[Clinical Treatment after Terrorist Attacks - Structures and Processes in Hospitals for terror-related Mass Casualty Incidents]. / Klinische Versorgung bei (Terror-)Anschlägen/lebensbedrohlichen Einsatzlagen.

Due to several peculiarities the clinical treatment after terror-related mass casualty incidents (TerrorMASCAL) differs from handling a conventional MCI. For this reason, TerrorMASCAL situations should get attention as an own entity in hospitals emergency preparedness and response. Among other challenges hospitals surrounding the emergency area will have to deal with a large amount of non-triaged, non-treated and seriously harmed patients, some of them with unfamiliar and disfiguring injuries. In addition, the hospitals themselves can be endangered as a target of further terrorist attacks. Therefore, security concepts depending on the individual circumstances must be elaborated in consultation with the local police authorities.The incident's clinical management should be put in hands of specially trained in-house institutions. Operational and tactical tasks close to patients ("on site") should be separated from strategic and administrative responsibilities ("in the background"). The function of an "Emergency Operational and Medical Coordinator" (EOMC = ZONK) is installed to manage initial diagnostics and therapy for seriously injured victims by prioritization and scheduling available clinical resources.In order to structure the process of emergency admission for numerous patients a triage- and holding area as well as specific in-house treatment areas for different severities of injury should be set up. The clinical triage should follow a consistent algorithm that is based on the cABCDE approach. It is recommended that this algorithm should be defined in hospitals disaster and emergency planning.Surgical strategies concerning the treatment of terror victims might be oriented according to the principles of "tactical abbreviated surgical care" (TASC). This means that in extreme cases the initial measures have to be concerted to save as much lives as possible while accepting a reduced individual outcome.

Metadata Correction: Patient Empowerment During the COVID-19 Pandemic by Ensuring Safe and Fast Communication of Test Results: Implementation and Performance of a Tracking System.

[This corrects the article DOI: 10.2196/27348.].

Patient Empowerment During the COVID-19 Pandemic by Ensuring Safe and Fast Communication of Test Results: Implementation and Performance of a Tracking System.

BACKGROUND: Overcoming the COVID-19 crisis requires new ideas and strategies for online communication of personal medical information and patient empowerment. Rapid testing of a large number of subjects is essential for monitoring and delaying the spread of SARS-CoV-2 in order to mitigate the pandemic's consequences. People who do not know that they are infected may not stay in quarantine and, thus, risk infecting others. Unfortunately, the massive number of COVID-19 tests performed is challenging for both laboratories and the units that conduct throat swabs and communicate the results. OBJECTIVE: The goal of this study was to reduce the communication burden for health care professionals. We developed a secure and easy-to-use tracking system to report COVID-19 test results online that is simple to understand for the tested subjects as soon as these results become available. Instead of personal calls, the system updates the status and the results of the tests automatically. This aims to reduce the delay when informing testees about their results and, consequently, to slow down the virus spread. METHODS: The application in this study draws on an existing tracking tool. With this open-source and browser-based online tracking system, we aim to minimize the time required to inform the tested person and the testing units (eg, hospitals or the public health care system). The system can be integrated into the clinical workflow with very modest effort and avoids excessive load to telephone hotlines. RESULTS: The test statuses and results are published on a secured webpage, enabling regular status checks by patients; status checks are performed without the use of smartphones, which has some importance, as smartphone usage diminishes with age. Stress tests and statistics show the performance of our software. CTest is currently running at two university hospitals in Germany-University Hospital Ulm and University Hospital Tübingen-with thousands of tests being performed each week. Results show a mean number of 10 (SD 2.8) views per testee. CONCLUSIONS: CTest runs independently of existing infrastructures, aims at straightforward integration, and aims for the safe transmission of information. The system is easy to use for testees. QR (Quick Response) code links allow for quick access to the test results. The mean number of views per entry indicates a reduced amount of time for both health care professionals and testees. The system is quite generic and can be extended and adapted to other communication tasks.

Laryngeal tube suction II or endotracheal intubation for laparoscopic radical prostatectomy in a head down position: A randomised controlled trial.

BACKGROUND: The laryngeal tube suction II (LTS II) is a supraglottic airway device (SAD) with a gastric drainage tube and enhanced seal properties as compared with other SADs. Therefore, its use has been proposed in situations with an elevated risk of aspiration. OBJECTIVES: To compare the safety and efficacy of airway management and controlled mechanical ventilation when using either an LTS II or an endotracheal tube for laparoscopic radical prostatectomy. DESIGN: Randomised, controlled, blinded and single-centre study. SETTING: Academic tertiary care centre in Leipzig from April 2014 to May 2015. PATIENTS: It was planned to include 100 patients but the study was stopped after 50 patients following an interim analysis. These 50 patients were randomised to either the LTS II group or the endotracheal tube group. All male patients aged more than 18 years for elective laparoscopic radical prostatectomy were eligible. Exclusion criteria included a BMI more than 30, American Society of Anesthesiologists class III or greater, a history of gastroesophageal reflux or other factors known to increase the risk of aspiration and a known difficult airway. INTERVENTIONS: All patients received general anaesthesia. Airway management was with either a LTS II or an endotracheal tube, according to the randomisation. MAIN OUTCOME MEASURES: The primary endpoint was successful insertion of the particular airway device during anaesthesia for laparoscopic radical prostatectomy. RESULTS: In 15 of the 28 patients randomised to LTS II, the device had to be removed and an endotracheal tube inserted, mainly because of an airway leak (n = 10) or swelling of the tongue (n = 3). Ventilation was successful in all patients (n = 22) randomised to endotracheal tube. Quality of ventilation was rated better in the endotracheal tube group. CONCLUSION: Our data suggest that LTS II should not be the preferred method of airway management in patients undergoing laparoscopic radical prostatectomy. TRIAL REGISTRATION: DRKS00008985 (German Clinical Trials Register).

Inhaled carbon monoxide protects time-dependently from loss of hypoxic pulmonary vasoconstriction in endotoxemic mice.

BACKGROUND: Inhaled carbon monoxide (CO) appears to have beneficial effects on endotoxemia-induced impairment of hypoxic pulmonary vasoconstriction (HPV). This study aims to specify correct timing of CO application, it's biochemical mechanisms and effects on inflammatory reactions. METHODS: Mice (C57BL/6; n = 86) received lipopolysaccharide (LPS, 30 mg/kg) intraperitoneally and subsequently breathed 50 ppm CO continuously during defined intervals of 3, 6, 12 or 18 h. Two control groups received saline intraperitoneally and additionally either air or CO, and one control group received LPS but breathed air only. In an isolated lung perfusion model vasoconstrictor response to hypoxia (FiO2 = 0.01) was quantified by measurements of pulmonary artery pressure. Pulmonary capillary pressure was estimated by double occlusion technique. Further, inflammatory plasma cytokines and lung tissue mRNA of nitric-oxide-synthase-2 (NOS-2) and heme oxygenase-1 (HO-1) were measured. RESULTS: HPV was impaired after LPS-challenge (p < 0.01). CO exposure restored HPV-responsiveness if administered continuously for full 18 h, for the first 6 h and if given in the interval between the 3(rd) and 6(th) hour after LPS-challenge (p < 0.05). Preserved HPV was attributable to recovered arterial resistance and associated with significant reduction in NOS-2 mRNA when compared to controls (p < 0.05). We found no effects on inflammatory plasma cytokines. CONCLUSION: Low-dose CO prevented LPS-induced impairment of HPV in a time-dependent manner, associated with a decreased NOS-2 expression.

Restrictive transfusion practice during extracorporeal membrane oxygenation therapy for severe acute respiratory distress syndrome.

Recommendations concerning the management of hemoglobin levels and hematocrit in patients on extracorporeal membrane oxygenation (ECMO) still advise maintenance of a normal hematocrit. In contrast, current transfusion guidelines for critically ill patients support restrictive transfusion practice. We report on a series of patients receiving venovenous ECMO (vvECMO) for acute respiratory distress syndrome (ARDS) treated according to the restrictive transfusion regimen recommended for critically ill patients. We retrospectively analyzed 18 patients receiving vvECMO due to severe ARDS. Hemoglobin concentrations were kept between 7 and 9 g/dL with a transfusion trigger at 7 g/dL or when physiological transfusion triggers were apparent. We assessed baseline data, hospital mortality, time on ECMO, hemoglobin levels, hematocrit, quantities of packed red blood cells received, and lactate concentrations and compared survivors and nonsurvivors. The overall mortality of all patients on vvECMO was 38.9%. Mean hemoglobin concentration over all patients and ECMO days was 8.30 ± 0.51 g/dL, and hematocrit was 0.25 ± 0.01, with no difference between survivors and nonsurvivors. Mean numbers of given PRBCs showed a trend towards higher quantities in the group of nonsurvivors, but the difference was not significant (1.97 ± 1.47 vs. 0.96 ± 0.76 units; P = 0.07). Mean lactate clearance from the first to the third day was 45.4 ± 28.3%, with no significant difference between survivors and nonsurvivors (P = 0.19). In our cohort of patients treated with ECMO due to severe ARDS, the application of a restrictive transfusion protocol did not result in an increased mortality. Safety and feasibility of the application of a restrictive transfusion protocol in patients on ECMO must further be evaluated in randomized controlled trials.

Initial Experience With a Percutaneous Approach to Redo Mitral Valve Surgery: Management and Procedural Success.

OBJECTIVE: The purpose of the study was to report the anesthetic management and immediate procedural success in the initial 20 patients undergoing percutaneous transapical mitral valve replacement. DESIGN: Retrospective review of collected data. SETTING: University-affiliated heart center. PARTICIPANTS: Twenty patients with mitral regurgitation or stenosis due to a degenerated valve or ring in the mitral position. INTERVENTIONS: TEE-guided transapical mitral valve replacement under general anesthesia and early extubation by means of an established fast-track protocol. MEASUREMENTS AND MAIN METHODS: Twenty patients underwent transapical mitral valve replacement by a beating heart procedure, avoiding cardiopulmonary bypass. The valve was either deployed due to a previously implanted bioprosthetic valve (valve-in-valve group), which degenerated, or a ring (valve-in-ring group), which predominantly showed regurgitation. There was a significant increase in the mitral valve opening area in stenosed valve pathology from 1.3-1.9 sq. cm (p = 0.004), and an increase in ejection fraction from 40% to 45% (p = 0.52). In the valve-in-ring group, valve area increased from 2.0 sq. cm to 2.6 sq. cm (p = 0.21), with an increase in ejection fraction from 30% to 35% (p = 0.18). Eighteen patients underwent successful deployment of the valve. The anesthesia duration for the procedure lasted 185.5 ± 25.4 minutes. CONCLUSIONS: There was a significant increase in opening area of the valve and improvement in ejection fraction in this patient group. TEE and fluoroscopy-guided imaging is necessary for the procedure's success and is an evolving alternative treatment for high-risk mitral valve patients who would otherwise be considered inoperable for routine surgery using sternotomy.

[Mechanically circulatory support devices--management of typical emergencies]. / Patienten mit linksventrikulären Assist Devices--Typische Notfälle versorgen.

The use of mechanically circulatory support devices (MCS) will become increasingly important as a therapy option in patients with end-stage heart failure, and emergency physicians will more frequently encounter MCS patients in the next few years. However, emergency management in MCS patients has not yet been standardized. In the following article, common MCS devices are presented and typical emergencies associated with MCS devices are discussed. Furthermore, we try to give recommendations for the management of MCS patients in an emergency situation and present an algorithm in order to facilitate a structured and timely efficient evaluation of the MCS patient.

Characterization of a double-hit murine model of acute respiratory distress syndrome.

The aim of the present study was to characterize a murine model of acute respiratory distress syndrome (ARDS) abiding by the Berlin definition of human ARDS and guidelines for animal models of ARDS. To this end, C57BL/6NCrl mice were challenged with lipopolysaccharide (LPS; 15 mg/kg, i.p.) followed 18 h later by injection of oleic acid (OA; 0.12 mL/kg, i.v.). Controls received saline injection at both time points. Haemodynamics were monitored continuously. Arterial blood gas analyses were performed just before and every 30 min after OA challenge. Ninety minutes after OA challenge, the chest of mice was scanned using micro-computed tomography (CT). Cytokine concentrations were measured in plasma samples. Lungs were harvested 90 min after OA challenge for histology, immunohistochemistry, lung weight measurements and tissue cytokine detection. A histological lung injury score was determined. Eighteen hours after LPS challenge, mice exhibited a severe systemic inflammatory response syndrome. Oxygenation declined significantly after OA injections (Pa o2 /Fi o2 283 ± 73 and 256 ± 71 mmHg at 60 and 90 min, respectively; P < 0.001). Bilateral patchy infiltrates were present on the micro-CT scans. Histology revealed parenchymal damage with accumulation of polymorphonuclear neutrophils, intra-alveolar proteinacous debris and few hyaline membranes. The lung wet : dry ratio indicated damage to the alveolar capillary membrane. Cytokine patterns evidenced a severe local and systemic inflammatory state in plasma and lung tissue. In conclusion, the described two-hit model of ARDS shows a pathological picture of ARDS closely mimicking human ARDS according to the Berlin definition and may facilitate interpretation of prospective experimental results.

Respiratory complications after diode-laser-assisted tonsillotomy.

Children with certain risk factors, such as comorbidities or severe obstructive sleep apnea syndrome (OSAS) are known to require extended postoperative monitoring after adenotonsillectomy. However, there are no recommendations available for diode-laser-assisted tonsillotomy. A retrospective chart review of 96 children who underwent diode-laser-assisted tonsillotomy (07/2011-06/2013) was performed. Data for general and sleep apnea history, power of the applied diode-laser (λ = 940 nm), anesthesia parameters, the presence of postoperative respiratory complications and postoperative healing were evaluated. After initially uncomplicated diode-laser-assisted tonsillotomy, an adjustment of post-anesthesia care was necessary in 16 of 96 patients due to respiratory failure. Respiratory complications were more frequent in younger children (3.1 vs. 4.0 years, p = 0.049, 95 % CI -1.7952 to -0.0048) and in children who suffered from nocturnal apneas (OR = 5.00, p < 0.01, 95 % CI 1.4780-16.9152) or who suffered from relevant comorbidities (OR = 4.84, p < 0.01, 95 % CI 1.5202-15.4091). Moreover, a diode-laser power higher than 13 W could be identified as a risk factor for the occurrence of a postoperative oropharyngeal edema (OR = 3.45, p < 0.01, 95 % CI 1.3924-8.5602). Postoperative respiratory complications should not be underestimated in children with sleep-disordered breathing (SDB). Therefore, children with SDB, children with comorbidities or children younger than 3 years should be considered "at risk" and children with confirmed moderate to severe OSAS should be referred to a PICU following diode-laser-assisted tonsillotomy. We recommend a reduced diode-laser power (<13 W) to reduce oropharyngeal edema.

Early prediction of survival after open surgical repair of ruptured abdominal aortic aneurysms.

BACKGROUND: Scoring models are widely established in the intensive care unit (ICU). However, the importance in patients with ruptured abdominal aortic aneurysm (RAAA) remains unclear. Our aim was to analyze scoring systems as predictors of survival in patients undergoing open surgical repair (OSR) for RAAA. METHODS: This is a retrospective study in critically ill patients in a surgical ICU at a university hospital. Sixty-eight patients with RAAA were treated between February 2005 and June 2013. Serial measurements of Sequential Organ Failure Assessment score (SOFA), Simplified Acute Physiology Score II (SAPS II) and Simplified Therapeutic Intervention Scoring System-28 (TISS-28) were evaluated with respect to in-hospital mortality. Eleven patients had to be excluded from this study because 6 underwent endovascular repair and 5 died before they could be admitted to the ICU. RESULTS: All patients underwent OSR. The initial, highest, and mean of SOFA and SAPS II scores correlated significant with in-hospital mortality. In contrast, TISS-28 was inferior and showed a smaller area under the receiver operating curve. The cut-off point for SOFA showed the best performance in terms of sensitivity and specificity. An initial SOFA score below 9 predicted an in-hospital mortality of 16.2% (95% CI, 4.3-28.1) and a score above 9 predicted an in-hospital mortality of 73.7% (95% CI, 53.8-93.5, p < 0.01). Trend analysis showed the largest effect on SAPS II. When the score increased or was unchanged within the first 48 h (score >45), the in-hospital mortality rate was 85.7% (95% CI, 67.4-100, p < 0.01) versus 31.6% (95% CI, 10.7-52.5, p = 0.01) when it decreased. On multiple regression analysis, only the mean of the SOFA score showed a significant predictive capacity with regards to mortality (odds ratio 1.77; 95% CI, 1.19-2.64; p < 0.01). CONCLUSION: SOFA and SAPS II scores were able to predict in-hospital mortality in RAAA within 48 h after OSR. According to cut-off points, an increase or decrease in SOFA and SAPS II scores improved sensitivity and specificity.

High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU: a randomized clinical trial.

IMPORTANCE: Enteral administration of immune-modulating nutrients (eg, glutamine, omega-3 fatty acids, selenium, and antioxidants) has been suggested to reduce infections and improve recovery from critical illness. However, controversy exists on the use of immune-modulating enteral nutrition, reflected by lack of consensus in guidelines. OBJECTIVE: To determine whether high-protein enteral nutrition enriched with immune-modulating nutrients (IMHP) reduces the incidence of infections compared with standard high-protein enteral nutrition (HP) in mechanically ventilated critically ill patients. DESIGN, SETTING, AND PARTICIPANTS: The MetaPlus study, a randomized, double-blind, multicenter trial, was conducted from February 2010 through April 2012 including a 6-month follow-up period in 14 intensive care units (ICUs) in the Netherlands, Germany, France, and Belgium. A total of 301 adult patients who were expected to be ventilated for more than 72 hours and to require enteral nutrition for more than 72 hours were randomized to the IMHP (n = 152) or HP (n = 149) group and included in an intention-to-treat analysis, performed for the total population as well as predefined medical, surgical, and trauma subpopulations. INTERVENTIONS: High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition, initiated within 48 hours of ICU admission and continued during the ICU stay for a maximum of 28 days. MAIN OUTCOMES AND MEASURES: The primary outcome measure was incidence of new infections according to the Centers for Disease Control and Prevention (CDC) definitions. Secondary end points included mortality, Sequential Organ Failure Assessment (SOFA) scores, mechanical ventilation duration, ICU and hospital lengths of stay, and subtypes of infections according CDC definitions. RESULTS: There were no statistically significant differences in incidence of new infections between the groups: 53% (95% CI, 44%-61%) in the IMHP group vs 52% (95% CI, 44%-61%) in the HP group (P = .96). No statistically significant differences were observed in other end points, except for a higher 6-month mortality rate in the medical subgroup: 54% (95% CI, 40%-67%) in the IMHP group vs 35% (95% CI, 22%-49%) in the HP group (P = .04), with a hazard ratio of 1.57 (95% CI, 1.03-2.39; P = .04) for 6-month mortality adjusted for age and Acute Physiology and Chronic Health Evaluation II score comparing the groups. CONCLUSIONS AND RELEVANCE: Among adult patients breathing with the aid of mechanical ventilation in the ICU, IMHP compared with HP did not improve infectious complications or other clinical end points and may be harmful as suggested by increased adjusted mortality at 6 months. These findings do not support the use of IMHP nutrients in these patients. TRIAL REGISTRATION: trialregister.nl Identifier: NTR2181.

Propofol versus flunitrazepam for inducing and maintaining sleep in postoperative ICU patients.

CONTEXT: Sleep deprivation is a common problem on intensive care units (ICUs) influencing not only cognition, but also cellular functions. An appropriate sleep-wake cycle should therefore be maintained to improve patients' outcome. Multiple disruptive factors on ICUs necessitate the administration of sedating and sleep-promoting drugs for patients who are not analgo-sedated. AIMS: The objective of the present study was to evaluate sleep quantity and sleep quality in ICU patients receiving either propofol or flunitrazepam. SETTINGS AND DESIGN: Monocentric, randomized, double-blinded trial. MATERIALS AND METHODS: A total of 66 ICU patients were enrolled in the study (flunitrazepam n = 32, propofol n = 34). Propofol was injected continuously (2 mg/kg/h), flunitrazepam as a bolus dose (0.015 mg/kg). Differences between groups were evaluated using a standardized sleep diary and the bispectral index (BIS). STATISTICAL ANALYSIS USED: Group comparisons were performed by Mann-Whitney U-Test. P < 0.05 was considered to be statistically significant. RESULTS: Sleep quality and the frequency of awakenings were significantly better in the propofol group (Pg). In the same group lower BIS values were recorded (median BIS propofol 74.05, flunitrazepam 78.7 [P = 0.016]). BIS values had to be classified predominantly to slow-wave sleep under propofol and light sleep after administration of flunitrazepam. Sleep quality improved in the Pg with decreasing frequency of awakenings and in the flunitrazepam group with increasing sleep duration. CONCLUSIONS: Continuous low-dose injection of propofol for promoting and maintaining night sleep in ICU patients who are not analgo-sedated was superior to flunitrazepam regarding sleep quality and sleep structure.

Impact of COVID-19 pandemic-induced surgical restrictions on operational performance: a case study at the University Hospital of Ulm.

INTRODUCTION: The operating room (OR) is a high-cost and high-revenue area in a hospital comprising extremely complex process steps to treat patients. The perioperative process quality can be optimized through an efficiency-oriented central OR management based on performance indices. However, during the COVID-19 pandemic with the corresponding OR restrictions, there was a significant nation- and worldwide decline in the performance, which may have a lasting impact. Therefore, we proposed the hypothesis that COVID-19 pandemic-related OR restrictions could reduce operative performance in the long term. METHODS: A retrospective, descriptive analysis of perioperative processing times was conducted exemplarily at the University Hospital Ulm using a pre-post design, examining the corresponding second quarters of 2019 to 2022. In total, n = 18,489 operations with n = 314,313 individual time intervals were analyzed. The statistical analyses included the Kruskal-Wallis test adjusted for multiple testing, and the significance level was set at p < 0.01. RESULTS: The results revealed not only a significant decrease in the case volume by 31% (2020) and 23% (2021) during the COVID-19 crisis years, but also significant time delays in various process steps; e.g. the median patient's OR occupancy time (column time) rose from 65 min (2019) to 87 min (2020) and remained elevated (72 min in 2021 and 74 min in 2022, respectively). Even in 2022, beyond the pandemic, the net anaesthesia time was permanently enhanced by 9 min per case. Furthermore, both, the incision-to-closure time and surgeon attachment time were each significantly prolonged by 7 additional minutes, and the time from the end of anaesthesia to the release of the next patient was extended by 4 min. Selected standardized index operations showed only a trend towards these changes, even with a decrease in the incision-to-closure time over time. CONCLUSION: Overall, long-term changes were found in essential perioperative process times even after retraction of the COVID-19 restrictions, indicating some processual "slow down" after the Covid-19-induced "shut down". Further analyses are needed to determine the appropriate targeted control measures to improve processing times and increase the process quality.

Bedside estimation of nonaerated lung tissue using blood gas analysis.

OBJECTIVES: Studies correlating the arterial partial pressure of oxygen to the fraction of nonaerated lung assessed by CT shunt yielded inconsistent results. We systematically analyzed this relationship and scrutinized key methodological factors that may compromise it. We hypothesized that both physiological shunt and the ratio between PaO2 and the fraction of inspired oxygen enable estimation of CT shunt at the bedside. DESIGN: : Prospective observational clinical and laboratory animal investigations. SETTING: ICUs (University Hospital Leipzig, Germany) and Experimental Pulmonology Laboratory (University of São Paulo, Brazil). PATIENTS, SUBJECTS AND INTERVENTIONS: Whole-lung CT and arterial blood gases were acquired simultaneously in 77 patients mechanically ventilated with pure oxygen. A subgroup of 28 patients was submitted to different Fio2. We also studied 19 patients who underwent repeat CT. Furthermore we studied ten pigs with acute lung injury at multiple airway pressures, as well as a theoretical model relating PaO2 and physiological shunt. We logarithmically transformed the PaO2/Fio2 to change this nonlinear relationship into a linear regression problem. MEASUREMENTS AND MAIN RESULTS: We observed strong linear correlations between Riley's approximation of physiological shunt and CT shunt (R = 0.84) and between logarithmically transformed PaO2/Fio2 and CT shunt (R = 0.86), allowing us to construct a look-up table with prediction intervals. Strong linear correlations were also demonstrated within-patients (R = 0.95). Correlations were significantly improved by the following methodological issues: measurement of PaO2/Fio2 during pure oxygen ventilation, use of logarithmically transformed PaO2/Fio2 instead of the "raw" PaO2/Fio2, quantification of nonaerated lung as percentage of total lung mass and definition of nonaerated lung by the [-200 to +100] Hounsfield Units interval, which includes shunting units within less opacified lung regions. CONCLUSION: During pure oxygen ventilation, logarithmically transformed PaO2/Fio2 allows estimation of CT shunt and its changes in patients during systemic inflammation. Relevant intrapulmonary shunting seems to occur in lung regions with CT numbers between [-200 and +100] Hounsfield Units.

Is real time 3D transesophageal echocardiography a feasible approach to detect coronary ostium during transapical aortic valve implantation?

OBJECTIVE: Transapical aortic valve implantation (TAVI) may lead to obstruction of coronary arteries during deployment. To prevent this, it is essential to determine the distance of the coronary ostium to the aortic annulus prior to valve placement. Multidetector computed tomography (MDCT) commonly is used to determine these measurements, but even marginal exposure to contrast agents can result in acute kidney injury in this high-risk group of multi-morbid patients. The aim of the study was to determine the feasibility of real-time 3D transesophageal echocardiography (RT 3D TEE) as the first-choice technique for noninvasive evaluation of the coronary ostium during TAVI. DESIGN: Retrospective study. SETTING: University hospital. INTERVENTIONS: Fifty patients underwent MDCT the evening before surgery. RT 3D TEE was performed intraoperatively before valve deployment. The dataset from both of these examinations was digitally stored and evaluated. MDCT was performed in nonanesthetized patients; however, in the RT 3D TEE group, general anesthesia was established. MEASUREMENTS AND MAIN RESULTS: The distances from the right coronary artery and the left coronary artery ostium were measured retrospectively. Bland-Altman Plots and linear regression analysis showed excellent correlation between the 2 methodologies; intraobserver and interobserver variance were calculated using analysis of variance. Krippendorff's α indicated excellent agreement between the 2 observers (0.96 and 0.98) as well as between RT 3D TEE and MDCT (0.97 and 0.98). CONCLUSIONS: The observations showed that RT 3D TEE reliably can measure the coronary ostium distance from the aortic annulus. It is feasible and an alternative method for evaluating these measurements and thereby preventing contrast exposure during MDCT, which may jeopardize the safety of patients with pre-existing renal disease.

Students benefit from developing their own emergency medicine OSCE stations: a comparative study using the matched-pair method.

BACKGROUND: Students can improve the learning process by developing their own multiple choice questions. If a similar effect occurred when creating OSCE (objective structured clinical examination) stations by themselves it could be beneficial to involve them in the development of OSCE stations. This study investigates the effect of students developing emergency medicine OSCE stations on their test performance. METHOD: In the 2011/12 winter semester, an emergency medicine OSCE was held for the first time at the Faculty of Medicine at the University of Leipzig. When preparing for the OSCE, 13 students (the intervention group) developed and tested emergency medicine examination stations as a learning experience. Their subsequent OSCE performance was compared to that of 13 other students (the control group), who were parallelized in terms of age, gender, semester and level of previous knowledge using the matched-pair method. In addition, both groups were compared to 20 students who tested the OSCE prior to regular emergency medicine training (test OSCE group). RESULTS: There were no differences between the three groups regarding age (24.3 ± 2.6; 24.2 ± 3.4 and 24 ± 2.3 years) or previous knowledge (29.3 ± 3.4; 29.3 ± 3.2 and 28.9 ± 4.7 points in the multiple choice [MC] exam in emergency medicine). Merely the gender distribution differed (8 female and 5 male students in the intervention and control group vs. 3 males and 17 females in the test OSCE group).In the exam OSCE, participants in the intervention group scored 233.4 ± 6.3 points (mean ± SD) compared to 223.8 ± 9.2 points (p < 0.01) in the control group. Cohen's effect size was d = 1.24. The students of the test OSCE group scored 223.2 ± 13.4 points. CONCLUSIONS: Students who actively develop OSCE stations when preparing for an emergency medicine OSCE achieve better exam results.

The Necessity of Interoperability to Uncover the Full Potential of Digital Health Devices.

Personalized health care can be optimized by including patient-reported outcomes. Standardized and disease-specific questionnaires have been developed and are routinely used. These patient-reported outcome questionnaires can be simple paper forms given to the patient to fill out with a pen or embedded in digital devices. Regardless of the format used, they provide a snapshot of the patient's feelings and indicate when therapies need to be adjusted. The advantage of digitizing these questionnaires is that they can be automatically analyzed, and patients can be monitored independently of doctor visits. Although the questions of most clinical patient-reported outcome questionnaires follow defined standards and are evaluated by clinical trials, these standards do not exist for data processing. Interoperable data formats and structures would benefit multilingual and cross-study data exchange. Linking questionnaires to standardized terminologies such as the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and Logical Observation Identifiers, Names, and Codes (LOINC) would improve this interoperability. However, linking clinically validated patient-reported outcome questionnaires to clinical terms available in SNOMED CT or LOINC is not as straightforward as it sounds. Here, we report our approach to link patient-reported outcomes from health applications to SNOMED CT or LOINC codes. We highlight current difficulties in this process and outline ways to minimize them.

Interaction Empowerment in Mobile Health: Concepts, Challenges, and Perspectives.

In its most trending interpretation, empowerment in health care is implemented as a patient-centered approach. In the same sense, many mobile health (mHealth) apps are being developed with a primary focus on the individual user. The integration of mHealth apps into the health care system has the potential to counteract existing challenges, including incomplete or nonstandardized medical data and lack of communication, especially in the intersectional context (eg, patients, medical forces). However, concerns about data security and privacy, regional differences in regulations, lack of accessibility, and nontransparent apps hinder the successful integration of mHealth into the health care system. One approach to address this is to rethink the interpretation of empowerment. On that basis, we here examine existing approaches of individual empowerment and subsequently analyze a different view of empowerment in digital health, namely interaction empowerment. Such a change of perspective could positively influence intersectoral communication and facilitate secure data and knowledge sharing. We discuss this novel viewpoint on empowerment, focusing on more efficient integration and development of mHealth approaches. A renewed interpretation of empowerment could thus buffer current limitations of individual empowerment while also advancing digitization of the health system.

Search for genetic variants in the ryanodine receptor 1 gene in patients with symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Cerebral vasospasm is one of the most serious complications after subarachnoid hemorrhage (SAH). The cerebral artery diameter is regulated by complex physiological mechanisms. Among them the regulation of intracellular calcium homeostasis seems to play a crucial role. Recent data suggest that ryanodine receptors (RYRs) are involved in regulating the luminal calcium concentration in vascular smooth muscle cells. In this gene association investigation, we studied the question as to whether variants in the gene for the ryanodine receptors subtype 1 (RYR1) are associated with symptomatic cerebral vasospasm following SAH. METHODS: After informed consent genomic DNA analysis was performed from a whole blood sample in 46 patients suffering from aneurysmal SAH. 16 Patients were affected by symptomatic vasospasm. The RYR1 gene was screened for possible genetic variants by means of direct sequencing. The association of these variants was correlated to the development of symptomatic vasospasm, which was confirmed by clinical examination combined with cerebral angiography, transcranial doppler sonography, or CT scan. RESULTS: Three different genetic RYR1 variants (c.5360C>T, c.6178G>T, and c.7244G>A) were identified in the study. The G/T genotype of RYR1 c.6178G>T was associated with an increased risk for development of symptomatic vasospasm (odds ratio 6.4; 95% CI 1.1-37.8; P = 0.04). CONCLUSION: Our pilot study suggests that RYRs are involved in the complex pathophysiology of vasospasm development following SAH. The potential role of RYR1 as a biomarker for prediction of cerebral vasospasm after SAH has to be confirmed in a larger clinical trial.