[Quality of documentation and treatment in the non-physician staffed ambulance: a retrospective analysis of emergency protocols from the city of Aachen]. / Dokumentations- und Behandlungsqualität im Rettungsdienst: eine retrospektive Analyse von Einsatzprotokollen in der Stadt Aachen.

BACKGROUND: Each year there are 7.3 million emergencies for the German rescue service, trend rising and around 59% of the emergency patients are treated by paramedics only; however, most of the studies focus on physicians, while their practical skills at the scene are rarely necessary. Accordingly, the responsibility for the patient lies with the paramedics most of the time. Their duty is to execute life-saving measures, stabilize the patient for the transport and the regular documentation of the operation. Retrospectively, the emergencies can only be analyzed based on the emergency protocols, which are mostly paper-based and handwritten. That causes an increased effort in the evaluation, which makes studies for the whole country hardly feasible. As of now there are only few data on quality of healthcare and documentation by the paramedics. Both were analyzed in this survey based on the emergency protocols. METHOD: A retrospective analysis of emergency protocols from June to July 2018 took place in Aachen, a major German city. A specific feature of Aachen is a 24­h available emergency physician via telemedicine. The quality of documentation and healthcare was analyzed by including standard operating procedures. Primary endpoints were the frequency of documentation, the achievement of complete documentation, the correct indications for a physician, the development of critical vital signs and the average on-scene time of the ambulance. RESULTS: Overall, 1935 protocols were analyzed. A complete documentation was achieved in 1323 (68.4%) suspected diagnoses, 456 (23.6%) anamneses, 350 (18.1%) initial and 52 (2.7%) vital signs at handover. Based on the documentation, there were 531 cases (27%) of patients treated by paramedics only, even though a physician would have been indicated. Out of those patients 410 critical initial vital signs were documented of which 69 (16.8%) improved, while there was no documentation of vital signs at handover in 217 (52.9%). Also, there was a significantly prolonged on-scene time for patients with belated indications for an emergency physician with 15:02 min in comparison to 13:05 min for patients without indications. CONCLUSION: Deficient documentation was found in multiple cases and several important vital signs for a complete differential diagnosis were missing. Furthermore, a quarter of all patients might have benefited from an emergency physician as they were taken to hospital with no or insufficient treatment, despite standard operating procedures. From a forensic point of view there is an alarmingly incomplete documentation of vital signs at handover. The on-scene time in general was within the predetermined time frame, but can still be reduced in different scenarios. Overall, we recommend strict adherence to the standard operating procedures and algorithms, to remove unnecessary documentation and implement a structured quality assurance. Moreover, the quality of treatment might benefit from the rising number of more specialized paramedics and an increasing use of telemedicine.

Selective yolk deposition and mannose phosphorylation of lysosomal glycosidases in zebrafish.

The regulation and function of lysosomal hydrolases during yolk consumption and embryogenesis in zebrafish are poorly understood. In an effort to better define the lysosomal biochemistry of this organism, we analyzed the developmental expression, biochemical properties, and function of several glycosidases in zebrafish eggs, embryos, and adult tissues. Our results demonstrated that the specific activity of most enzymes increases during embryogenesis, likely reflecting a greater need for turnover within the embryo as yolk-derived nutrients are depleted. Analysis of glycosidase activity in zebrafish and medaka eggs revealed selective deposition of enzymes required for the degradation of N-linked glycans, including an abundance of acidic mannosidases. Treatment of zebrafish embryos with the α-mannosidase inhibitor swainsonine resulted in the accumulation of glycosylated vitellogenin fragments and demonstrated a function for maternally deposited acid α-mannosidase in yolk consumption. Surprisingly, we also found that, unlike mammals, acid α-glucosidase from zebrafish and medaka does not appear to be modified with mannose 6-phosphate residues. We further showed these residues were not acquired on human acid α-glucosidase when expressed in zebrafish embryos, suggesting unique differences in the ability of the human and zebrafish N-acetylglucosamine-1-phosphotransferase to recognize and modify certain lysosomal glycosidases. Together, these results provide novel insight into the role of acidic glycosidases during yolk utilization and the evolution of the mannose 6-phosphate targeting system in vertebrates.