Comparison of all completed suicides in Frankfurt am Main (Hessen) before and during the early COVID-19 pandemic.

To research the effect of the COVID-19 pandemic on mental health, the prevalence and characteristics of all completed suicides in the city of Frankfurt am Main were compared for a 10-month period before the pandemic (March 2019-December 2019) with one during the early pandemic (March 2020-December 2020). Medicolegal data collected in the context of the FraPPE suicide prevention project were evaluated using descriptive statistical methods. In total, there were 81 suicides during the early pandemic period, as opposed to 86 in the pre-pandemic period. Though statistically not significant, the proportion of male suicides (73%) was higher during the early pandemic period than before (63%). The age-at-death was comparable in the pre-pandemic and pandemic periods (average, 54.8 vs. 53.1 years). Between these two periods, there was no difference in respect to the three most commonly used suicide methods by men: fall from a height (26% vs. 22%), intoxication, and strangulation (each 24% vs. 19%). For women, there was, however, a shift in methods from strangulation (38%), intoxication (28%), and fall from a height (19%) to fall from a height (50%), strangulation (18%), intoxication, and collision with a rail vehicle (14% each). There was a trend towards more suicides among non-German nationals during the early pandemic (suicide rate/100,000 inhabitants: German, 14.3 vs. 11.5; non-German, 4.4 vs. 8.8). Before the pandemic, 54% of the suicides were known to have a mental illness in contrast to 44% during the early pandemic. Overall, no increase in completed suicides could be observed in Frankfurt am Main during the early pandemic.

Helium poisoning: new procedure for sampling and analysis.

An increasing number of suicidal asphyxiation with a plastic bag with inert gases, and in particular helium (He), have been reported from numerous countries over the last decade. These cases are differently managed and lead to different and variable interpretations. Based on the 12 last cases analysed in the laboratory and on the review of the most recent literature about this topic, updated autopsy guidelines for sampling have been proposed regarding to the samples choice and analytical challenges required by the gaseous state of this substance. Biological samples from airways (lungs lobe) followed by brain and cardiac blood are the best matrices to take during the autopsy to diagnose He exposure. Gaseous samples from trachea, pulmonary bronchi, gastric and cardiac areas are also recommended as alternative samples. The anatomical site of sampling must be carefully detailed, and to this end, forensic imaging constitutes a beneficial tool. Even if He detection is sufficient to conclude to He exposure, He concentrations in samples may be related to He exposure conditions (duration, breathing rate, etc.). A quantification in biological samples could be helpful to document more precisely the case. He concentrations in gaseous samples are reported up to 6.0 µmol/mL (tracheal gas), 2.4 µmol/mL (pulmonary gas), 0.64 µmol/mL (cardiac gas) and 12 µmol/mL (gastric gas). He concentrations in solid/liquid samples are reported up to 28 µmol/g (lungs) and 0.03 µmol/g (cardiac blood). The other matrices usually sampled during autopsy such as urine, peripheral blood, liver, fat matter and kidney appear as not relevant.

[Improvement of sonographic visualization of cannula needle tips by alignment of the needle lumen : In vitro investigation of established needle tip forms]. / Verbesserung der sonographischen Sichtbarkeit von Kanülenspitzen durch Ausrichtung der Öffnungsfläche : In-vitro-Untersuchung etablierter Schliffformen.

BACKGROUND: In the context of ultrasound-guided peripheral nerve blocks (regional anesthesia), clear visualization of the needle tip and the target structure are mandatory for the performance of a safe puncture and injection. The purpose of this in vitro study was to analyze the visualization of different forms of needle tips and calibers of cannulas in a phantom simulating human tissue, with the help of a standardized image analysis system. Different depths and angles of the puncture needle in relation to the ultrasound probe were tested. MATERIAL AND METHODS: Cannula needles established for use in regional anesthesia with different surfaces, diameters and needle tip form in 23 different combinations were analyzed. A gelatine-based phantom was used to simulate human tissue. The standardized visualization of the needle tip with the ultrasound probe was performed in plane at different angles (30°, 45° and 60°), depths of penetration (1 cm, 2 cm and 3 cm) and two different alignments of the cannula needle lumen to the ultrasound probe (0° and 180°). The screenshots of the ultrasound pictures were analyzed by quantifying the pixel brightness around the needle tip (region of interest) with a standardized software (score 0-255). RESULTS: In this study 1104 ultrasound images of cannula needles were analyzed. Diminished scores (reduced pixel brightness) of the needle tips were documented with increasing distance from the ultrasound probe. Comparison of punctures at angles of 30° and 45° showed no differences in needle tip visibility (same scores) but punctures at an angle of 60° were poorly visualized compared with 30° and 45° (mean scores 87.90 ± 11.60 vs. 78.40 ± 12.07, p < 0.001 and 81.85 ± 11.79 vs. 78.40 ± 12.07, p < 0.001, respectively). The direct alignment of the cannula lumen towards the ultrasound probe (0°) was significantly more easily visualized when compared with the reverse alignment of 180° (mean scores 86.90 ± 12.74 vs. 84.80 ± 11.66, p = 0.003, respectively). No differences in visibility were detected between the different cannula needle diameters examined. The Sprotte cannula showed the best visibility score with respect to the cut of the needle tip (mean score 89.40 ± 11.72). CONCLUSION: The visibility of cannulas in ultrasound scans depends on the ultrasound frequency, angle of the puncture in relation to the ultrasound probe and the depth of penetration. The results of this study showed that direct alignment of the cannula needle lumen towards the ultrasound probe (0°) independently improved needle tip visualization. This simple measure allows a significant improvement in the safe performance of ultrasound-guided peripheral nerve blocks.

[Guidance of axillary multiple injection technique for plexus anesthesia. Ultrasound versus nerve stimulation]. / Steuerung der axillären Multiinjektionstechnik zur Plexusanästhesie. Ultraschall vs. Nervenstimulation.

BACKGROUND: Ultrasound guidance is still a young method in regional anesthesia when compared to nerve stimulation and only a few studies exist comparing these two techniques in an axillary multiple injection approach. AIM: This prospective, randomized, observer-blinded study compared an ultrasound-guided (SONO) quadruple injection axillary block (out of plane, perineural) with a nerve stimulation-guided (STIM) triple injection axillary block for upper limb surgery. MATERIAL AND METHODS: A total of 60 patients were randomized to either the SONO (n = 30) or STIM (n = 30) group. For the block 40-50 ml mepivacaine 1.5 % (plexus) and 5-10 ml mepivacaine 0.5 % (subcutaneous in the medial skin of the arm) was used. Anesthesia time was recorded as the primary end point. After evaluation of block-related pain using a visual analog scale (VAS) a blinded observer tested sensory and motor function of the median nerve (MED), ulnar nerve (ULN), radial nerve (RAD), musculocutaneous nerve of the upper limb (MUC) and medial cutaneous nerve of the forearm (CAM) at defined times. The main outcome variable was onset time (defined loss of sensory/motor function). RESULTS: No differences were observed between the groups in terms of onset time (single nerves 10-20 min, plexus 20-25 min) and success rate (SONO 90 %, STIM 89 %). Patient satisfaction as measured by block-related pain score (VAS 2 cm), complications (vascular puncture SONO 7 %, STIM 11 %; paresthesia SONO 21 %, STIM 22 %) and patient acceptance (SONO 92 %, STIM 91 %) showed no differences. Performance time was shorter in the SONO group (6.68 ± 1.72 min vs. 8.05 ± 2.58, p = 0.02). CONCLUSION: Nerve stimulation-guided axillary plexus blocks performed by trained anesthesiologists may result in similar onset times and success rates compared to ultrasound-guided blocks.

[Trauma centre admission of severely injured or critically ill patients: comparison of estimated and real arrival times]. / Schockraumaufnahme schwerverletzter oder kritisch kranker Patienten: Geschätzte und tatsächliche Eintreffzeiten im Vergleich.

BACKGROUND: During early in-hospital management of the arriving trauma patient the timing of the trauma team alert is an important organisational step. To evaluate the accordance of the estimated and the real arriving time we performed a retrospective data analysis at a level I German trauma centre. METHODS: Retrospective data analysis. Trauma team alerts from September 2010 until March 2011 were analysed. According to the hospitals pre-alert algorithm, trauma team alert took place 10 min before the estimated time of arrival. RESULTS: There were 165 trauma team alerts included in the analysis. The estimated arrival time coincided with the real arrival time in less than 10 % of cases. In 76 % of the cases, the patient arrived in an acceptable time frame with the trauma team waiting less than 14 min. In 3 % of the cases, the patient arrived prior to the trauma team. CONCLUSION: An exact estimation of the arrival time is rare. With a trauma team alert 10 min prior to the estimated time of arrival, an acceptable waiting time can be achieved. Arrival of the patient prior to the trauma team can be avoided.

Hepatic effects of an open lung strategy and cardiac output restoration in an experimental lung injury.

BACKGROUND: Ventilation with high positive end-expiratory pressure (PEEP) can lead to liver dysfunction. We hypothesized that an open lung concept (OLC) using high PEEP impairs liver function and integrity dependent on the stabilization of cardiac output. METHODS: Juvenile female Pietrain pigs instrumented with flow probes around the common hepatic artery and portal vein, pulmonary and hepatic vein catheters underwent a lavage-induced lung injury. Ventilation was continued with a conventional approach (CON) using pre-defined combinations of PEEP and inspiratory oxygen fraction or with an OLC using PEEP set above the lower inflection point of the lung. Volume replacement with colloids was guided to maintain cardiac output in the CON(V+) and OLC(V+) groups or acceptable blood pressure and heart rate in the OLC(V-) group. Indocyanine green plasma disappearance rate (ICG-PDR), blood gases, liver-specific serum enzymes, bilirubin, hyaluronic acid and lactate were tested. Finally, liver tissue was examined for neutrophil accumulation, TUNEL staining, caspase-3 activity and heat shock protein 70 mRNA expression. RESULTS: Hepatic venous oxygen saturation was reduced to 18 + or - 16% in the OLC(V-) group, while portal venous blood flow decreased by 45%. ICG-PDR was not reduced and serum enzymes, bilirubin and lactate were not elevated. Liver cell apoptosis was negligible. Liver sinusoids in the OLC(V+) and OLC(V-) groups showed about two- and fourfold more granulocytes than the CON(V+) group. Heat shock protein 70 tended to be higher in the OLC(V-) group. CONCLUSIONS: Open lung ventilation elicited neutrophil infiltration, but no liver dysfunction even without the stabilization of cardiac output.

A local neighborhood volunteer network improves response times for simulated cardiac arrest.

AIM: Each minute is crucial in the treatment of out-of-hospital cardiac arrest (CA). Immediate chest compressions and early defibrillation are keys to good outcomes. We hypothesized that a coordinated effort of alerting trained local neighborhood volunteers (vols) simultaneously with 911 activation of professional EMS providers would result in substantial decreases in call-to-arrival times, leading to earlier CPR and defibrillation. METHODS: We developed a program of simultaneously alerting CPR- and AED-trained neighborhood vols and the local EMS system for CA events in a retirement residential neighborhood in Southern Arizona, encompassing approximately 440 homes. The closest EMS station is 3.3 miles from this neighborhood. Within this neighborhood, 15 vols and the closest EMS station were involved in multiple days of mock CA notifications and responses. RESULTS: The two groups differed significantly in distance to the mock CA event and in response times. The volunteers averaged 0.3 ±â€¯0.2 miles from the mock CA incidences while the closest EMS station averaged 3.4 ±â€¯0.1 miles away (p < 0.0001). Response times (time from call to arrival) also differed. Two volunteers, one bringing an AED, averaged 1 min 38 s ±â€¯53 s in Phase 1, while it took the EMS service an average of 7 min 20 s ±â€¯1 min 13 s to arrive on scene; p < 0.0001. CONCLUSION: Local neighborhood volunteers were geographically closer and arrived significantly sooner at the mock CA scene than did the EMS service. The approximate time savings from call to arrival with the volunteers was 4-6 min.

Arteriovenous extracorporeal lung assist as integral part of a multimodal treatment concept: a retrospective analysis of 22 patients with ARDS refractory to standard care.

BACKGROUND AND OBJECTIVES: Pumpless arteriovenous extracorporeal lung assist is increasingly used as a rescue therapy in acute respiratory distress syndrome. Arteriovenous extracorporeal lung assist is highly efficient in eliminating carbon dioxide and allows the application of ventilator techniques that prioritize lung protection and aim to reduce ventilator-induced lung injury and remote organ dysfunction. METHODS: Retrospective data analysis performed in a 12-bed university hospital ICU. In all, 22 patients with acute respiratory distress syndrome refractory to standard care were included. Arteriovenous extracorporeal lung assist as central part of a multimodal treatment concept was combined with tidal volume (VT) reduction below 4 mL kg-1 predicted body weight, a positive end-expiratory pressure titrated to optimize oxygenation and continuous axial rotation. RESULTS: Hypercapnia was reversed within 24 h in survivors (39 mmHg (35-42) (median and interquartile range) vs. 65 mmHg (54-72), P < 0.05) and non-survivors (5.2 kPa (5.5-6.0) vs. 10 kPa (6.9-13.9), P < 0.05). Oxygenation was significantly improved in survivors after 24 h (PaO2/FiO2 ratio 20.7 kPa (17.4-22.7) vs. 11.7 kPa (7.3-20.8), P < 0.05). All patients required norepinephrine infusion and volume resuscitation. The overall complication rate was 23%, predominantly due to reversible lower limb ischaemia. One patient (5%) was permanently disabled due to amputation of a seriously injured lower leg 9 days after initiation of arteriovenous extracorporeal lung assist therapy; however, the patient survived without neurological deficits despite an initial oxygenation index of 4.4 kPa. The overall mortality rate was 27%. CONCLUSIONS: A multimodal treatment concept with arteriovenous extracorporeal lung assist as its central part provides reversal of hypercapnia and stabilization of oxygenation. In an attempt to maximize lung protection and potentially reduce ventilator-induced lung injury, a further VT reduction below 4 mL kg(-1) predicted body weight combined with a high mean airway pressure and continuous axial rotation is safely possible.

[Cholestasis and liver dysfunction in critical care patients]. / Cholostase und Leberinsuffizienz beim Intensivpatienten.

Cornerstones of the diagnostic investigations of disturbances in liver function are analysis and sophisticated evaluation of serum liver enzymes, bilirubin and ammonia. Coagulation factors, serum albumin and cholinesterase levels are indicators of the hepatic metabolic capacity. Dynamic assessment of complex liver functions allows quantification of the hepatic metabolic activity and excretory function. Imaging techniques permit visualization of the size and texture of the liver, the vascular supply and perfusion as well as an assessment of the gall bladder and the extra-hepatic and intra-hepatic bile ducts. Manifold causes for cholestasis and/or liver dysfunction are known, such as ventilation with high pressure, total parenteral nutrition, shock, hypoxia and certain drugs. Obstructive cholestasis requires reconstitution of bile duct drainage, while non-obstructive cholestasis primarily requires treatment of the causative disease. The symptomatic therapy of liver insufficiency is rarely possible via direct treatment of the cause, but mostly requires specific management of secondary organ dysfunctions related to hepatic dysfunction including circulatory failure, hepatorenal syndrome and hepatic encephalopathy. In rare cases a temporary liver surrogate is necessary. The molecular absorbent recirculating system (MARS), a form of extracorporeal albumin dialysis, is introduced as a modality for the treatment of liver failure.

[In-vivo diagnosis of malignant hyperthermia susceptibility: a microdialysis study]. / In-vivo-Diagnostik einer malignen-Hyperthermie-Disposition: Eine Mikrodialysestudie.

BACKGROUND: In malignant hyperthermia (MH), volatile anesthetics induce hypermetabolism, lactic acidosis and rhabdomyolysis in predisposed patients. The authors hypothesized that intramuscular caffeine and halothane application would increase local lactate concentration in MH susceptible (MHS) individuals more than in non-susceptible (MHN) subjects without initiating the full MH syndrome. METHODS: In 14 MHS, 12 MHN and 7 control individuals, microdialysis probes were placed in the rectus femoris muscle and perfused with Ringer's solution at 1 microl/min. After equilibration, 250 microl caffeine (80 mM) was injected through the first microdialysis probe, halothane 10 vol% dissolved in soybean oil was perfused through a second microdialysis probe and a third probe was used for control measurements. Dialysate samples were analyzed for lactate spectrophotometrically. Systemic hemodynamic and metabolic parameters were measured. Data are presented as median and quartiles. RESULTS: Intramuscular caffeine and halothane significantly increased local peak concentrations of lactate in MHS probands [5.0 mM (3.4-8.1 mM) and 3.7 mM (2.6-5.0 mM), respectively] compared to MHN [1.6 mM (1.3-2.0 mM) and 1.9 mM (1.6-2.0 mM)] or control individuals [2.1 mM (1.9-2.3 mM) and 2.0 mM (1.6-2.1 mM)]. This was accompanied by a higher serum creatine kinase level in the MHS group. Hemodynamic and metabolic parameters were normal in the investigated groups. CONCLUSION: Intramuscular caffeine and halothane application induces a temporary and abnormal increase of local lactate in MHS individuals. No serious systemic side effects occurred. This study presents evidence that metabolic monitoring with local stimulation by caffeine and halothane may allow a minimally invasive diagnosis of MH susceptibility.

Femur-bending properties as influenced by gravity: III. Sex-related weakness after 4-G mouse growth.

Optimum gravitational intensity for growth stimulation depends upon the type of growth measurement. Although the 4-G field resulted in relatively weaker male bones, relative bone size increased. The more moderate 3-G field is known to stimulate relative bone-strength as well. Femurs from 36 male white mice demonstrated no growth of load-supporting ability Fu after 1 to 8 weeks of chronic centrifugation at 4-G from the fifth week of age. Although measurable with 35 female mice, this growth intended to fall below the control rate. When compared to 82 younger control femurs of the same cross-sectional geometry, experimental female femurs could sustain comparable moments Mu while experimental male femurs could not.

Femur-bending properties as influenced by gravity: II. Ultimate load, moment, and stress for 3-G mice.

Material strength as approximated from bending studies of fresh femurs grew during 1 to 8 weeks of hypergravity at rates which were not measurably affected, even though the animal's body growth was measurably slower. As a result, femurs could support greater ultimate loads, moments, and stresses when compared to control bones of comparable rotational moments of their cross-sectional areas. Chronic centrifugation simulated 3.1 G for 45 male. Swiss Webster mice compared to 37 control animals. Effects were most noticeable after the first week of exposure and for younger animals. Effect were only about 50% that noted in comparable treatment of rats. This suggests that four times more mice than rats may be necessary for space-experiments designed to test the effects of weightlessness.

Femur-bending properties as influenced by gravity: IV. Limits after high and low weight-bearing.

Gravity enhances femur growth as measured in terms of strength sigma u, but shows little or even a growth-retarding effecting in terms of "relative brittleness," defined as the inverse 1/epsilon u of ultimate or tolerable strain. Chronic weightlessness was simulated by harness suspension or by extrapolation of results from 3-G centrifugation. Experimental results from 45 male, white rats (34-520 d old) were compared to 72 control or baseline rats (28-520 d old) white correction for age and size differences. After suspension, the youngest rats showed subnormal epsilon u. Combined results, however, although predicting 19 +/- 1% below normal sigma u, after a week of weightlessness, predicted less effect (1 +/- 4%) for epsilon u.

Knee-ligament loading properties as influenced by gravity: I. Junction with bone of 3-G rodents.

After chronic 3-G centrifugation of rats, their bone-to-ligament junctions exhibited 95 +/- 12% of the control junctions' force-sustaining capacity (F). F was actually 29 +/- 5% greater for centrifuged rats than for control rats of comparable size, as experimental animals grew to smaller body mass. This suggests that gravity determines part of F's magnitude. These junctions are, therefore, hypothesized to be weaker after development in a weightless environment. The effect was less measurable for mice. F was measured in situ as load needed to separate the knee's medial collateral ligament from the tibia of 34 male rats (Sprague-Dawley, 27-320 d of age, exposed 4-65 d), 30 control rats, 22 male mice (Swiss Webster, 35-166 d, exposed 9-56 d), and 15 control mice.

Femur-bending properties as influenced by gravity: V. Strength vs. calcium and gravity in rats exposed for 2 weeks.

Growing bone material strength (S) can increase with gravitational intensity (g). That would be consistent with demineralization reported during space flight and reports that strength increases with mineral content. This study, however, shows an increase in material strength independent of calcium content (C). Male, Sprague-Dawley rats were exposed to chronic simulations of altered gravity from the 28th to 42nd d of age. Zero G was stimulated for 13 animals by harness suspension and 3 G for 30 animals by centrifugation. For fresh femurs, S as determined by bending and C as determined by AA spectrometry were compared with results for 11 harnessed, control animals and 13 normal, control animals. Multiple regression shows significant dependence of S (10(6) N.m-2) upon g (multiples of Earth's gravity, G) as independent from C (% by mass) for which there is no significant coefficient of partial regression: S = (62 +/- 1) + (7 +/- 1 g) + (0 +/- C).

Femur-bending properties as influenced by gravity: I. Ultimate load and moment for 3-G rats.

Fresh experimental bones can withstand greater bending forces and moments after 1.0 to 2.5 weeks of 3-G exposure. This appears more attributable to a 50% greater strength of bone material than to effects upon size or shape, and is most measurable for animals of 5 to 8 weeks of age. Experimental bone material seems to grow to its mature level at a younger age rather than there being so marked an effect upon the mature level itself. We simulated 3.1 G by chronic centrifugation of 66 albino rats and compared them to 63 1-G controls. Extrapolation of the simplest mathematical description of the present results to weaker, zero-G bones could be tested by a total of 60 space-based control and experimental animals. A flight of only 15 animals would be necessary for comparison to ground-based control animals. This is consistent with reports of bone demineralization during space-flight. In light of the differences in bone histology, however, extrapolation of these results to humans would be premature and, if at all applicable, are most likely to be so for children rather than adults.

Early repair of open abdomen with a tailored two-component mesh and conditioning vacuum packing: a safe alternative to the planned giant ventral hernia.

PURPOSE: Once open abdomen therapy has succeeded, the problem of closing the abdominal wall must be addressed. We present a new four-stage procedure involving the application of a two-component mesh and vacuum conditioning for abdominal wall closure of even large defects. The aim is to prevent the development of a giant ventral hernia and the eventual need for the repair of the abdominal wall. METHODS: Nineteen of 62 patients treated by open abdomen over a two-year period could not receive primary abdominal wall closure. To achieve closure in these patients, we applied the following four-stage procedure: stage 1: abdominal damage control and conditioning of the abdominal wall; stage 2: attachment of a tailored two-component mesh of polyglycolic acid (PGA) and large pore polypropylene (PP) in intraperitoneal position (IPOM) plus placement of a vacuum bandage; stage 3: vacuum therapy for 3-4 weeks to allow granulation of the mesh and optimization of dermatotraction; stage 4: final skin suture. During stage 3, eligible patients were weaned from respirator and mobilized. RESULTS: The abdominal wall gap in the 19 patients ranged in size from 240 cm(2) to more than 900 cm(2). An average of 3.44 vacuum dressing changes over 19 days were required to achieve 60-100 % granulation of the surface area, so final skin suture could be made. Already in stage 3, 14 patients (73.68 %) could be weaned from respirator an average of 6.78 days after placement of the two-component mesh; 6 patients (31.57 %) could be mobilized on the edge of the bed and/or to a bedside chair after an average of 13 days. No mesh-related hematomas, seromas, or intestinal fistulas were observed. CONCLUSION: The four-stage procedure presented here is a viable option for achieving abdominal wall closure in patients treated with open abdomen, enabling us to avoid the development of planned giant ventral hernias. It has few complications and has the special advantage of allowing mobilization of the patients before final skin closure. Long-term course in a large number of patients must still confirm this result.