Easy-to-implement educational interventions to bring climate-smart actions to daily anesthesiologic practice: a cross-sectional before and after study.

BACKGROUND: Anesthesia contributes significantly to a hospital's carbon footprint. Climate-smart actions have the potential to reduce greenhouse gas emissions. Prerequisites for sustainable behavior of providers are knowledge and awareness. We aimed to assess the change in anesthesiologists' climate-friendly behavior before and after educational interventions in three areas that every anesthesiologist can address in their daily clinical routine: 1) energy use; 2) recycling opportunities; 3) consumption of volatile anesthetics. METHODS: We performed a cross-sectional before-and-after single center sub-study within the multicenter "Provider Education and Evaluation Project" at the Department of Anesthesiology, RWTH Aachen University hospital from May3 2021 to May 1 2022. Educational interventions consisted of stickers, posters and a presentation on climate-smart actions in anesthesiologists' work routine between the first and the second assessment. For each cross-sectional assessment, all central 28 ORs were observed for one week. During the before-and-after comparison we analyzed: 1) energy wasted in unoccupied ORs because of running computers and turned-on lights at 9 p.m.; 2) feasibility of recycling preoperative anesthesia plastic packaging by determining the difference between calculated weight of unseparated preoperative plastic waste in the first assessment and the weight of actual separated waste in the second assessment; 3) fresh gas flow in balanced anesthesia cases in steady state at 9 a.m., and purchased hypnotics converted to bottles/1000 general anesthesia cases in 2018-2022. RESULTS: We observed a reduction of wasted energy by 44% in unoccupied ORs. Usage of low fresh gas flow settings increased from 55% to 75%. The average of purchased desflurane in 2018-2020 decreased by 72% in 2022. We calculated 10.33 kg of preoperative plastic waste per week but were unable to implement waste separation for infrastructural and logistical reasons. CONCLUSIONS: We found that environment-friendly working behaviors increased after the implementation of educational interventions. The causality between the interventions and the observed improvements remains to be proven.

Visions for planetary health: Results from open-ended questions of survey participants after a virtual planetary health lecture series.

INTRODUCTION: A profound transformation of all areas of human activities is urgently needed for planetary health. Developing a shared vision of the future that is grounded in values aligned with planetary health is indispensable in this regard. The Planetary Health Academy is the first open online lecture series in Germany aiming for transformative planetary health education. As part of a recent evaluation of the impact of the lecture series, participants' visions for planetary health were also examined. METHODS: As part of a retrospective, cross-sectional, self-administered online survey, participants were asked to respond to an open-ended question on their visions for planetary health. Results were analysed using summarising qualitative content analysis according to Mayring. Sociodemographic details of those participants who provided a valid answer (n = 197) were calculated. RESULTS: Eight main categories were developed to summarise participants' visions for planetary health. These were: Awareness for planetary health - Planetary health integrated in all types of education - Establishment and development of the concept - A different understanding of health (care) - A transformative movement and global community - Transforming human activities - Planetary health as a guiding principle - The future state of planetary health. DISCUSSION: Broadly, the participants' visions were about planetary health as a goal and the means necessary to achieve this goal. Our findings can only be seen as a first explorative step in eliciting aspects of a common vision for planetary health, as our study design did not include a mechanism of building consensus towards one common vision. Besides the field of planetary health, similar concepts and associated movements exist or are emerging. Facilitating dialogue and exchange across disciplines and narratives about the prevailing future visions will be key to achieving what we call planetary health and what others might call Ubuntu or buen vivir. CONCLUSION: The results of this study provide first insights into the planetary health visions of those whom we would consider members of a movement aligned behind the idea of planetary health. In future editions, the Planetary Health Academy could integrate more discursive elements with a particular focus on negotiating future visions to support the creation of a critical mass of change agents within the health community and beyond.

Preoperative Midazolam and Patient-Centered Outcomes of Older Patients: The I-PROMOTE Randomized Clinical Trial.

Importance: The effect of oral midazolam premedication on patient satisfaction in older patients undergoing surgery is unclear, despite its widespread use. Objective: To determine the differences in global perioperative satisfaction in patients with preoperative administration of oral midazolam compared with placebo. Design, Setting, and Participants: This double-blind, parallel-group, placebo-controlled randomized clinical trial was conducted in 9 German hospitals between October 2017 and May 2019 (last follow-up, June 24, 2019). Eligible patients aged 65 to 80 years who were scheduled for elective inpatient surgery for at least 30 minutes under general anesthesia and with planned extubation were enrolled. Data were analyzed from November 2019 to December 2020. Interventions: Patients were randomized to receive oral midazolam, 3.75 mg (n = 309), or placebo (n = 307) 30 to 45 minutes prior to anesthesia induction. Main Outcomes and Measures: The primary outcome was global patient satisfaction evaluated using the self-reported Evaluation du Vécu de l'Anesthésie Generale (EVAN-G) questionnaire on the first postoperative day. Key secondary outcomes included sensitivity and subgroup analyses of the primary outcome, perioperative patient vital data, adverse events, serious complications, and cognitive and functional recovery up to 30 days postoperatively. Results: Among 616 randomized patients, 607 were included in the primary analysis. Of these, 377 (62.1%) were male, and the mean (SD) age was 71.9 (4.4) years. The mean (SD) global index of patient satisfaction did not differ between the midazolam and placebo groups (69.5 [10.7] vs 69.6 [10.8], respectively; mean difference, -0.2; 95% CI, -1.9 to 1.6; P = .85). Sensitivity (per-protocol population, multiple imputation) and subgroup analyses (anxiety, frailty, sex, and previous surgical experience) did not alter the primary results. Secondary outcomes did not differ, except for a higher proportion of patients with hypertension (systolic blood pressure ≥160 mm Hg) at anesthesia induction in the placebo group. Conclusion and Relevance: A single low dose of oral midazolam premedication did not alter the global perioperative patient satisfaction of older patients undergoing surgery or that of patients with anxiety. These results may be affected by the low dose of oral midazolam. Further trials-including a wider population with commonplace low-dose intravenous midazolam and plasma level measurements-are needed. Trial Registration: ClinicalTrials.gov Identifier: NCT03052660.

Measuring informal workplace learning outcomes in residency training: a validation study.

BACKGROUND: Informal workplace learning (WPL) has no concrete learning objective and takes place without a responsible supervisor, which makes it difficult to assess its learning outcomes. Formal learning situations, as they are known from universities or schools, do not exist in this context and make a conventional assessment of learning goals and achievements impossible. Informal learning in the workplace is of central importance, and the assessment of informal learning outcomes in medical education is an under-researched area. The aim of our study was to adapt and validate an informal WPL questionnaire (originally developed for social workers) to assess learning outcomes due to informal WPL in residency training. METHODS: A total of 528 residents (n = 339 female; age: M = 29.79; SD = 3.37 years) completed an adapted questionnaire on informal WPL outcomes and the Freiburg Questionnaire to Assess Competencies in Medicine (i.e. medical knowledge, communication, and scholarship). Exploratory factor analysis was used to determine the underlying factor structure. The reliability of the factors was tested using McDonald's omega, and the correlation between the factors and the three subscales of the Freiburg questionnaire was tested using Spearman's rho correlation coefficient. To investigate construct validity, a structural equation model was calculated to examine the relationships between medical competencies and informal learning outcomes. RESULTS: The exploratory factor analysis yielded a four-factor solution that best fit the data. The scores of all four factors (GLO-CD: generic learning outcomes-competence development, GLO-R: generic learning outcomes-reflection, JSLO: job-specific learning outcomes, and OLLO: organisational learning outcomes) showed good internal consistency (Ω ≥ .69). The structural equation model showed that "medical expertise" had an impact on all four factors of informal learning at work. "Scholarship" seemed to predict GLO-CD and GLO-R. CONCLUSIONS: Our four-factor model reveals meaningful determinants of informal WPL in relation to residency training. The instrument is therefore the first promising attempt to assess informal WPL in the broader context of medical education during residency, thus supporting its construct validity.

Local Recurrence in Choroidal Melanomas following Robotic-Assisted Radiosurgery (CyberKnife).

Introduction: Tumor recurrence in choroidal melanoma has been associated with decreased overall survival due to metastatic spreading. To detect risk factors of local recurrence and side effects, we analyzed tumor planning and treatment parameters in patients with recurrence of choroidal melanoma after treatment with robotic-assisted radiosurgery (CyberKnife). Methods: Six hundred ninety-four patients treated with CyberKnife between 2005 and 2019 were retrospectively reviewed. Age, gender, best-corrected visual acuity, tumor height, and diameter were recorded. Treatment planning and radiation doses were reviewed. Salvage therapy, overall survival, metastasis, and complications were recorded. Results: Seventy-four patients showed local recurrence. Local recurrence occurred after 42.1 months post CyberKnife treatment (mean; range: 5-100 months). Fourteen out of 74 patients (18.9%) died during follow-up. Recurrence treatment included enucleation in 51 patients (68.9%) and radiosurgery in 19 patients (25.7%). Treatment planning without contrast medium MRI, radiation dose of less than 21 Gy, and insufficient margin delineation were identified as risk factors incrementing local control. Discussion: Robotic-assisted radiosurgery (CyberKnife) is a suitable treatment option for large choroidal melanoma up to 12 mm. Patients with significantly better visual acuity received repeat CyberKnife treatment as salvage therapy and showed an eye retention rate of 81%.

Performance of the SEDLine Monitor: Age Dependency and Time Delay.

BACKGROUND: Devices monitoring the hypnotic component of general anesthesia can help to guide anesthetic management. The main purposes of these devices are the titration of anesthesia dose. While anesthesia at low doses can result in awareness with intraoperative memory formation, excessive administration of anesthetics may be associated with an increased risk of postoperative neurocognitive disorder. We have previously shown for various indices that they are significantly influenced by the patient's age and that the monitors have a significant time delay. Here, we evaluated the influence of patient's age and time delay on the patient state index (PSI) of the SEDLine monitor. METHODS: To analyze the influence of the patient's age, we replayed 2 minutes of electroencephalography (EEG) of 141 patients (19-88 years, ASA I-IV) undergoing general anesthesia maintained with desflurane, sevoflurane, or propofol to the SEDLine monitor. We extracted the PSI as well as the spectral edge frequency (SEF) and performed a linear regression analysis. For evaluation of the time delay, we replayed 5 minutes of EEG of stable episodes of adequate anesthesia (PSI between 25 and 50) or light sedation/wake (PSI >70) in different orders to the SEDLine to simulate sudden changes between the states. Time delays were defined as the required time span of the monitor to reach the stable target index. RESULTS: PSI and SEF increased significantly with the patient's age. These findings did not depend on the administered anesthetic. The evaluation of the correlation between SEF and PSI showed a strong correlation with Spearman's correlation coefficient of ρ = 0.86 (0.82; 0.89). The time delays depended on the type of transition. We found a median time delay of 54 (Min: 46; Max: 61) seconds for the important transition between adequate anesthesia and awake and 55 (Min: 50; Max: 67) seconds in the other direction. CONCLUSIONS: With our analyses, we show that the indices presented on the SEDLine display, the PSI and the SEF, increase with age for patients under general anesthesia. Additionally, a delay of the PSI to react to sudden neurophysiologic changes due to dose of the maintenance anesthetic is of a time course that is clinically significant. These factors should be considered when navigating anesthesia relying on only the proprietary index for the SEDLine monitor.

The Planetary Health Academy-a virtual lecture series for transformative education in Germany.

The planetary crises require health professionals to understand the interlinkages between health and environmental changes, and how to reduce ecological harm (ie, ecological footprint) and promote positive change (ie, ecological handprint). However, health professions' education and training are mostly lacking these aspects. In this Viewpoint, we report findings from the evaluation of the Planetary Health Academy, the first open online lecture series for transformative planetary health education in Germany. In a retrospective online survey, 458 of 3656 Planetary Health Academy participants reported on their emotions towards climate change, attitudes towards health professionals' responsibilities, self-efficacy, and the contribution of the Planetary Health Academy to their knowledge and actions. Additionally, motivators and barriers to acting were assessed. Our findings provide insights that can inform future efforts for transformative education. Combined with network and movement building, education could act as a social tipping element toward actions to mitigate global environmental changes.

Pars-plana-vitrectomy for endophthalmitis treatment and the role of standardized ultrasound.

PURPOSE: Endophthalmitis is a severe inflammation following surgery or endogenous spread of pathogens. Besides clinical signs and symptoms, standardized ultrasound might help to confirm the diagnosis. Thus, we analyzed 172 cases of endophthalmitis for pathogens, visual acuity (VA) and the predictive value of standardized ultrasound. METHODS: Retrospective analysis of patients treated with pars-plana-vitrectomy for endophthalmitis at the University Eye Hospital was performed. Sex, age, VA at presentation, first day after surgery, four weeks postoperatively, and at last follow-up, as well as pathogen culture, and presence of standardized ultrasound before vitrectomy were recorded. Mann-Whitney U and Chi-square tests were used for groupwise comparisons. RESULTS: A total of 172 patients (male = 47.7%) with a median age of 76 years (IQR 65-82 years) treated for endophthalmitis (exogenous = 85.5%) were included. Median follow-up time was 65 days (IQR 12-274 days). Visual acuity at presentation was 2.30 logMAR (IQR 2.70-2.30 logMAR); it increased to 1.00 logMAR (1.4-0.40 logMAR) at last follow-up. A total of 79 patients (45.9%) underwent standardized ultrasound before vitrectomy. Patients with positive ultrasound criteria had a significantly decreased VA at presentation (p = 0.034). Positive microbiological cultures for Streptococcus spp. and Enterococcus faecalis were associated with decreased VA (p = 0.028) at last follow-up. CONCLUSION: Standardized ultrasound is an easy and robust tool in the diagnosis of endophthalmitis. Positive criteria are significantly associated with decreased VA at presentation. The recovery of VA depends on pathogens and is significantly worse for certain species (Streptococcus spp., Enterococcus faecalis).

Calling for Help-Peer-Based Psychosocial Support for Medical Staff by Telephone-A Best Practice Example from Germany.

BACKGROUND: A telephone support hotline (PSU-HELPLINE) was established at the beginning of the pandemic due to the burden on health professionals and the lack of support at the workplace. The aim of this study was to evaluate the telephone support service for health professionals in terms of its burden, benefits, and mechanisms of action. METHODS: Data collection was conducted during and after calls by PSU-HELPLINE counsellors. In addition to the socio-demographic data evaluation, burdens of the callers and the benefits of the calls were collected. The content-analytical evaluation of the stresses as well as the effect factors were based on Mayring's (2022). RESULTS: Most of the callers were highly to very highly stressed. The usefulness of the conversation was rated as strong to very strong by both callers and counsellors. The PSU-HELPLINE was used primarily for processing serious events and in phases of overload. The support work was carried out through the following aspects of so-called effect factors, among others: psychoeducation, change of perspective, resource activation, problem actualization, connectedness, information, problem solving, self-efficacy, and preservation of resources. CONCLUSIONS: The expansion of local peer support structures and the possibility of a telephone helpline are recommended. Further research is needed.

The absence of dominant alpha-oscillatory EEG activity during emergence from delta-dominant anesthesia predicts neurocognitive impairment- results from a prospective observational trial.

STUDY OBJECTIVE: Postoperative neurocognitive disorders (PND) are common complications after surgery under general anesthesia. In our aging society the incidence of PND will increase. Hence, interdisciplinary efforts should be taken to minimize the occurrence of PND. Electroencephalographic (EEG) monitoring of brain activity during anesthesia or emergence from anesthesia is a promising tool to identify patients at risk. We therefore investigated whether we could identify specific EEG signatures during emergence of anesthesia that are associated with the occurrence of PND. DESIGN AND PATIENTS: We performed a prospective observational investigation on 116 patients to evaluate the EEG features during emergence from general anesthesia dominated by slow delta waves in patients with and without delirium in the postoperative care unit (PACU-D) as assessed by the CAM-ICU and the RASS. MAIN RESULTS: During emergence both the frontal and global EEG of patients with PACU-D were significantly different from patients without PACU-D. PACU-D patients had lower relative alpha power and reduced fronto-parietal alpha coherence. CONCLUSIONS: With our analysis we show differences in EEG features associated with anesthesia emergence in patients with and without PACU-D. Frontal and global EEG alpha-band features could help to identify patients with PACU-D. CLINICAL TRIAL NUMBER: NCT03287401.

Differences in beginner and expert neurointerventionalists" heart rate variability during simulated neuroangiographies.

BACKGROUND: Likewise work experience, heart rate variability (HRV) has repeatedly been correlated with improved performance under real life and simulator conditions. Using HRV as a correlate of workload, it is meaningful to assess the impact of work experience. To understand the impact of work experience on HRV metrics, we examined differences in HRV among experts and beginners during simulated endovascular neuroradiological procedures. METHODS: Six inexperienced radiologists (beginners) and five experts in neurological endovascular intervention each performed 10 diagnostic angiographies on a Vascular Interventional System Trainer (VIST) simulator (Mentice AB, SW). Beyond total time, fluoroscopy time, and amount of contrast medium used, heart rate variability and the NASA-task load index were gathered as correlates of workload. The t-Test for independent samples as well as Mann-Whitney-U tests were applied for group-wise comparison between beginners and experts. Multivariate regression was used to assess the influence of age and expert status. RESULTS: Ten participants completed all scenarios; one participant only completed the first five scenarios. Accordingly, 105 simulations were analyzed (beginners N = 60; experts N = 45, respectively). The heart rate variability of experts and beginners significantly differed in three time domain HRV metrics (decreased RMSSD, NN50, pNN50 in experts; all p < 0.05) as well as with respect to its distribution in the frequency spectrum (LF/HF ratio; p < 0.001, increased high frequency components in experts). CONCLUSIONS: The HRV of beginners and expert neurointerventionalists significantly differed during simulated endovascular neuroradiological procedures. Experts presented decreased HRV, this could be a cardiovascular surrogate to the effort the subjects expend on their performance. It is in line with previous studies on vagal influences on the heart and cognitive-executive performance.

Mitigation of climate change in health care: A survey for the evaluation of providers' attitudes and knowledge, and their view on their organization's readiness for change.

BACKGROUND: Climate change is the 21st century's greatest threat to health. Anaesthesia is responsible for high levels of waste production, significant greenhouse gas emissions and extensive energy consumption. Our aim was to design an instrument to assess attitudes and knowledge among anaesthetists as well as their organisation's readiness for change regarding climate action. METHODS: In 2020, the Provider Education and Evaluation Project (PEEP) questionnaire was sent to anaesthetists working at a university hospital, which contains 65 items in five areas: demographics, personal attitudes, organisational readiness, opportunities, and specific anaesthesiologic knowledge regarding climate action. Except for two open text questions, all questions were closed questions. RESULTS: 104 anaesthetists responded to the survey (response rate 62%). Environmental protection and sustainability were important to all participants (100%). Most felt threatened by the ongoing climate crisis (94.2%). While most participants agreed that their employer had the financial or technological capacities and that sustainability targets were compatible with core business activities (approval >60% for all), they felt unprepared and stated that they had too little time to consider environmental aspects during daily routines (disapproval >60% for all). Furthermore, knowledge on topics such as ongoing efforts to tackle climate change or the climate footprint of drugs and medical products, was rather scarce. CONCLUSION: The PEEP questionnaire is an applicable and viable tool to assess anaesthetists' knowledge and attitudes towards climate change and organisational readiness for change. While participants care about the climate crisis, organisational readiness was low, especially when it comes to staff readiness (i.e., skills and knowledge) and cultural readiness (i.e., shared values). These aspects need to be considered in order to successfully implement a carbon neutral health care system.

[Health and investment: How are the 237 billion euro of the German professional pension funds invested?] / Gesundheit und Kapitalanlagen - wie sind die € 237 Mrd. der berufsständigen Versorgungswerke angelegt?

BACKGROUND: Exceeding ecological limits through climate crisis, loss of biodiversity, altered biogeochemical cycles and novel substances is dangerous and leads to increased morbidity. Hence, financial assets should be divested from hazardous industries and re-allocated to support the transformation to an economy that keeps activities within ecological limits. The present study investigates how sustainability criteria are applied to the assets of German pension funds. METHODS: A survey containing 26 items on 1) business practice, 2) implementation of sustainability strategies, 3) application of ESG criteria to investment decisions, and 4) projects and goals was sent to each and every of 93 German professional pension funds. Furthermore, their annual business reports and publications were analyzed for information on sustainability efforts. RESULTS: 37 of 93 pension funds responded to our survey, 8 of them returned the query. All agreed that ESG criteria are part of their business culture. Predominantly, they adhere to common standards for sustainable investments (UNPRI [United Nations Principles for Responsible Investment], 75% approval); yet, they do not exclude the production of goods that are potentially harmful to health (e.g., tobacco and alcohol). DISCUSSION: A minority of the participating pension funds agrees that ESG criteria are part of their business culture. However, only few of them provide information about their actual application. Nevertheless, there are pension funds that do not respect sustainability criteria in an appropriate way, and thus take unnecessary financial risks and invest in harmful industries.

Robotic CyberKnife radiosurgery for small choroidal melanomas.

Plaque brachytherapy is the most common procedure for the treatment of small choroidal melanoma, especially in posteriorly located tumors. However, there is only little information on outcome after treatment with stereotactic radiosurgery, for example, CyberKnife radiosurgery. We reviewed patients with choroidal melanoma (maximum tumor height 4 mm) treated with CyberKnife radiosurgery. Demographic information, tumor dimension, complications, metastasis and overall survival during the whole follow-up were tracked and analyzed with a specific focus on local tumor control and potential risk factors. One hundred eighty-eight patients (102 female, 54.2%) with a median age of 63 years [interquartile range (IQR): 54-73 years] were analyzed over a median of 46 months (IQR: 24-62 months). Metastasis occurred in 14 patients (7.4%) in median of 18 months after treatment (IQR: 13-47 months) and survival was achieved in 178 patients (94.7%). Within the observation period, eye retention was observed in 166 patients (88.3%). Superior local control was achieved in patients who received a prescription dose of at least 21 Gy or more (91.6%; P = 0.04). Other potential risk factors incrementing local control were treatment planning with missing MRI in advance and too small target delineation during the planning process. Radiosurgery (CyberKnife) in a single, outpatient procedure is suitable for the treatment of small choroidal melanoma. We found local control rate after 3 years compared to the standard treatment with plaque brachytherapy. On the study side, 15 years of CyberKnife treatment allowed to identify risk factors that might increment local control and thus improve treatment regimens.

[Climate protection in practices - current status, motivation and challenges in outpatient care]. / Klimaschutz in der Praxis ­ Status quo, Bereitschaft und Herausforderungen in der ambulanten Versorgung.

INTRODUCTION: The impact of climate change on health and the necessity to reduce emissions in the health sector is becoming an increasingly discussed topic. Little is known about medical doctors' (MDs) attitude towards climate protection measures in outpatient practices. METHODS: Between October 2020 and February 2021, a survey was conducted among MDs in German practices. 1,683 participants answered 39 questions on energy use, transportation, disposable materials, budget and patient counselling. Data were collected on status, motivation, obstacles and needs regarding climate protection in practices. RESULTS: 83% considered climate change an urgent problem requiring immediate action. A majority reported climate effects on their patients' health. Most MDs felt responsible for climate protection in their practices, showing a high degree of willingness to implement climate-friendly measures. Obstacles reported include lack of information and institutional support as well as the expected financial burden. A majority of MDs called on professional associations and politics to develop climate-friendly strategies. CONCLUSION: In view of national climate targets and the willingness of outpatient MDs to contribute to climate protection, support from medical associations is required, e. g. through practical recommendations and financial help, in order to transform the health sector in accordance with the idea of Planetary Health. Accompanying studies should provide further evidence on effective measures to reduce greenhouse gas emissions in practices.

Simulation Training in Neuroangiography-Validation and Effectiveness.

PURPOSE: Simulators are increasingly used in the training of endovascular procedures; however, for the use of the Mentice vascular interventional system trainer (VIST) simulator in neuroradiology, the validity of the method has not yet been proven. The study was carried out to test the construct validity of such a simulator by demonstrating differences between beginner and expert neurointerventionalists and to evaluate whether a training effect can be demonstrated in repeated cases for different levels of experience. METHODS: In this study 4 experts and 6 beginners performed 10 diagnostic angiographies on the VIST simulator (Mentice AB, Gothenburg, Sweden). Of the cases four were non-recurring, whereas three were repeated once and ten subjects performed all tasks. Additionally, another expert performed only five non-recurring cases. The simulator recorded total time, fluoroscopy time, amount of contrast medium and number of material changes. Furthermore, gaze direction and heart rate were recorded, and subjects completed a questionnaire on workload. RESULTS: Beginners and experts showed significant differences in total duration time, fluoroscopy time and amount of contrast agent (all p < 0.05). Gaze direction, dwell time and heart rate were similar between both groups. Only beginners improved during training with respect to total duration time, fluoroscopy time and amount of contrast agent. If a case was previously known to them, the total duration and fluoroscopy time were significantly shortened (p < 0.001). CONCLUSION: This study demonstrated both the construct validity of a diagnostic neuroangiography simulator as well as a significant training effect for beginners. Therefore, in particular beginner neurointerventionalists should use such simulation tools more extensively in their initial training.

Do private German health insurers invest their capital reserves of €353 billion according to environmental, social and governance criteria?

BACKGROUND: To prevent the planet from catastrophic global warming a reduction of greenhouse gas emissions to net zero is required. Thus, divestment from fossil fuels must be a strategic interest for health insurers. The aim of this study was to analyse the implementation of environmental, social and governance (ESG) criteria in German private health insurers' investments. METHODS: In 2019 a survey about ESG strategies was sent to German private health insurance companies. The survey evaluated investment strategies and thresholds for the exclusion of sectors and business practices, as well as company strategies for sustainable business development. FINDINGS: Given their business reports, German private health insurers manage assets of more than €350 billion. 11 of 40 insurance companies provided quantitative data, 10 refused to answer. According to quantitative data, €66 billion of assets is managed according to any ESG criteria; this equals an average of 76% of each company's bonds. None of these insurers excluded the production and sale of fossil fuels. All excluded coal mining but only at high thresholds. For €226 billion, no data were provided. INTERPRETATION: The findings are in contrast to the expected intrinsic economic interest of the insurers to stop global warming and improve public health. The majority of assets are managed in a highly problematic manner, especially the absence of capital allocated in fields contrary to medical ethics (eg, firearms, armour) cannot be presumed. Lack of transparency is a major problem that limits clients in choosing the insurer who has the most advanced ESG criteria.

The association of the anesthesiologist's academic and educational status with self-confidence, self-rated knowledge and objective knowledge in rational antibiotic application.

OBJECTIVE: This study aimed to investigate the association of anesthetists' academic and educational status with self-confidence, self-rated knowledge and objective knowledge about rational antibiotic application. Therefore, anesthetists in Germany were asked about their self-confidence, self-rated knowledge and objective knowledge on antibiotic therapy via the Multiinstitutional Reconnaissance of practice with Multiresistant bacteria (MR2) survey. Other analysis from the survey have been published elsewhere, before. RESULTS: 361 (52.8%) questionnaires were completed by specialists and built the study group. In overall analysis the Certification in Intensive Care (CIC) was significantly associated with self-confidence (p < 0.001), self-rated knowledge (p < 0.001) and objective knowledge (p = 0.029) about antibiotic prescription. Senior consultant status was linked to self-confidence (p < 0.001) and self-rated knowledge (p = 0.005) but not objective knowledge. Likewise, working on Intensive Care Unit (ICU) during the last 12 months was significantly associated with self-rated knowledge and self-confidence (all p < 0.001). In a logistic regression model, senior consultant status was not associated with any tested influence factor. This analysis unveiled that CIC and working on ICU were more associated with anesthesiologists' self-confidence and self-rated knowledge than senior consultant status. However, neither of the characteristics was thoroughly associated with objective knowledge.

Rational application of antibiotics-The influence of anaesthetists' gender on self-confidence and knowledge.

BACKGROUND: High rates of multiresistant pathogens require detailed knowledge about rational utilization of antibiotics. Many physicians consider themselves uncertain about the interpretation of microbiological diagnostics. We examined whether self-confidence, self-rated knowledge, and objective knowledge regarding the use of antibiotics are associated with gender. METHODS: For this survey study, in 2017, anaesthesiologists and residents of 16 anaesthetic departments in Germany were asked to complete the Multiinstitutional Reconnaissance of practice with Multiresistant bacteria (MR2) survey. It consists of 55 items evaluating self-confidence regarding the practical use of antibiotics (n = 6), self-rated theoretical knowledge (n = 16), and objective knowledge (n = 5). Their answers to these items in relation to their gender were analysed using Chi-square, Kruskal-Wallis-H-Tests, and unadjusted as well as adjusted logistic regression models. RESULTS: Six hundred eighty-four (response rate: 53.9 %) questionnaires were returned and were available for analysis. Female doctors (35.5 %) felt less self-confident (P < 0.001). Self-rated knowledge differed in overall mean (P = 0.014) and the unadjusted (odds ratio [OR]: 0.55; P = 0.013) but not in the adjusted logistic regression (OR: 0.84; P = 0.525). Objective knowledge differed after pooling questions (61.2% correct answers vs 65.4%, P = 0.01) but not with respect to single items and the adjusted logistic regression (OR: 0.83, P = 0.356). CONCLUSION: Less self-confidence and a lower self-rated knowledge were found in female anaesthetists; this is consistent to the gender phenomena observed by other researchers. Nevertheless, between the 2 groups objective knowledge did not differ significantly in any item.

The impact of the patient's initial NACA score on subjective and physiological indicators of workload during pre-hospital emergency care.

BACKGROUND: Excessive workload may impair patient safety. However, little is known about emergency care providers' workload during the treatment of life-threatening cases including cardiopulmonary resuscitation (CPR). Therefore, we tested the hypothesis that subjective and physiological indicators of workload are associated with the patient's initial NACA score and that workload is particularly high during CPR. METHODS: NASA task load index (NASA-tlx) and alarm codes were obtained for 216 sorties of pre-hospital emergency medical care. Furthermore, initial NACA scores of 140 patients were extracted from the physicians' protocols. The physiological workload indicators mean heart rate (HR) and permutation entropy (PeEn) were calculated for 51 sorties of primary care. General linear mixed models were used to analyze the association of NACA scores with subjective (NASA-tlx) and physiological (mean HR, PeEn) measures of workload. RESULTS: In contrast to the physiological variables PeEn (p = 0.10) and HR (p = 0.19), the mental (p<0.001) and temporal demands (p<0.001) as well as the effort (p<0.001) and frustration (p = 0.04) subscale of the NASA-tlx were significantly associated with initial NACA scores. Compared to NACA = I, an initial NACA score of VI (representing CPR) increased workload by a mean of 389.5% (p = 0.001) in the mental and 345.9% (p<0.001) in the temporal demands, effort by a mean of 446,8% (p = 0.002) and frustration by 190.0% (p = 0.03). In line with the increase in NASA-tlx, PeEn increased by 20.6% (p = 0.01) and HR by 6.4% (p = 0.57). CONCLUSIONS: Patients' initial NACA scores are associated with subjective workload. Workload was highest during CPR.