Video versus direct laryngoscopy to improve the success rate of nasotracheal intubations in the neonatal intensive care setting: a randomised controlled trial.

OBJECTIVE: To assess whether video laryngoscopy (VL) for tracheal intubation of neonates results in a higher first-attempt success rate and fewer adverse tracheal intubation-associated events (TIAEs) when compared with direct laryngoscopy (DL). DESIGN: Single-centre, parallel group, randomised controlled trial. SETTING: University Medical Centre Mainz, Germany. PATIENTS: Neonates <440/7 weeks postmenstrual age in whom tracheal intubation was indicated either in the delivery room or in the neonatal intensive care unit. INTERVENTION: Intubation encounters were randomly assigned to either VL or DL at first attempt. PRIMARY OUTCOME: First-attempt success rate during tracheal intubation. RESULTS: Of 121 intubation encounters assessed for eligibility, 32 (26.4%) were either not randomised (acute emergencies (n=9), clinicians' preference for either VL (n=8) or DL (n=2)) or excluded from the analysis (declined parental consent (n=13)). Eighty-nine intubation encounters (41 in the VL and 48 in the DL group) in 63 patients were analysed. First-attempt success rate was 48.8% (20/41) in the VL group compared with 43.8% (21/48) in the DL group (OR 1.22, 95% CI 0.51 to 2.88).The frequency of adverse TIAEs was 43.9% (18/41) and 47.9% (23/48) in the VL and DL group, respectively (OR 0.85, 95% CI 0.37 to 1.97). Oesophageal intubation with concomitant desaturation never occurred in the VL group but in 18.8% (9/48) of intubation encounters in the DL group. CONCLUSION: This study provides effect sizes for first-attempt success rates and frequency of TIAEs with VL compared with DL in the neonatal emergency setting. This study was underpowered to detect small but clinically important differences between the two techniques. The results of this study may be useful in planning future trials.

PerIoperative iNflammatory reSponse assessment In hiGH-risk patienTs undergoing non-cardiac surgery (INSIGHT): study protocol of a prospective non-interventional observational study.

INTRODUCTION: Increased inflammatory processes after non-cardiac surgery are very common. The association between postoperative inflammation and the occurrence of cardiovascular complications after non-cardiac surgery are still not entirely clear. Therefore, we will evaluate the association between postoperative inflammation and the occurrence of major cardiovascular complications in patients at-risk for cardiovascular complications undergoing non-cardiac surgery. We will further evaluate the association of postoperative inflammation and days-at-home within 30 days after surgery (DAH30), the incidence of acute kidney injury, postoperative N-terminal probrain natriuretic peptide (NT-proBNP) concentrations and neurocognitive decline. METHODS AND ANALYSIS: In this multicentre study, we will include 1400 patients at-risk for cardiovascular complications undergoing non-cardiac surgery. Our primary aim is to evaluate the association of postoperative maximum C-reactive protein concentration and the occurrence of a composite of five major cardiovascular complications (myocardial infarction, myocardial injury after non-cardiac surgery, new onset of atrial fibrillation, stroke and death) within 30 days after surgery using a Mann-Whitney-U test as well as a logistic regression model. As our secondary aim, we will evaluate the association of a composite of three inflammatory biomarkers (interleukin 6, procalcitonin and copeptin) on the occurrence of our composite of five cardiovascular complications within 30 days and 1 year after surgery, acute kidney injury, DAH30 and NT-proBNP concentrations using linear or logistic regression models. We will measure inflammatory biomarkers before surgery, and on the first, second, third and fifth postoperative day. We will check medical records and conduct a telephone survey 30 days and 1 year after surgery. We evaluate neurocognitive function, using a Montreal Cognitive Assessment, before and 1 year after surgery. ETHICS AND DISSEMINATION: This study was approved by the ethics committees at the Medical University of Vienna (2458/2020) and at the Medical University of Graz (33-274 ex 20/21). TRIAL REGISTRATION NUMBER: NCT04753307.

Mechanical ventilation with ten versus twenty breaths per minute during cardio-pulmonary resuscitation for out-of-hospital cardiac arrest: A randomised controlled trial.

AIM OF THE STUDY: This study sought to assess the effects of increasing the ventilatory rate from 10 min-1 to 20 min-1 using a mechanical ventilator during cardio-pulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) on ventilation, acid-base-status, and outcomes. METHODS: This was a randomised, controlled, single-centre trial in adult patients receiving CPR including advanced airway management and mechanical ventilation offered by staff of a prehospital physician response unit (PRU). Ventilation was conducted using a turbine-driven ventilator (volume-controlled ventilation, tidal volume 6 ml per kg of ideal body weight, positive end-expiratory pressure (PEEP) 0 mmHg, inspiratory oxygen fraction (FiO2) 100%), frequency was pre-set at either 10 or 20 breaths per minute according to week of randomisation. If possible, an arterial line was placed and blood gas analysis was performed. RESULTS: The study was terminated early due to slow recruitment. 46 patients (23 per group) were included. Patients in the 20 min-1 group received higher expiratory minute volumes [8.8 (6.8-9.9) vs. 4.9 (4.2-5.7) litres, p < 0.001] without higher mean airway pressures [11.6 (9.8-13.6) vs. 9.8 (8.5-12.0) mmHg, p = 0.496] or peak airway pressures [42.5 (36.5-45.9) vs. 41.4 (32.2-51.7) mmHg, p = 0.895]. Rates of ROSC [12 of 23 (52%) vs. 11 of 23 (48%), p = 0.768], median pH [6.83 (6.65-7.05) vs. 6.89 (6.80-6.97), p = 0.913], and median pCO2 [78 (51-105) vs. 86 (73-107) mmHg, p > 0.999] did not differ between groups. CONCLUSION: 20 instead of 10 mechanical ventilations during CPR increase ventilation volumes per minute, but do not improve CO2 washout, acidaemia, oxygenation, or rate of ROSC. CLINICALTRIALS: gov Identifier: NCT04657393.

Association of immediate versus delayed extubation of patients admitted to intensive care units postoperatively and outcomes: A retrospective study.

AIM OF THIS STUDY: This study seeks to investigate, whether extubation of tracheally intubated patients admitted to intensive care units (ICU) postoperatively either immediately at the day of admission (day 1) or delayed at the first postoperative day (day 2) is associated with differences in outcomes. MATERIALS AND METHODS: We performed a retrospective analysis of data from an Austrian ICU registry. Adult patients admitted between January 1st, 2012 and December 31st, 2019 following elective and emergency surgery, who were intubated at the day 1 and were extubated at day 1 or day 2, were included. We performed logistic regression analyses for in-hospital mortality and over-sedation or agitation following extubation. RESULTS: 52 982 patients constituted the main study population. 1 231 (3.3%) patients extubated at day 1 and 958 (5.9%) at day 2 died in hospital, 464 (1.3%) patients extubated at day 1 and 613 (3.8%) at day 2 demonstrated agitation or over-sedation after extubation during ICU stay; OR (95% CI) for in-hospital mortality were OR 1.17 (1.01-1.35, p = 0.031) and OR 2.15 (1.75-2.65, p<0.001) for agitation or over-sedation. CONCLUSIONS: We conclude that immediate extubation as soon as deemed feasible by clinicians is associated with favourable outcomes and may thus be considered preferable in tracheally intubated patients admitted to ICU postoperatively.

Evaluation of the usefulness of non-invasive serum haemoglobin measurement in a perioperative setting in a prospective observational study.

Patient Blood Management (PBM) programmes seek to reduce the number of missed anaemic patients in the run-up to surgery. The aim of this study was to evaluate the usefulness of haemoglobin (Hb) measured non-invasively (SpHb) in preoperative screening for anaemia. We conducted a prospective observational study in a preoperative clinic. Adult patients undergoing examination for surgery who had their Hb measured by laboratory means also had their Hb measured non-invasively by a trained health care provider. 1216 patients were recruited. A total of 109 (9.3%) patients (53 men and 56 women) was found to be anaemic by standard laboratory Hb measurement. Sensitivity for SpHb to detect anaemic patients was 0.50 (95% CI 0.37-0.63) in women and 0.30 (95% CI 0.18-0.43) in men. Specificity was 0.97 (95% CI 0.95-0.98) in men and 0.93 (95% CI 0.84-1.0) in women. The rate of correctly classified patients was 84.7% for men and 89.4% for women. Positive predictive value for SpHb was 0.50 (95% CI 0.35-0.65) in men and 0.40 (95% CI 0.31-0.50) in women; negative predictive value was 0.93 (95% CI 0.92-0.94) in men and 0.95 (95% CI 0.94-0.96) in women. We conclude that due to low sensitivity, SpHb is poorly suitable for detecting preoperative anaemia in both sexes under standard of care conditions.

National Planetary Health learning objectives for Germany: A steppingstone for medical education to promote transformative change.

Physicians play an important role in adapting to and mitigating the adverse health effects of the unfolding climate and ecological crises. To fully harness this potential, future physicians need to acquire knowledge, values, skills, and leadership attributes to care for patients presenting with environmental change-related conditions and to initiate and propel transformative change in healthcare and other sectors of society including, but not limited to, the decarbonization of healthcare systems, the transition to renewable energies and the transformation of transport and food systems. Despite the potential of Planetary Health Education (PHE) to support medical students in becoming agents of change, best-practice examples of mainstreaming PHE in medical curricula remain scarce both in Germany and internationally. The process of revising and updating the Medical Licensing Regulations and the National Competency-based Catalog of Learning Objectives for Medical Education in Germany provided a window of opportunity to address this implementation challenge. In this article, we describe the development and content of national Planetary Health learning objectives for Germany. We anticipate that the learning objectives will stimulate the development and implementation of innovative Planetary Health teaching, learning and exam formats in medical schools and inform similar initiatives in other health professions. The availability of Planetary Health learning objectives in other countries will provide opportunities for cross-country and interdisciplinary exchange of experiences and validation of content, thus supporting the consolidation of Planetary Health learning objectives and the improvement of PHE for all health professionals globally.

Impact of the COVID-19 pandemic on incidence, time of diagnosis and delivery of healthcare among paediatric oncology patients in Germany in 2020: Evidence from the German Childhood Cancer Registry and a qualitative survey.

BACKGROUND: The indirect impact of the COVID-19 pandemic on cancer care and timely diagnosis is of increasing concern. We investigated the impact of the COVID-19 pandemic on incidence, time of diagnosis and delivery of healthcare among paediatric oncology patients in Germany in 2020. METHODS: We analysed incident paediatric cancer cases diagnosed in 0- to 17-year olds in Germany in 2020 using data of the German Childhood Cancer Registry. Absolute numbers and age-standardised incidence rates (ASR) in 2020 were compared to the previous five years (2015-2019). Moreover, we conducted a survey with open-ended questions, gathering perceptions of the diagnostic process and healthcare delivery for paediatric oncology patients during the COVID-19 pandemic. FINDINGS: More or similar numbers of paediatric cancer patients were newly diagnosed each month throughout 2020 in comparison to the previous five years. The estimated ASRs showed markedly higher incidence rates, overall and across diagnostic groups, in 2020 compared to 2015-2019. Results from the qualitative survey indicated that diagnostic processes, timeliness of diagnosis, and delivery of treatment were hardly affected during the COVID-19 pandemic. However, psychosocial supportive care and non-urgent appointments were considerably reduced during the lockdown periods. INTERPRETATION: We found no indications of severe adverse effects of the COVID-19 pandemic on diagnosis and delivery of healthcare among children with cancer in Germany. The underlying reasons of the increase in incidence rates remain speculative. Continued close monitoring of incidence patterns may shed light on the underlying reasons of the present increase and contribute to understanding disease aetiology. FUNDING: None.

[Planetary health-transformative education regarding the climate and sustainability crises for health professionals]. / Planetare Gesundheit ­ transformative Lehr- und Lernformate zur Klima- und Nachhaltigkeitskrise für Gesundheitsberufe.

The urgency of the climate and sustainability crises and their health effects are receiving increasing attention in the German health system. To avoid further exacerbation of these crises, profound transformative processes in all sectors of society are needed (e.g. transport, energy production, and food systems). Based on the ethical imperative of non-maleficence and the high levels of trust in society, health professionals have great potential to make an important contribution to the necessary transformative processes.In order to fully harness this potential, health professionals should be supported in developing competencies to take transformative action during their pre- and postgraduate education and professional training. In this article, we introduce the concept of planetary health, as this concept provides orientation for this both ethically and with regards to the subject matter. Furthermore, we provide an overview of current teaching and learning formats and identify aspects that could contribute to further developing planetary health education.

Subjectively and objectively assessed social and physical environmental correlates of preschoolers' accelerometer-based physical activity.

BACKGROUND: Overweight and low levels of physical activity (PA) in preschoolers are major public health concerns. However, to date only few studies have investigated subjective and objective correlates of PA across different socioecological domains in preschoolers. We therefore simultaneously investigate associations between preschoolers' objectively measured leisure-time PA and a comprehensive set of subjective and objective potential PA correlates across the behavioral, social and physical environmental domains on both family- and community-level. METHODS: In this cross-sectional study time spent in moderate-to-vigorous PA (MVPA) and total PA (TPA) were measured by combined accelerometry and heart rate monitoring in 735 3-6 year-old children from 52 preschools in Southern Germany. Family- and community-level potential correlates of PA from different domains (behavioral, social and physical environmental) were subjectively (i.e. by parent proxy-report) and objectively assessed. Their associations with PA on weekend days and weekday afternoons were tested by covariate-adjusted multilevel regression models. RESULTS: While none of the objective social and physical environmental factors showed associations with PA, subjective parental traffic safety perceptions were positively associated with MVPA and TPA on weekends. Also, preschoolers' participation in organized sports was positively correlated with MVPA (on weekends) and TPA (both on weekends and weekday afternoons). CONCLUSION: Subjective traffic safety perceptions and participation in organized sports, an indicator and a result of parental support towards PA - i.e. subjective parental perceptions of environmental factors and family-level correlates which are more proximal to preschoolers - might be more central to PA in preschool age than objectively assessed community-level environmental features which tend to be more distal correlates. If replicable, targeting parental perceptions of environmental factors and parental support for PA in preschool age might be powerful leverages for public health policy.

How are physical activity behaviors and cardiovascular risk factors associated with characteristics of the built and social residential environment?

BACKGROUND: The aim of our study was to identify perceptions of built and social residential characteristics and their association with behaviors such as physical activity (PA), nutrition and smoking and with cardiovascular risk factors (elevated BMI and fasting blood glucose). METHODS: Among participants of a preventive medical checkup at an Austrian District Health Insurance Fund (n=904, response rate = 82.2%, 42% women, 18-91 years) self-reported and measured data were collected. RESULTS: Total PA was positively associated with the presence of trees along the streets and high levels of pro-physical activity social modeling (SM) and it was negatively related to perceived safety from crime. More leisure-time PA was associated with higher levels of cycling/walking infrastructure and high levels of SM. PA for transportation was positively related to high levels of connectivity and high levels of SM. Better behavioral cardiovascular risk factor profiles (smoking and nutrition) were associated with high levels of SM and high levels of total PA. Lower BMI values were associated with high levels of infrastructure and high levels of SM. CONCLUSIONS: Both built and social residential characteristics are important correlates of PA as well as of major cardiovascular risk factors besides PA.