurance measures to the minimum requirements but to deliberately go beyond them. There is a great deal of evidence to indicate that this will not only serve to increase the motivation of personnel and the quality of treatment but simultaneously the economic situation can also be improved.

[Comprehensive stroke unit]. / Erweiterte Stroke-Unit.

The concept of a "comprehensive stroke unit" (in German: Erweiterte Stroke-Unit) is an additional structural option for those stroke units already certified in Germany. Its aim is to complement the semi-intensive management of stroke unit patients in Germany by early mobilisation and neuropsychological rehab procedures. This concept is recommended in many European countries as well. It is based on the proof of efficacy of the combined treatment package in several randomised controlled trials. According to the Helsingborg Declaration, every stroke patient in Europe should have access to a chain of care best provided by a comprehensive stroke unit. Both early mobilisation and rehabilitation treatment can be integrated and continued without creating an interface between the acute stroke unit and the general neurological or medical ward. The monitoring beds of the acute stroke unit and the non-monitoring "enhanced care" beds are located within the same geographical area of the hospital and are run as a comprehensive stroke care entity. Continuous management of the acute stroke patients by the same team on the same unit means an increase in quality of care, better usage of staff resources and an additional gain in time. The scientific background of the advantages of a comprehensive stroke unit is described as are the structural and staff requirements. The clientel particularly benefiting from treatment on wards with enhanced care beds is described, and the spectrum of treatment services is defined. This concept will be used as the basis for an add-on qualification of already certified German stroke units. An important step was to fit the requirements of the comprehensive stroke unit to the already existing facilities and their infrastructures. From an economic point of view, the comprehensive stroke unit is expected to be cost-effective, either balanced or even positive.

R1--systemic thrombolysis in German stroke units--the experience from the German Stroke data bank.

BACKGROUND: Systemic thrombolysis with tissue plasminogen activator (t-PA) for treatment of acute ischemic stroke was approved in Germany in 2000. Up to now, only data from single centers have been available for the study of the use of thrombolysis in a hospital-based approach outside controlled trials. We therefore sought to determine the frequency of application and complications as well as the patient outcome after t-PA treatment in clinical routine of specialized stroke centers in Germany. METHODS: Within the German Stroke Data Bank Collaboration, 6234 consecutive patients with ischemic stroke were prospectively documented in 20 stroke centers between 1998 and 1999. The patients were centrally followed via telephone interview after 3 months and 1 year to assess global functional outcome using the Modified Rankin Scale. RESULTS: 250 patients (4 %) received systemic t-PA treatment during the study period. The baseline characteristics of these patients were comparable to large clinical trials and phase IV studies. Symptomatic and asymptomatic parenchymal hemorrhage occurred in 22 patients (8.8 %) and was fatal in 3 patients. Follow-up data after 3 months were obtained in 82.4 % of all patients, of which 35 % had a favorable functional outcome (mRS /= 4) and 17 % had died. CONCLUSION: The results of our study agree with the assumption that thrombolytic therapy can be performed safely and effectively in daily clinical practice. Nevertheless, the small proportion of patients receiving thrombolysis even in specialized stroke centers calls for further improvement of acute stroke management in Germany.