[Ultrasound-guided peripheral venous puncture in patients with a poor venous status]. / Die ultraschallgesteuerte periphere Venenpunktion bei schlechtem Venenstatus.

BACKGROUND: In the case of a poor peripheral venous status the use of conventional approaches is associated with several failed attempts, delay of treatment, increased pain and escalation to more invasive techniques. Ultrasound-guided venous access has become increasingly popular for difficult venous access; however, in German-speaking countries it has not yet become as popular as in English-speaking countries. First attempt success rates are high, but the factors contributing to the time needed for ultrasound-guided venous access are not well investigated. It is hypothesized that body mass index (BMI), vein diameter and depth contribute to the time needed for successfully establishing a peripheral vein access in patients with a difficult venous status. METHODS: This study included 68 patients with a poor venous status. After written consent was obtained patient characteristics were documented and upper extremity veins eligible for access were scanned with ultrasound with the aim of performing an ultrasound-guided venous access. The following time periods were documented: 1) first skin contact with the ultrasound probe, 2) time to identify an accessible vein, 3) time for venous access. RESULTS: Of the patients 67 were successfully punctured by ultrasound-guided venous access, 65 at the first attempt and 2 at the second attempt. In one patient conventional venous access was obtained at the same time. A higher BMI was associated with a significantly shorter total puncture time (+1 BMI point ≙ -2.25 s) and a shorter vein identification time (+1 BMI point ≙ -1.82 s). A greater vein diameter correlated with a shorter total time (-14.23 s/mm) and a greater depth correlated with an increased total time (+1.65 s/mm). CONCLUSION: A greater vein diameter and a higher BMI contribute to a shorter time period for ultrasound-guided venous access. Obese patients with difficult venous access may benefit from ultrasound-guided venous access, which could be explained by the imaging contrast with a higher proportion of subcutaneous fatty tissue.

[Emergency departments--2016 update]. / Zentrale Notaufnahme--Update 2016.

Acute medical care in hospital emergency departments has experienced rapid development in recent years and gained increasing importance not only from a professional medical point of view but also from an economic and health policy perspective. The present article therefore provides an update on the situation of emergency departments in Germany. Care in emergency departments is provided with an increasing tendency to patients of all ages presenting with varying primary symptoms, complaints, illnesses and injury patterns. In the process, patients reach the emergency department by various routes and structural provision. Cross-sectional communication and cooperation, prioritization and organization of emergency management and especially medical staff qualifications increasingly play a decisive role in this process. The range of necessary knowledge and skills far exceeds the scope of prehospital medical emergency care and the working environment differs substantially. In addition to existing structural and economic problems, the latest developments, as well as future proposals for the design of in-hospital emergency medical care in interdisciplinary emergency departments are described.

[Standardized documentation in emergency departments with the core dataset of the DIVI]. / Standardisierte Dokumentation im Schockraum mit dem Kerndatensatz "Notaufnahme" der DIVI.

In Germany the documentation of every prehospital emergency medical treatment has been standardized since 1997 based on the core data-set MIND (minimal emergency physician data-set). Against this background it is very surprising that there is still no standardized data-set implemented for the documentation of early inhospital emergency care. In order to create such a data-set the current state of documentation in many different hospitals all over the country was scrutinized. In addition existing registries and international requirements were taken into consideration. Finally, a modular data-set was created using a Delphi process. This data-set was tested, clinically validated and finally ratified by the executive committee of the DIVI (German Interdisciplinary Association of Critical Care Medicine). The modular data-set was designed in such a way that a basic module forms the foundation for every patient. Process-oriented modules (e.g. surveillance) and symptom-oriented modules (e.g. trauma, neurology) were added if necessary. Along with this data-set a set of six modules was created for graphical representation when required. This high level of standardization not only allows an internal and external quality assessment but also provides a sophisticated documentation system especially to the trauma team in the emergency department. In terms of content major parameters of interhospital quality management are recorded and important factors of process management, such as MTS (Manchester triage system), ATLS (advanced trauma life support) and EWS (early warning score) have been implemented. The data-set includes all necessary information for transfers between physicians and non-academic staff as well as between physicians and could also be used as a fundamental discharge letter. Moreover, this new core data-set is the implementation of items required by existing registries into the daily routine documentation in order to reduce unnecessarily time-consuming and error-prone secondary data acquisition. For example, all items of the preclinical and emergency room documentation for the TraumaRegister DGU® (documentation phase S, A and B of the standard and QM form) have been included. This is sufficient for participation as a TraumaNetzwerk DGU® member as far as the early clinical treatment of multiple injured patients is concerned.

[Interdisciplinary emergency departments : first experiences from the ENT and head and neck perspective]. / Interdisziplinäre Notfallzentren : Erste Erfahrungen aus HNO-ärztlicher Sicht.

BACKGROUND: Centralized emergency departments are becoming a major source of health care in Germany. In this study, we evaluated the importance for ENT health care. METHODS: In a retrospective study, all ENT emergency patients between May and July 2011 were characterized by diagnosis, therapy, and urgency (measured using the Manchester Triage System [MTS]). General epidemiological data from the emergency department were recorded between 2009 and 2011. RESULTS: Between 2009 and 2011, 50,699 patients were treated in the centralized emergency department of the University Hospital Bonn. A total of 15,658 (30.8%) needed ENT health care. During May 2011 to July 2011, ENT emergency patients had not only a wide variety of diseases but also a broad range of ages (0-98 years). Using the MTS, emergency patients (4% acute emergencies) were identified and urgency was determined prior to first contact with the physician. CONCLUSION: ENT emergency care plays an important role for centralized emergency departments. Most of the patients have ENT diseases treatable as an outpatient in a single visit. MTS can be used to determine the appropriate level of urgency.

[Facial impalement in childhood : obtain an overview before actionism]. / Kraniofaziale Pfählungsverletzung im Kindesalter : Überblick vor Aktionismus.

Facial impalement in childhood is very rare. In most cases, it is caused by accident. We present two young patients who suffered a facial impalement injury and were treated in the interdisciplinary emergency room of the University Hospital Bonn, Germany. The degree of injury could not be completely determined during the first examination. Serious complications could be excluded after examination via computed tomography (CT) and surgical exploration. The indication to use CT or magnetic resonance imaging in childhood has to be considered in order to obtain full and exact information about the extent of injury.

[COVID-19 and lockdown: Impact on pregnancy complications]. / COVID-19 et confinement : impact sur les complications de la grossesse.

OBJECTIVE: The COVID-19 lockdown led to the establishment of a national lockdown in France from March 17th to May 11th, 2020. The purpose of our study is to evaluate the impact of lockdown on the rate of hospitalization for threatened preterm delivery and on the rate of preterm delivery. METHODS: Multicenter retrospective epidemiological study carried out over the lockdown period from March 15th to May 31st, 2020 compared to the same period over the previous two years (2018 and 2019) in Picardy hospitals (University Hospital center Amiens Picardie, Hospital Center of Beauvais, Compiègne and Saint-Quentin). RESULTS: In total, 608 patients were included. Our study shows a decrease in hospitalisations (207 in 2019 vs. 176 in 2020). We find a significant reduction in Premature Ruptures of Membranes (16.9% [73/432] in 2018/2019 vs. 9.7% [17/176] in 2020; P=0.02) and also in the preterm delivery rate (9.3% (276/2961) in 2018/2019 vs. 6.8% [96/1416] in 2020; P<0.05). CONCLUSION: A reduction in the rate of preterm birth is observed during the first lockdown's period. It would also be interesting to evaluate the psychological impact of lockdown.

Fish bones--a highly available calcium source for growing pigs.

In general, there is a lack of scientific documentation of nutritional value of marine by-products. The bone fraction from fish has been regarded as waste. Due to the high mineral content of fish bones, this material can be well suitable as a natural calcium source. In the present study, apparent calcium absorption of different fish bone sources was tested using growing pigs. The experimental diets consisted of boiled salmon frames, or salmon, saithe or cod bones treated with enzymes. Calcium carbonate (CaCO(3)) was used as control. The experimental diets were formulated to contain 0.7% total calcium of which the added calcium source to be tested contributed about 71% (study 1) and 86% (study 2). Except for the calcium and phosphorus sources, the animals received similar basal diets. Apparent calcium digestibility coefficient was calculated using yttrium as indicator (both studies) and was based on complete collection of faeces and urine (study 2). The experimental design was parallel and cross-over in study 1 and study 2, respectively. In study 1, piglets getting salmon bone treated with enzymes had significantly higher calcium absorption than piglets getting boiled fish bone or calcium carbonate. Therefore, in the second study only enzymatically treated fish bones were included. The higher calcium absorption from enzymatically treated salmon bone was also found in study 2, but this time not significant. Calcium from boiled salmon bones in study I, and from enzymatically treated saithe and cod bones in study II were absorbed as well as the calcium carbonate control. The results indicate that fish bones may be a useful and well absorbed calcium source. Due to the high mineral content of the bone fraction, salmon bones can be well suitable as a natural calcium and phosphorus source in, for example, food, feed or as supplement.

[Older emergency patients in the emergency department : A key performance indicator analysis based on the DIVI emergency department protocol]. / Ältere Notfallpatienten in der zentralen Notaufnahme : Eine Kennzahlenauswertung auf Basis des DIVI-Notaufnahmeprotokoll.

BACKGROUND: Overall, there is only little data in health care research on the subject of emergency care in older patients in Germany. The aim of the present study is to assess the older emergency patient in regard to the core data set "Emergency Department" of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI). MATERIALS AND METHODS: Monocentric, retrospective observational study. RESULTS: In the observation period, a total of 29,391 emergency patients were treated at the interdisciplinary emergency center. Of these, 8072 emergency patients were ≥65 years old (27.4%). With increasing age, paramedic ambulances (RTW) or physician-led ambulances (NEF) are increasingly used (p < 0.001). Older emergency patients arriving by a physician-led emergency service show a 38.9-fold increase in mortality compared to ambulatory patients (odds ratio = 38.98 [29.22-51.87]). The initial assessment, using the Manchester Triage System (MTS), shows a steady rise towards higher urgency levels with increasing age (p < 0.001). In the multivariate analysis within the individual age clusters, there is a correlation between the triage level and hospital mortality, unrelated to gender (p < 0.001). Likewise the use of consulting physicians can be linked to advanced age (p < 0.001). Also the length of stay in the interdisciplinary emergency center correlates highly with age (p < 0.001). CONCLUSION: The older emergency patient clearly differs from younger emergency patients in all key performance indicators considered and already poses a special challenge to emergency departments.

[Neglected, lonely and sick - the social breakdown : A special patient group in the emergency department]. / Verwahrlost, einsam und krank ­ der soziale Breakdown : Eine spezielle Patientengruppe in der zentralen Notaufnahme.

BACKGROUND: The emergency department (ED) is increasingly becoming the primary care unit of patients who are no longer able to meet the necessary minimum requirements for a healthy life. In the emergency medical care of these patients, fixation errors and stereotyped thinking can distract from serious illnesses, which can be tended by emergency medicine. This group of patients, with their multifactorial problems, represents a special challenge for the staff of the ED. The aim of this study is to improve the quality of the care for a special patient group. MATERIALS AND METHODS: A monocentric retrospective observation study was conducted at the University Hospital Bonn (UKB). On the basis of case studies, the emergency medical care of this special patient group was examined in the ED. RESULTS: Over the period of 7 years (2009 to 2016), 17 patients in a state of total neglect could be examined. The endpoints identified, during the emergency care, are the therapy of life-threatening diseases, laboratory pathologies, introduction of infectious protective measures, initiation of diagnostic measures, measures to be initiated within different departments (operating room, intensive care unit) and outcome. CONCLUSION: Patients in a state of total neglect require interdisciplinary primary care at a hospital with extended care structures. The apparent primary impression of these patients must not lead to a fixation error. Due to the often not obtainable history of the patient's and the complex appearance of these patients, the evaluation should be carried out according to a defined algorithm in the emergency room.

Defective protein kinase C-mediated actions in cystic fibrosis neutrophils.

Neutrophils from cystic fibrosis (CF) patients have been shown previously to be defective in their response (beta-glucuronidase exocytosis, NADPH oxidase activation) to the chemotactic peptide FMLP. In this work, we attempted to identify the defective step in this response. We showed that stimulated CF and control neutrophils do not differ in the formation of inositol phosphates. On the other hand, direct stimulation of protein kinase C with phorbol myristate acetate (PMA) revealed a subnormal stimulation of beta-glucuronidase exocytosis in CF neutrophils. Furthermore, retroinhibition exerted by PMA-activated protein kinase C on stimulated inositol phosphates or on beta-glucuronidase exocytosis was marginal or absent in CF neutrophils, whereas it was significant in the case of control neutrophils. Our observations suggest that the CFTR gene is expressed in neutrophils and is involved in protein kinase C-mediated actions.

Carbachol and sodium fluoride, but not TSH, stimulate the generation of inositol phosphates in the dog thyroid.

In dog thyroid slices prelabeled with myo-[2-3H]inositol, carbachol (10(-7)-10(-4) M) and NaF (10-20 mM) stimulated IP1, IP2 and IP3 generation. These effects did not require the presence of extracellular calcium. Atropine and PDBu inhibited the action of the cholinergic agonist. No effect of TSH (1-100 mU/ml) could be detected on PIP2 hydrolysis and IP production. These results suggest that IP3 could play a role in the metabolic actions of carbachol in the thyroid; a G-protein coupling the hormone-receptor binding to phospholipase C activation exists in the thyroid membrane; the well known TSH-induced increased PI turnover does not result in IP3 accumulation.

Optimization of murine CD8+ cytotoxic T-lymphocyte responses to pseudorabies virus.

The aim of this work was to optimize the procedures used to elicit a cellular immune response to pseudorabies virus (PrV) in mice, using various immunization schedules and routes. An Eu-labeling-based cytotoxic T-lymphocyte (CTL) test was developed to measure the response. This necessitated optimization of numerous steps. In suspension, Eu labeling required high concentrations of dextran-sulfate (DXS) and Eu with a 30-min labeling time at room temperature. For anchored cells, the labeling time was 1 to 48 h, and the labeling efficiency depended strongly on the Eu concentration, but only marginally on the DXS concentration. In vivo and in vitro stimulation protocols were also optimized for the CTL test. For in vitro stimulation, spleen cells were cultured in T-25 flasks at a multiplicity of infection (m.o.i.) of 2. The CTL test was validated by specific depletion of CD8+ CTL, FACS analysis, and by comparing Eu and 51 Cr labeling. Then groups of mice were vaccinated once or twice by various routes (intraperitoneal (i.p.), intravenous (i.v.), subcutaneous (s.c.) and in the rear footpads (FP)) and according to different time schedules. CTL activity was detected only in boosted animals immunized FP, i.p. or i.v. That the cellular immune response contributes to protection was further suggested by the observation that i.p. immunization conferred better protection against challenge than s.c. immunization.

Dual activation by thyrotropin of the phospholipase C and cyclic AMP cascades in human thyroid.

In human thyroid slices prelabeled with myo-[2-3H]inositol, thyrotropin (TSH, 3-30 mU/ml) stimulated IP3, IP2 and IP1 generation over a prolonged time course. The cAMP response was much more sensitive to TSH, peaking between 1 and 5 mU/ml. Forskolin (10(-5) M) and isoproterenol had no effect on basal IP levels, while carbamylcholine (10(-5) M, 10(-4) M) also increased IP accumulation. These data suggest that in the human thyroid, TSH activates a phospholipase C generating IP3 and diacylglycerol independently of the well-known adenylate cyclase stimulation. They validate in the human model a dual mode of action of the hormone previously proposed on the basis of indirect observations.

[Hospital-based acute care of emergency patients: the importance of interdisciplinary teamwork]. / Innerklinische Akutversorgung von Notfallpatienten : Stellenwert und Aspekte der interprofessionellen Teamarbeit.

BACKGROUND: The care of emergency patients with life-threatening injuries or diseases presents a special challenge to the treatment team. Good interdisciplinary cooperation is essential for fast, priority-oriented, and efficient emergency room management. Particularly in complex situations, such as trauma room care, so-called human factors largely determine the safety and performance of the individual as well as the team. Approximately 70 % of all adverse events stem from human factors rather than from a lack of medical expertise. It has been shown that 70-80 % of such incidents are preventable through special training. OBJECTIVES: Established course concepts based on so-called ABCDE schemes are a good basis for creating algorithms for targeted therapy, yet they are not sufficient for the training of team-specific issues. For this, special course concepts are required, such as crew resource management, which is provided through simulator-based training scenarios. This includes task management, teamwork, decision-making, and communication. The knowledge of what needs to be done in a team under the adverse and complex conditions of a medical emergency must be gained by training based on realistic and effective measures. CONCLUSION: Course concepts that are geared toward interdisciplinary and interprofessional team training optimize patient safety and care by supporting the nontechnical abilities of team members.

[Medical emergency teams in hospitals]. / Medizinische Notfallteams im Krankenhaus.

BACKGROUND: In-hospital emergencies represent an increasing challenge with regard to risk management in hospitals and until now, no binding recommendations for in-hospital emergency management are available in Germany. Time delays in the detection and treatment of critically ill patients on the wards often lead to serious adverse events. The concept of traditional resuscitation teams is not adequate, because they are initiated only after acute deterioration or cardiac arrest has already occurred. OBJECTIVE: The introduction of a rapid response system with a preventive approach based on a medical emergency team (MET) represents an essential improvement in the management of in-hospital emergencies. However, it is not sufficient to simply rename and restructure the existing resuscitation team to a MET. Rather, the introduction of standardized preventive alarm criteria and structured processes, standardization of training and emergency equipment in the clinic, and the provision of a MET associated with the intensive care unit are required. CONCLUSION: For a hospital with an already established resuscitation team, this represents a fundamental paradigm shift to a sustainable, interdisciplinary, and institutionalized process of rethinking and reorganizing. A clear commitment and ongoing joint efforts of the hospital management and all hospital staff are prerequisite for this.

The role of magnetoelastic and magnetostrictive energies in the magnetization process of MnAs/GaAs epilayers.

In this work we present a detailed study of the anisotropic magnetic behavior of MnAs epilayers grown by molecular beam epitaxy on GaAs(001) and GaAs(111)B substrates. An extended approach of the Stoner-Wohlfarth model is used to simulate magnetic hysteresis loops of MnAs epilayers for temperatures around the magnetostructural phase transition. We demonstrate that magnetoelastic and magnetostrictive energy contributions to the magnetic free energy density are crucial to correctly describe the magnetization of both kinds of MnAs epilayers.

Ferromagnetism induced by oxygen and cerium vacancies above the percolation limit in CeO2.

We studied the structural, chemical and magnetic properties of non-doped ceria (CeO(2)) thin films electrodeposited on silicon substrates. Experimental results confirm that the observed room temperature ferromagnetism is driven by both cerium and oxygen vacancies. We investigated ceria films presenting vacancy concentrations well above the percolation limit. Irradiation experiments with neon ions were employed to generate highly oxygen defective CeO(2-δ) structures. X-ray photoelectron spectroscopy and x-ray absorption near-edge structure spectroscopy were used to estimate the concentration of Ce(3+) sites in the films, which can reach up to 50% of Ce(3+) replacing Ce(4+), compared to a stoichiometric CeO(2) structure. Despite the increment of structural disorder, we observe that the saturation magnetization continuously increases with Ce(3+) concentration. Our experiments demonstrate that the ferromagnetism observed in ceria thin films, highly disordered and oxygen-deficient, preserving the fluorite-type structure only in a nanometer scale, remains intrinsically stable at room temperature.