[Development of violence-associated penetrating trauma in the Düsseldorf metropolitan region over a 5-year period (GewPen study)]. / Entwicklung gewaltassoziierter penetrierender Traumata in der Metropolregion Düsseldorf über einen fünfjährigen Zeitraum (GewPen-Studie).

INTRODUCTION: Penetrating injuries are a rare but recurring emergency situation in the out-of-hospital and in-hospital emergency settings. The purpose of this study was to determine the incidence and characteristics of injuries associated with penetrating violence across a German metropolitan region over a 5-year period. MATERIAL AND METHODS: In the retrospective study, a database query of the control center of the Düsseldorf rescue service area was used to identify and descriptively analyze all rescue service operations with penetrating violence-associated injuries in the years 2015, 2017, and 2019. For those patients who were transferred to the major trauma center, a further analysis of the in-hospital course was performed. RESULTS: In the 3 years 2015, 2017 and 2019 a total of 266 patients (age: 33 ± 14 years, male: 79%) could be recorded (2015 vs. 2017 vs. 2019: n = 81 vs. n = 93 vs. n = 92, respectively). The most common age group involved had an age range of 15-34 years. A particularly higher frequency of emergency calls was found for the areas of Old Town, City Center, and one other district (Oberbilk). A high frequency of rescue missions was found in the nights from Saturday to Sunday between 20.00 p.m. and 04.00 a.m. Rescue missions with emergency physicians on board increased over the years (2015 vs. 2019: 27 vs. 42%, p = 0.04). The primary weapons used were knives (56%), broken glass bottles (18%) and broken glasses (6%). Out of all patients 71 (27%, injury severity score 11 ± 14) were admitted to the major trauma center. Among these patients, the proportion of immediate surgical care (2015 vs. 2019: 20% vs. 35%, p < 0.05) and positive alcohol detection increased over the years (2015 vs. 2019: 10% vs. 43%, p < 0.05). The 30-day mortality in the 3 years studied was 1.1% (n = 3). CONCLUSION: Penetrating injuries associated with violence are relevant but rare rescue missions. Future care strategies should focus on deployment of rescue resources close to the scene of the incident ("old town guard", central station), and prevention strategies should focus on weapon prohibition zones. A control of alcohol consumption should be discussed.

Reference Managers.

Reference Managers (RMs) are software applications designed to build web-based libraries to organize, annotate, and reference literature when compiling a research study. With an ever-increasing volume of literature, RMs not only serve to centralize information but also allow seamless in-text citation and 1-click bibliography creation, with the ability to format each citation based on target journal specifications. There are many different RMs available for utilization; some of the most popular are EndNote, Zotero, Mendeley, and Paperpile. Each of these aforementioned applications has its own pros and cons, which this paper aims to summarize, though authors should take their individual research needs into consideration when deciding on their preferred reference manager.

Risk of noise-induced hearing loss in the spine surgeon.

Background: Occupation-related noise-induced hearing loss (NIHL) has both negative economic and quality of life implications. The risk spine surgeons undertake in regards to NIHL during operative intervention is unknown. Governing bodies, including the National Institute for Occupational Safety and Health, have recommended exposure limits not to exceed 85 decibels (dB) over 8 hours. The purpose of this study is to characterize noise exposure to spine surgeons in the operating room (OR). Methods: Prospective collection of intraoperative recordings of spinal surgeries (cervical and thoracic/lumbar) was undertaken. Data gathered included procedure, operative duration, presence of background music, and noise information. Noise information included maximum decibel level (MDL), Peak level (LCPeak), Equivalent continuous sound pressure level, time weighted average (TWA), dose, and projected dose. Noise measurements were compared with baseline controls with and without music (empty ORs). Results: Two hundred seven noise recordings were analyzed. One hundred eighteen of those being spinal surgeries, 49 baseline recordings without music, and 40 with music. Maximum decibel level reached a maximum value of 111.5 dBA, with an average amongst surgical recordings of 103 dBA. Maximum decibel level exceeded 85 dBA in 100% of cases and was greater than 100 dBA in 78%. The maximum LCPeak recorded was 132.9 dBC with an average of 120 dBC. Furthermore, the average dose was 7.8% with an average projected dose of 26.5%. The highest dose occurred during a laminectomy at 72.9% of daily allowable noise. Maximum projected dose yielded 156% during a 3-level anterior cervical discectomy and fusion. Conclusions: Spine surgeons are routinely exposed to damaging noise levels (>85 dBA) during operative intervention. With spine surgeons often performing multiple surgeries a day, the cumulative risk of noise exposure cannot be ignored. The synergistic effects of continuous and impact noise places spine surgeons at risk for the development of occupation-related NIHL.

[Survey on the presence of palliative care knowledge and palliative care structures in German emergency departments]. / Befragung zum Vorhandensein palliativmedizinischen Wissens sowie palliativmedizinischer Strukturen in deutschen Notaufnahmen.

Patients with life-limiting or palliative illnesses represent a challenge for emergency departments because, despite the growing availability of specialized outpatient palliative care resources at home, patients often present during symptom exacerbations or when family caregivers become overwhelmed. Also, as life-limiting illnesses are frequently first diagnosed there and treatment goals are adjusted, it appears advantageous to establish early connections between emergency patients with palliative needs and palliative care resources. The objective of this study was to conduct a survey evaluating the availability of fundamental palliative care knowledge and palliative care structures in clinical acute and emergency medicine. For this purpose, an online survey was distributed via emergency medicine blogs, targeting physicians working in emergency departments. In total, 383 fully completed questionnaires were analyzed. It was found that the respondents often encounter patients with palliative needs. However, both outpatient and inpatient palliative resources are not universally accessible, and where, for instance, consultation services are available, there is a lack of consensus regarding the appropriate timing for their utilization. Structures for end of life care are largely in place, although time and personnel are often insufficiently available. There is an expressed interest in further education and training in palliative care. In conclusion, as emergency departments serve as the interface between outpatient and inpatient care, an interdisciplinary and holistic approach can be employed to lay the groundwork for ongoing palliative care, benefiting patients with palliative needs.

Should gastroenterologists prescribe cannabis? The highs, the lows and the unknowns.

Cannabis, commonly known as marijuana, is a drug extracted from the Cannabis plant known for its psychotropic and medicinal properties. It has been used for healing purposes during ancient times, although its psychoactive components led to its restricted use in medicine. Nonetheless, cannabis is found to have modulatory effects on the endocannabinoid system exhibiting its medicinal role in the gastrointestinal (GI) system. Emerging animal and human studies demonstrate the influential effects of cannabis on a variety of GI diseases including inflammatory bowel disease, motility disorders and GI malignancies. It also has a regulatory role in GI symptoms including nausea and vomiting, anorexia, weight gain, abdominal pain, among others. However, both its acute and chronic use can lead to undesirable side effects such as dependency and addiction, cognitive impairment and cannabinoid hyperemesis syndrome. We will discuss the role of cannabis in the GI system as well as dosing strategies to help guide gastroenterologists to assess its efficacy and provide patient counseling before prescription of medical marijuana.

The Effect of Preoperative Exposure to Benzodiazepines on Opioid Consumption After One and Two-level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Investigate the relationship between preoperative benzodiazepine exposure and postoperative opioid use in patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion (ACDF). BACKGROUND: Little is known about the effect of preoperative benzodiazepine exposure on postoperative opioid use in spine surgery. PATIENTS AND METHODS: Patients undergoing primary 1 or 2-level ACDF at a single institution from February 2020 to November 2021 were identified through electronic medical records. The prescription drug monitoring program was utilized to record the name, dosage, and quantity of preoperative benzodiazepines/opioids filled within 60 days before surgery and postoperative opioids 6 months after surgery. Patients were classified as benzodiazepine naïve or exposed according to preoperative usage, and postoperative opioid dose and duration were compared between groups. Regression analysis was performed for outcomes that demonstrated statistical significance, adjusting for preoperative opioid use, age, sex, and body mass index. RESULTS: Sixty-seven patients comprised the benzodiazepine-exposed group whereas 90 comprised the benzodiazepine-naïve group. There was no significant difference in average daily morphine milligram equivalents between groups (median: 96.0 vs 65.0, P = 0.11). The benzodiazepine-exposed group received postoperative opioids for a longer duration (median: 32.0 d vs 12.0 d, P = 0.004) with more prescriptions (median: 2.0 vs 1.0, P = 0.004) and a greater number of pills (median: 110.0 vs 59.0, P = 0.007). On regression analysis, preoperative benzodiazepine use was not significantly associated with postoperative opioid duration [incidence rate ratio (IRR): 0.93, P = 0.74], number of prescriptions (IRR: 1.21, P = 0.16), or number of pills (IRR: 0.89, P = 0.58). CONCLUSIONS: While preoperative benzodiazepine users undergoing primary 1 or 2-level ACDF received postoperative opioids for a longer duration compared with a benzodiazepine naïve cohort, preoperative benzodiazepine use did not independently contribute to this observation. These findings provide insight into the relationship between preoperative benzodiazepine use and postoperative opioid consumption. LEVEL OF EVIDENCE: Level III.

Application of xanthan gum as coagulant-aid for decolorization of synthetic Congo red wastewater.

In recent years, utilization of polysaccharides as natural coagulant and coagulant-aid has become a topic of interest, due to the nature of biopolymers that are renewable, biodegradable, and non-toxic. In this study, Congo red, as a model dye substance, was treated using polyaluminium chloride (PAC) as the main coagulant and xanthan gum as the coagulant aid. For this purpose, the effect of pH (3-9), xanthan gum dose (0.5-4 mg/L), and the initial concentration of Congo red dye (50-100 mg/L) to the dye removal and sludge volume were investigated. The outcome of this investigation indicates that the best pH for Congo red coagulation occurred at pH 3, due to the charge neutralization mechanism. The addition of coagulant-aid dose increases the %-removal and sludge volume until reaching the best coagulant-aid dose of 2 mg/L that results in a %-removal value of 93.81% and a sludge volume of 23.5 mL/L. Further addition of xanthan gum reduced the %-removal and sludge volume due to the inter-polymer force causing more difficult floc formation. The best initial concentration of dye occurred at a Congo red concentration of 50 mg/L, with a %-removal value of 93.81% with PAC (15 mg/L) and xanthan gum (2 mg/L) coagulants. This value is considerably higher than PAC and xanthan gum only which amounts to 81.16 and 7.18%, respectively. Based on these results, it is apparent that xanthan gum can positively contribute to dye coagulation while reducing the use of harmful inorganic coagulant.

Impaired humoral immunity to BQ.1.1 in convalescent and vaccinated patients.

Determining SARS-CoV-2 immunity is critical to assess COVID-19 risk and the need for prevention and mitigation strategies. We measured SARS-CoV-2 Spike/Nucleocapsid seroprevalence and serum neutralizing activity against Wu01, BA.4/5 and BQ.1.1 in a convenience sample of 1,411 patients receiving medical treatment in the emergency departments of five university hospitals in North Rhine-Westphalia, Germany, in August/September 2022. 62% reported underlying medical conditions and 67.7% were vaccinated according to German COVID-19 vaccination recommendations (13.9% fully vaccinated, 54.3% one booster, 23.4% two boosters). We detected Spike-IgG in 95.6%, Nucleocapsid-IgG in 24.0%, and neutralization against Wu01, BA.4/5 and BQ.1.1 in 94.4%, 85.0%, and 73.8% of participants, respectively. Neutralization against BA.4/5 and BQ.1.1 was 5.6- and 23.4-fold lower compared to Wu01. Accuracy of S-IgG detection for determination of neutralizing activity against BQ.1.1 was reduced substantially. We explored previous vaccinations and infections as correlates of BQ.1.1 neutralization using multivariable and Bayesian network analyses. Given a rather moderate adherence to COVID-19 vaccination recommendations, this analysis highlights the need to improve vaccine-uptake to reduce the COVID-19 risk of immune evasive variants. The study was registered as clinical trial (DRKS00029414).

Resuscitation room management of patients with non-traumatic critical illness in the emergency department (OBSERvE-DUS-study).

BACKGROUND: Few studies address the care of critically ill non-traumatic patients in the emergency department (ED). The aim of this study was to assess the epidemiology, management, and outcome of these patients. METHODS: In this retrospective study, we identified and analyzed data from all consecutive adult critically ill non-traumatic ED patients treated from March 2018 to February 2019. Patient characteristics, major complaint leading to admission, out-of-hospital, and in-hospital interventions and 30-day mortality were extracted from medical records of the electronic patient data management system. RESULTS: During the study period, we analyzed 40,764 patients admitted to the ED. Of these, 621 (1.5%) critically ill non-traumatic patients were admitted for life-threatening emergencies to the resuscitation room (age: 70 ± 16 years, 52% male). Leading problem on admission was disability/unconsciousness (D), shock (C), respiratory failure (B), airway obstruction (A), and environment problems (E) in 41%, 31%, 25%, 2%, and 1%, respectively. Out-of-hospital and in-hospital measures included: intravenous access (61% vs. 99%), 12-lead ECG (55% vs. 87%), invasive airway management (21% vs. 34%) invasive ventilation (21% vs. 34%), catecholamines (9% vs. 30%), arterial access (0% vs. 52%), and cardiopulmonary resuscitation (11% vs. 6%). The underlying diagnoses were mainly neurological (29%), followed by cardiological (28%), and pulmonological (20%) emergencies. The mean length of stay (LOS) in the resuscitation room and ED was 123 ± 122 and 415 ± 479 min, respectively. The 30-day mortality was 18.5%. CONCLUSION: The data describe the care of critically ill non-traumatic patients in the resuscitation room. Based on these data, algorithms for the structured care of critically ill non-traumatic patients need to be developed.

Effectiveness of Intraoperative Neuromonitoring in a Patient Undergoing a One-Level Transforaminal Lumbar Interbody Fusion: A Case Report.

Posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) are common modes of operative treatment of lumbar radiculopathy and spondylolisthesis. An integral part of these procedures is the appropriate placement of pedicle screws to ensure proper fusion. Breach of the medial cortex during pedicle screw fixation can potentially cause permanent impairment for a patient; significant technology and resources have been universally devoted to preventing this complication. Intraoperative neuromonitoring (IONM) is a frequently used tool by spine surgeons, which, along with fluoroscopy, is traditionally thought to reduce the incidence of neurologic injury. Unfortunately, IONM is not infallible and, in certain studies, has not been shown to decrease the risk of neurologic compromise. This case presentation details the clinical course of a 55-year-old who underwent an L4-5 TLIF. Despite benign electromyography recordings intraoperatively, the patient presented postoperatively with a new-onset left foot drop and a CT scan that confirmed bilateral L4 screw malposition with a breach of the medial cortex. We hope to further advance the discussion regarding the dangerous inconsistency of IONM in hopes of identifying a multimodal approach to avoid dreaded complications like this one in the future.

Impact of the route of adrenaline administration in patients suffering from out-of-hospital cardiac arrest on 30-day survival with good neurological outcome (ETIVIO study).

BACKGROUND: Over the past decades, international guidelines for cardiopulmonary resuscitation (CPR) have changed the recommendation for alternative routes for drug administration. Until now, evidence for the substantial superiority of one route with respect to treatment outcome after CPR has been lacking. The present study compares the effects of intravenous (IV), intraosseous (IO) and endotracheal (ET) adrenaline application during CPR in out-of-hospital cardiac arrest (OHCA) on clinical outcomes within the database of the German Resuscitation Registry (GRR). METHODS: This registry analysis was based on the GRR cohort of 212,228 OHCA patients between 1989 and 2020. Inclusion criteria were: OHCA, application of adrenaline, and out-of-hospital CPR. Excluded from the study were patients younger than 18 years, those who had trauma or bleeding as suspected causes of cardiac arrest, and incomplete data sets. The clinical endpoint was hospital discharge with good neurological outcome [cerebral performance category (CPC) 1/2]. Four routes of adrenaline administration were compared: IV, IO, IO + IV, ET + IV. Group comparisons were done using matched-pair analysis and binary logistic regression. RESULTS: In matched-pair group comparisons of the primary clinical outcome hospital discharge with CPC 1/2, the IV group (n = 2416) showed better results compared to IO (n = 1208), [odds ratio (OR): 2.43, 95% confidence interval (CI): 1.54-3.84, p < 0.01] and when comparing IV (n = 8706) to IO + IV (n = 4353), [OR: 1.33, 95% CI: 1.12-1.59, p < 0.01]. In contrast, no significant difference was found between IV (n = 532) and ET + IV (n = 266), [OR: 1.26, 95% CI: 0.55-2.90, p = 0.59]. Concurrently, binary logistic regression yielded a highly significant effect of vascular access type (χ² = 67.744(3), p < 0.001) on hospital discharge with CPC1/2, with negative effects for IO (regression coefficient (r.c.) = - 0.766, p = 0.001) and IO + IV (r.c. = - 0.201, p = 0,028) and no significant effect for ET + IV (r.c. = 0.117, p = 0.770) compared to IV. CONCLUSIONS: The GRR data, collected over a period of 31 years, seem to emphasize the relevance of an IV access during out-of-hospital CPR, in the event that adrenaline had to be administered. IO administration of adrenaline might be less effective. ET application, though removed in 2010 from international guidelines, could gain importance as an alternative route again.

["B problems" in non-traumatic resuscitation room management]. / "B-Probleme" des nichttraumatologischen Schockraummanagements.

In the primary survey of resuscitation room management in critically ill nontrauma patients, the ABCDE (airway, breathing, circulation, disability, exposure) approach is used for immediate recognition and treatment of life-threatening conditions. "B problems" are associated with respiratory failure and require immediate treatment. The pathogenesis is diverse, especially in the nontrauma resuscitation room. Clinical examination, emergency sonography and knowledge of oxygenation techniques and ventilation are important components of diagnosis and therapy. Standardized procedures and regular training in the emergency room are of fundamental importance.

Epidemiology, management, and outcome of infection, sepsis, and septic shock in a German emergency department (EpiSEP study).

Background: The adjacent conditions infection, sepsis, and septic shock are among the most common causes of treatment in the emergency department (ED). Most available data come from intensive care units (ICU) and include nosocomial infections acquired during hospitalization. Epidemiological data from German EDs are not yet available, although the ED is one of the first points of contact for patients. The aim of this study was to investigate the epidemiology, causes, diagnosis, mortality, and treatment of patients with infections in the ED. Materials and methods: In this retrospective, single-center observational study, routinely collected data from the patient data management system and from the hospital information system were analyzed. All adult patients who presented to the ED in connection with an infection during the study period from 01/01 to 28/02/2019 were included. Exclusion criteria were age ≤ 17 years and incomplete records. Three groups (I. Infection, II. Sepsis, and III. Septic shock) were defined according to SEPSIS-3 definitions. Results: During the study period, a total of 6,607 patients were treated in the ED. Of these patients, 19.3% (n = 1,278) had an infection (mean age 56 ± 23 years, 50% female). The sites of infection were distributed as follows: Respiratory tract 35%, genitourinary tract 18%, maxillofacial/ears/nose/throat 14%, intraabdominal 13%, soft tissues 10%, central nervous system 1%, other cause 3%, or unknown cause 6%. Infection only, sepsis and septic shock were present in 86, 10, and 3%, respectively. There were significant differences in vital signs as well as in the various emergency sepsis scores across the predefined groups [I vs. II vs. III: SOFA (pts.): 1 ± 1 vs. 4 ± 2 vs. 7 ± 3 (p < 0.0001), systolic blood pressure (mmHg): 137 ± 25 vs. 128 ± 32 vs. 107 ± 34 (p < 0.05), heart rate (bpm): 92 ± 18 vs. 99 ± 23 vs. 113 ± 30 (p < 0.05), respiratory rate (min-1): 18 ± 4 vs. 20 ± 7 vs. 24 ± 10 (p < 0.05)]. In the three groups, blood cultures were obtained in 34, 81, and 86%, of cases, respectively and antibiotics were administered in the ED in 50, 89, and 86%, of cases respectively. The 30-day mortality rate in the three groups was 1.6, 12.0, and 38.1%, respectively. Conclusion: This study is the first to show the incidence, management, and outcome of patients classified as infection, sepsis, and septic shock in a German ED. The findings of our real-world data are important for quality management and enable the optimization of treatment pathways for patients with infectious diseases.

Gastric Cancer Due to Chronic H. pylori Infection: What We Know and Where We Are Going.

Helicobacter pylori is an established cause of many gastrointestinal pathologies including peptic ulcer disease, gastritis, and gastric cancer. It is an entity that affects the global population, and its true nature has only been known since the 1980s. Although there is much known about H. pylori including its pathophysiology, detection, and eradication, resistance to current therapy models is common. This is problematic because untreated or inadequately treated H. pylori increases morbidity and mortality related to gastric cancer and peptic ulcer disease among others. In order to improve the treatment and reduce resistance, there is significant ongoing research identifying new detection and eradication methods for H. pylori. This review aims to highlight what has already been established regarding H. pylori's epidemiology, pathophysiology, detection, and treatment as well as the most current and novel research involving detection and treatment of H. pylori.

Development of the Interdisciplinary and Interprofessional Course Concept "Advanced Critical Illness Life Support".

The Advanced Critical Illness Life Support (ACiLS) course was developed on behalf of the German Society for Interdisciplinary Emergency and Acute Medicine (DGINA). The goal of the ACiLS course is to provide a nationally recognized and certified life support course that teaches medical professionals the key principles of initial care of critically ill patients in the emergency department, including the (PR_E-)AUD2IT-algorithm. It is designed for interdisciplinary and multi-professional staff in the resuscitation room to optimize patient safety and outcome. ACiLS includes a new blended learning concept with a theoretical part as comprehensive e-learning and a two-day practical part with strong focus on team training in scenarios and workshops. The course format was conceived to balance best teaching practices within the limited instructional time and resources available. This article describes the development of the ACiLS course and provides an overview of its future implementation.

Intravascular ultrasound guided transcatheter electrosurgical revascularization of an interrupted aortic arch.

Interrupted aortic arch is a rare (prevalence 1:100000) but malignant cause of secondary hypertension, with late sequela of early myocardial infarction, stroke, and heart failure. We present the case of a 49-year-old male patient with aortic interruption successfully treated by intravascular ultrasound guided transcatheter electrosurgical wire crossing and revascularization using a covered stent. Learning objective: Transcatheter electrosurgical wire techniques utilizing intravascular ultrasound facilitate safe and effective percutaneous revascularization of complex aortic coarctation patients.

Coarctation of the Aorta and Anomalous Origin of the Left Coronary from the Opposite Sinus of Valsalva in a 6-Year-Old Male.

Coarctation of the aorta is a form of congenital heart disease requiring surgical intervention. If is often associated with other forms of congenital heart disease. Anomalous origin of the left coronary artery (ALCA) from the opposite sinus of Valsalva is implicated in sudden cardiac death. We report the first case in the literature of coarctation of the aorta associated with ALCA from the opposite aortic sinus and describe surgical correction of these two lesions.