Self-assessment of people with relapsing-remitting and progressive multiple sclerosis towards burden of disease, progression, and treatment utilization-Results of a large-scale cross-sectional online survey (MS Perspectives).

BACKGROUND: Assessment of the disease course by people with multiple sclerosis (pwMS) themselves is important for a better understanding of the complex disease, patient counseling and treatment decisions. This may also facilitate identifying the often-unnoticed transition from relapsing-remitting (RRMS) to secondary progressive multiple sclerosis (SPMS). OBJECTIVE: MS Perspectives was designed to collect data on patients' self-assessment of multiple sclerosis (MS) symptoms, relapse-independent progression, and impact on everyday life. METHODS: MS Perspectives is a cross-sectional online survey conducted among adult pwMS in Germany. The questionnaire included 36 items on sociodemographic and clinical characteristics as well as pharmacological and non-pharmacological treatment. RESULTS: In total, 4555 pwMS completed the survey between December 2021 and February 2022, 69.2% had RRMS, 15.1% had SPMS. Relapse-independent worsening of symptoms was reported by 88.9% of RRMS patients with marked to severe and by 61.8% with no or mild to moderate disability. Problems with walking were most frequently (32.1%) mentioned as most bothersome by RRMS patients with marked to severe disability, fatigue, and cognitive impairment by RRMS patients with no or mild to moderate disability. CONCLUSION: MS Perspectives gives an important insight in the self-assessed disease course and impact on daily life in a large-scale cohort of pwMS.

[Oncological emergencies with special consideration of the side effects of checkpoint inhibitors]. / Onkologische Notfälle mit besonderer Berücksichtigung der Nebenwirkungen von Checkpoint-Inhibitoren.

Oncological patients are already exceedingly burdened due to their underlying disease, so that another complication can quickly cause significant deterioration of the state of health. Febrile neutropenia should be rapidly treated with anti-infective agents and malignant hypercalcemia requires a rapid diagnosis. In the case of suspected checkpoint inhibitor-associated toxicity, an interdisciplinary consultation is often necessary.

Anti-PF4 VITT antibodies are oligoclonal and variably inhibited by heparin.

BACKGROUND: COVID-19 vaccines have been associated with a rare thrombotic and thrombocytopenic reaction, Vaccine-induced immune thrombotic thrombocytopenia (VITT) characterized by platelet-activating anti-PF4 antibodies. This study sought to assess clonality of VITT antibodies and evaluate their characteristics in antigen-based and functional platelet studies. METHODS: Anti-PF4 antibodies were isolated from five patients with VITT secondary to ChAdOx1 nCoV-19 (n=1) or Ad26.COV2.S (n=4) vaccination. For comparative studies with heparin-induced thrombocytopenia (HIT), anti-PF4 antibodies were isolated from one patient with spontaneous HIT, another with "classical" HIT, and two patients with non-pathogenic (non-platelet activating) anti-PF4 antibodies. Isolated antibodies were subject to ELISA and functional testing, and mass spectrometric evaluation for clonality determination. RESULTS: All five VITT patients had oligoclonal anti-PF4 antibodies (3 monoclonal, one bi- and one tri-clonal antibodies), while HIT anti-PF4 antibodies were polyclonal. Notably, like VITT antibodies, anti-PF4 antibodies from a spontaneous HIT patient were monoclonal. The techniques employed did not detect non-pathogenic anti-PF4 antibodies. The ChAdOx1 nCoV-19-associated VITT patient made an excellent recovery with heparin treatment. In vitro studies demonstrated strong inhibition of VITT antibody-induced platelet activation with therapeutic concentrations of heparin in this and one Ad26.COV2.S-associated VITT patient. Oligoclonal VITT antibodies with persistent platelet-activating potential were detected at 6 and 10 weeks after acute presentation in two patients tested. Two of the 5 VITT patients had recurrence of thrombocytopenia and one patient had focal seizures several weeks after acute presentation. CONCLUSION: Oligoclonal anti-PF4 antibodies mediate VITT. Heparin use in VITT needs to be further studied.

Early standardized clinical judgement for syncope diagnosis in the emergency department.

BACKGROUND: The diagnosis of cardiac syncope remains a challenge in the emergency department (ED). OBJECTIVE: Assessing the diagnostic accuracy of the early standardized clinical judgement (ESCJ) including a standardized syncope-specific case report form (CRF) in comparison with a recommended multivariable diagnostic score. METHODS: In a prospective international observational multicentre study, diagnostic accuracy for cardiac syncope of ESCJ by the ED physician amongst patients ≥ 40 years presenting with syncope to the ED was directly compared with that of the Evaluation of Guidelines in Syncope Study (EGSYS) diagnostic score. Cardiac syncope was centrally adjudicated independently of the ESCJ or conducted workup by two ED specialists based on all information available up to 1-year follow-up. Secondary aims included direct comparison with high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) concentrations and a Lasso regression to identify variables contributing most to ESCJ. RESULTS: Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of ESCJ for cardiac syncope as quantified by the area under the curve (AUC) was 0.87 (95% CI: 0.84-0.89), and higher compared with the EGSYS diagnostic score (0.73 (95% CI: 0.70-0.76)), hs-cTnI (0.77 (95% CI: 0.73-0.80)) and BNP (0.77 (95% CI: 0.74-0.80)), all P < 0.001. Both biomarkers (alone or in combination) on top of the ESCJ significantly improved diagnostic accuracy. CONCLUSION: ESCJ including a standardized syncope-specific CRF has very high diagnostic accuracy and outperforms the EGSYS score, hs-cTnI and BNP.

[Quality of life and posttraumatic stress disorder after out-of-hospital cardiac arrest]. / Lebensqualität und posttraumatische Belastungsstörung nach außerklinischer Reanimation.

BACKGROUND: Survival rate after out-of-hospital cardiac arrest (OHCA) is increasing. However, there is a lack of data concerning long-term quality of life of affected patients. OBJECTIVES: This study aims to investigate the psychological effects of out-of-hospital cardiopulmonary resuscitation. METHODS: All patients who were admitted to our hospital after OHCA between 01 January 2008 and 30 June 2015 and could be discharged in good neurological condition were asked to fill out the Impact of Event Scale-Revised (IES-R) and 36-Item Short Form Health Survey (SF-36). For statistical analysis, the mean, standard deviation and student's t­test were used (level of significance p < 0.05). RESULTS: Of 280 OHCA survivors, 56 patients (20.0%) were discharged from the hospital in good neurological condition. Of those, 20 patients (35.7%) were willing to participate in this study, among them 11 women and 9 men. Compared to the cohort of the German normative data, the results of the SF-36 questionnaire of OHCA survivors showed significantly lower values in all SF-36 subscales and also for the summary scores. There was no significant difference compared to patients with myocardial infarction. Average values of the IES-R subscales for intrusion and avoidance were 9.9 ± 9.3 and 9.7 ± 7.7, respectively, and 11.3 ± 7.4 for hyperarousal. Calculations indicated the suspected diagnosis of posttraumatic stress disorder in 2 of the 20 patients (10%). DISCUSSION: Even in patients who could be discharged from the hospital after OHCA in good neurological condition, the quality of life is significantly lower compared to the standard population but not compared to patients with myocardial infarction. The data also suggest that a relevant number of patients after OHCA is affected by posttraumatic stress disorder. Further research efforts on optimization of post-resuscitation care should not only focus on survival rates but also on improving quality of life.

[Supraglottic airway devices and intraosseous access in the treatment of patients after out-of-hospital cardiac arrest : Do we use the wrong tool too often?] / Supraglottische Atemwegssicherung und intraossärer Zugang in der Behandlung von Patienten nach außerklinischem Herz-Kreislauf-Stillstand : Verwenden wir das falsche Hilfsmittel zu oft?

INTRODUCTION: Only a little is known about the frequency of use of supraglottic airway devices (SADs) and intraosseous (IO) access in patients who have had out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS: We analyzed data from all patients who had had OHCA admitted to our hospital between 1 January 2008 and 31 December 2017. RESULTS: A total of 135 (33.8%) patients who had had OHCA were admitted with a SAD, 223 (55.8%) with an endotracheal tube, 3 (0.8%) with mask ventilation, and 32 (8.0%) breathed spontaneously on admission to hospital. Three hundred and twenty-eight patients (82.0%) were admitted with a peripheral intravenous line, one (0.3%) with a central venous catheter, one (0.3%) with a port catheter, and 32 (8.0%) with IO access. CONCLUSIONS: Irrespective of an increasing number of studies that raise the question whether the airway management of patients who have had OHCA using an SGA might be inferior to that with endotracheal tubes, approximately one third of all patients who have had OHCA were admitted with an SAD in this study. On the other hand, IO access is significantly less frequently used, despite fewer critical study results overall.

[Anticoagulation in geriatric patients with atrial fibrillation : With what and for whom no more?] / Antikoagulation bei Vorhofflimmern im Alter : Womit und bei wem nicht mehr?

Based on established risk scores, such as the CHA2DS2-VASc score, the indications for oral anticoagulation are given for patients over 65 years old with atrial fibrillation and even more so for patients over 75 years old. Before beginning anticoagulation a geriatric assessment for evaluation of the cognitive ability, the activities of daily living and the risk of falling should be made because of the known complications of anticoagulation. Geriatric patients with non-valvular atrial fibrillation (AF) are increasingly being treated with non-vitamin K antagonist oral anticoagulants (NOAC) to prevent ischemic stroke. The European Society for Cardiology (ESC) guidelines for the management of AF recommended NOACs as the preferred treatment and vitamin K antagonists (VKA) only as an alternative option. Meanwhile, apixaban, rivaroxaban, and edoxaban as factor Xa inhibitors and dabigatran as a thrombin inhibitor, are more commonly used in clinical practice in patients with AF. Although, these drugs have pharmacodynamics and pharmacokinetic similarities and are often grouped together, it is important to recognize that the pharmacology and dose regimens differ between compounds. Especially in elderly patients the new drugs have interesting advantages compared to VKA, i. e., less drug-drug interactions with concomitant medication and a more favorable risk-benefit ratio mostly driven by the reduction of bleeding. Treatment of anticoagulation in elderly patients requires weighing the serious risk of stroke with an equally high risk of major bleeding and pharmacoeconomic considerations. The easier practicality of NOACs in routine practice must be emphasized as no international normalized ratio (INR) monitoring is necessary and the interruption of treatment for planned interventions is uncomplicated. A regular monitoring of the indications for NOACs is indispensable (as for all other medications). Especially elderly patients have the greatest benefit from NOAC along with a low renal elimination rate and they should certainly not be withheld from elderly patients who have a clear need for oral anticoagulation.

[Are emergency physicians influenced by nonmedical aspects in their choice of the hospital : Observations in 280 victims of out-of-hospital cardiac arrest in times of hospital alliances]. / Sind Notärzte bei der Wahl der Zielklinik durch nichtmedizinische Aspekte beeinflusst : Beobachtungen an 280 Patienten nach außerklinischem Herzstillstand in Zeiten der Krankenhauskooperationen.

INTRODUCTION: Emergency physicians are responsible for the out-of-hospital treatment of victims from out-of-hospital cardiac arrest (OHCA), not only with regard on the medical treatment, but also in terms of the choice of the most suitable hospital. We therefore wanted to determine whether nonmedical processes such as hospital alliances lead to changing rates of hospital admissions of patients following OHCA. MATERIALS AND METHODS: All patients who were admitted in our hospital following OHCA between 1 January 2008 and 30 June 2015 were identified and their data were anonymously stored in a central database. Afterward, we divided the study period into three periods: (1) the period prior to the publication of the ERC guidelines 2010, (2) the period after the publication of the ERC guidelines 2010, and (3) the period after a contract for hospital alliances with another hospital in town was signed. RESULTS: Of the 280 OHCA victims, we could analyze the emergency physician's reports of 238 victims from nontraumatic OHCA; there were 143 men (60.1 %) and 95 women (39.9 %) with an age of 69.1 ± 13.7 years. Following the changes in the guidelines in 2010, we observed a 42.8 % increase of hospital admissions from 2.15 admissions per month to 3.07 in period 2 following OHCA compared to period 1. After signing of the hospital alliance, there was an additional increase of 42.3 % to an average of 4.37 hospital admissions per month. DISCUSSION AND CONCLUSION: According to our data, it might be possible that not only medical influences (e.g., changes in the guidelines) but also nonmedical aspects (e.g., hospital alliances) might influence the choice of hospital for the further treatment of victims from OHCA.

[Pharmacokinetics and pharmacodynamics of antibiotics in intensive care]. / Pharmakokinetik und Pharmakodynamik von Antibiotika in der Intensivmedizin.

Optimized dosage regimens of antibiotics have remained obscure since their introduction. During the last two decades pharmacokinetic(PK)-pharmacodynamic(PD) relationships, originally established in animal experiments, have been increasingly used in patients. The action of betalactams is believed to be governed by the time the plasma concentration is above the minimum inhibitory concentration (MIC). Aminoglycosides act as planned when the peak concentration is a multiple of the MIC and vancomycin seems to work best when the area under the plasma vs. time curve (AUC) to MIC has a certain ratio. Clinicians should be aware that these relationships can only be an indication in which direction dosing should go. Larger studies with sufficiently high numbers of patients and particularly severely sick patients are needed to prove the concepts. In times where all antibiotics can be measured with new technologies, the introduction of therapeutic drug monitoring (TDM) is suggested for ICUs (Intensive Care Unit). The idea of a central lab for TDM of antibiotics such as PEAK (Paul Ehrlich Antibiotika Konzentrationsmessung) is supported.

Accuracy of Point-of-Care B-Line Lung Ultrasound in Comparison to NT-ProBNP for Screening Acute Heart Failure.

AIM: The objective of this pilot study was to determine the accuracy of point-of-care B-line lung ultrasound in comparison to NT Pro-BNP for screening acute heart failure. MATERIALS AND METHODS: An 8-zone lung ultrasound was performed by experienced sonographers in patients presenting with acute dyspnea in the ED. AHF was determined as the final diagnosis by 2 independent reviewers. RESULTS: Contrary to prior studies, B-line ultrasound in our study was highly specific, but moderately sensitive for identifying patients with AHF. There was a strong association between elevated NT-proBNP levels and an increased number of B-lines. CONCLUSION: In conclusion, point-of-care lung ultrasound is a helpful tool for ruling in or ruling out important differential diagnoses in ED patients with acute dyspnea.

Acute heart failure and cardiogenic shock: a multidisciplinary practical guidance.

PURPOSE: Acute heart failure (AHF) causes high burden of mortality, morbidity, and repeated hospitalizations worldwide. This guidance paper describes the tailored treatment approaches of different clinical scenarios of AHF and CS, focusing on the needs of professionals working in intensive care settings. RESULTS: Tissue congestion and hypoperfusion are the two leading mechanisms of end-organ injury and dysfunction, which are associated with worse outcome in AHF. Diagnosis of AHF is based on clinical assessment, measurement of natriuretic peptides, and imaging modalities. Simultaneously, emphasis should be given in rapidly identifying the underlying trigger of AHF and assessing severity of AHF, as well as in recognizing end-organ injuries. Early initiation of effective treatment is associated with superior outcomes. Oxygen, diuretics, and vasodilators are the key therapies for the initial treatment of AHF. In case of respiratory distress, non-invasive ventilation with pressure support should be promptly started. In patients with severe forms of AHF with cardiogenic shock (CS), inotropes are recommended to achieve hemodynamic stability and restore tissue perfusion. In refractory CS, when hemodynamic stabilization is not achieved, the use of mechanical support with assist devices should be considered early, before the development of irreversible end-organ injuries. CONCLUSION: A multidisciplinary approach along the entire patient journey from pre-hospital care to hospital discharge is needed to ensure early recognition, risk stratification, and the benefit of available therapies. Medical management should be planned according to the underlying mechanisms of various clinical scenarios of AHF.

[Cardiogenic shock after drug therapy for atrial fibrillation with tachycardia : Case report of an 89-year-old woman]. / Kardiogener Schock nach bradykardisierender Therapie bei tachykardem Vorhofflimmern : Fallvorstellung einer 89-jährigen Patientin.

ß-Blockers and calcium channel blockers are commonly used drugs in the treatment of atrial fibrillation with tachycardia. However, in patients with high myocardial susceptibility and vulnerability, combination therapy with ß-blockers and non-dihydropyridine calcium channel blockers (verapamil or diltiazem) but also individual administration can cause drug-induced cardiogenic shock. Thus, the simultaneous administration of ß-blockers and non-dihydropyridine calcium channel blockers is absolutely contraindicated. In case of acute heart failure, isolated application is also contraindicated. In the treatment of a cardiogenic shock induced by ß-blockers and/or non-dihydropyridine calcium channel blockers, administration of intravenous calcium, glucagon or high-dose insulin is recommended.

[The availability of living wills in an interdisciplinary emergency department: results of a patient survey]. / Verfügbarkeit von Patientenverfügungen in einer interdisziplinären Notaufnahme.

INTRODUCTION: Despite an increasing attention to living wills, the effects of such living wills on patient care in the emergency departments remains unknown. MATERIAL AND METHODS: All patients who were admitted to our emergency department between September 24th, 2014 and November 23th, 2014 were asked, whether they have signed living wills previously and if so, whether they have it on hand at admission. RESULTS: 496 patients (229 men (46.2 %), 267 women (53.8 %)) with a mean age of 64.9 ±â€…18.8 years were included in this survey. 138 patients (27.8 %) had a living will but only 16 patients (3.2 %) had it on hand.Altogether, the existence of living wills increased with an increasing patient`s age; only 5 of 117 patients aged 50 years old or younger (4,3 %) had a living will, but 133 of 379 patients older than 50 years (35,1 %). DISCUSSION AND CONCLUSION: Despite an obviously broad acceptance of living wills especially in the elderly population, there are hardly any consequences on the daily patient care in an emergency department by now, as hardly any patient has hers or his living will on hand at admission. We therefore see the need for further educational work to guarantee that living wills get adequate priority in patient care at emergency departments.

[Quality management in emergency departments: Lack of uniform standards for fact-based controlling]. / Qualitätsmanagement in der Notaufnahme: Fehlende einheitliche Standards zur kennzahlenbasierten Steuerung.

BACKGROUND: The general high occupancy of emergency departments during the winter months of 2014/2015 outlined deficits in health politics. Whether on the regional, province, or federal level, verifiable and accepted figures to enable in depth analysis and fact-based controlling of emergency care systems are lacking. OBJECTS: As the first step, reasons for the current situation are outlined in order to developed concrete recommendations for individual hospitals. METHODS: This work is based on a selective literature search with focus on quality management, ratio driven management, and process management within emergency departments as well as personal experience with implementation of a key ratio system in a German maximum care hospital. RESULTS AND CONCLUSION: The insufficient integration of emergencies into the DRG systematic, the role as gatekeeper between inpatient and outpatient care sector, the decentralized organization of emergency departments in many hospitals, and the inconsistent representation within the medical societies can be mentioned as reasons for the lack of key ratio systems. In addition to the important role within treatment procedures, emergency departments also have an immense economic importance. Consequently, the management of individual hospitals should promote implementation of key ratio systems to enable controlling of emergency care processes. Thereby the perspectives finance, employees, processes as well as partners and patients should be equally considered. Within the process perspective, milestones could be used to enable detailed controlling of treatment procedures. An implementation of key ratio systems without IT support is not feasible; thus, existing digital data should be used and future data analysis should already be considered during implementation of new IT systems.

[Recognition of infections in elderly emergency patients]. / Erkennen von Infektionen beim älteren Notfallpatienten.

BACKGROUND: Elderly patients represent an increasing population in the emergency department (ED) and physicians often have to deal with multimorbidity and complexity. Infections are one of the major reasons for ED presentations of older patients and the main cause of mortality; however, infections are often difficult to diagnose in older patients. AIM: This article provides a review of important indicators for infections, diagnostic tools and limitations in elderly patients. MATERIAL AND METHODS: A literature search was carried out using PubMed in the period 1990-2015 and in addition own published data are presented. RESULTS AND CONCLUSION: Infections in the elderly are difficult to assess in the emergency department due to atypical symptoms. Even subtle changes need to be recognized. For the diagnosis of infections in older ED patients unspecific symptoms, vital parameters, laboratory parameters, including C-reactive protein (CRP) and procalcitonin levels, cognitive function and functionality of the patient need to be taken into account.

[Chest pain units or chest pain algorithm?]. / Chest Pain Units oder Chest-Pain-Algorithmus?

BACKGROUND: A large number of patients present to the emergency department (ED) for evaluation of acute chest pain. About 10-15% are caused by acute myocardial infarction (MI), and over 50% of cases are due to noncardiac reasons. Further improvement for chest pain evaluation appears necessary. OBJECTIVES: What are current options to improve chest pain evaluation in Germany? METHODS: A selective literature search was performed using the following terms: "chest pain", "emergency department", "acute coronary syndrome" and "chest pain evaluation". RESULTS AND DISCUSSION: A working group of the German Society of Cardiology published recommendations for infrastructure, equipment and organisation of chest pain units in Germany, which should be separated from the ED of hospitals and be under the leadership of a cardiologist. A symptom-based decision for acute care would be preferable if all differential diagnoses of diseases could be managed by one medical specialty: However, all four main symptoms of patients with acute MI (chest pain, acute dyspnea, abdominal pain, dizziness) are also caused by diseases of different specialties. Evaluation and treatment of acute chest pain by representatives of one specialty would lead to over- or undertreatment of affected patients. Therefore we suggest a multidisciplinary evaluation of patients with acute chest pain including representatives of emergency and critical care physicians, cardiologists, internists, geriatricians, family physicians, premedics and emergency nurses. Definition of key indicators of performance and institutionalized feedback will help to further improve quality of care.

[Who observes out-of-hospital cardiac arrests in Germany?]. / Wer beobachtet in Deutschland den außerklinischen Herzstillstand?

INTRODUCTION: It still remains unknown why there are so poor rates of lay-resuscitation in Germany. We wanted to find out who observes the out-of-hospital cardiac arrests (OHCA) in Germany. PATIENTS AND METHODS: All patients who were admitted in our hospital between January, 1st 2008 and December, 31st 2013 following non-traumatic OHCA were identified and the patients' data were stored on a central data base. RESULTS: Data on 204 patients (124 male [60,8 %], 80 female [39,2 %], aged 69,1 ±â€Š14,2 years [range 18-97 years]) were analysed. Altogether, 137 OHCA were witnessed (67,2 %): 83 cases (40,7 %) by laypersons and 54 further cases (26,5 %) by medical professionals. Among laypersons, most OHCA were witnessed by the partner (17,2 %) and further relatives (11,8 %) but resuscitation rates among partner (3,9 %) and relatives (5,9 %) were poor. Altogether, immediate resuscitation attempts were started in 93 patients, hereunder in 35 cases (17,2 %) by layperson and 58 cases (28,4 %) by medical professionals. CONCLUSION: Rates of lay-resuscitation remain poor despite high rates of witnessed events: unfortunately, especially partner and relatives act too rarely. However, the motivation to approve their knowledge in first-aid and resuscitation might rise among lays if they are informed that it is more likely to observe a partner's or relative´s OHCA than a stranger's.