[Young Respiratory Physicians in Germany - Current Situation and Future Perspectives]. / Pneumologischer Nachwuchs in Deutschland.

BACKGROUND: Demographic changes in the society and among doctors, as well as changing attitudes towards and norms of how living should be structured are creating challenges regarding the organization of work environment in the hospital. In addition, organization of medical training is increasingly being influenced by economic considerations as well as a high level of medical specialization. We asked young respiratory physicians how they assessed their current situation with respect to quality of medical training and organization of their work environment. METHODS: From September to November 2019, we performed an online survey adressing young respiratory physicians in Germany. Participants were recruited via three emails (baseline and reminders after 2 and 6 weeks) sent by the German Respiratory Society (DGP) and the German Union of Pulmonologists (BdP). The questionnaire consisted of a maximum of 62 questions. Apart from own questions that had been aligned with other questionnaires from similar surveys in other medical specialties, we also assessed the effort-reward ratio (ER ratio) based on the short version of the effort-reward imbalance questionnaire (16 questions). RESULTS: We recuited n = 224 participants (33.8 ±â€Š4.5 years, 5.4 ±â€Š2.9 years of medical training, 54.4 % female , 86.8 % with German nationality). A little under half of the interviewees (n = 103, 46 %) reported to be very or generally satisfied with their working conditions, while n = 60 (27 %) were unsure. The main reasons for not being satisfied were long working hours and high work-load, as well as a lack of streamlining the work environment in the hospital to the specific needs of doctors. Despite the fact that many participants were satisfied, a large majority (n = 166, 88.2 %) depicted an unfavorable effort-reward ratio imbalance (adjusted mean 1.89 ±â€Š2.18). CONCLUSION: Compared to many other European countries and internationally, the German healthcare system offers high-quality patient care and a well-equipped work environment. Increasing demands in the health care sector, however, are leading to a gratification crisis that not only harms the health and work performance of doctors but is also leading to reduced attractiveness of the job that might possibly lead to the search for new fields of activity or migration. Respiratory medicine is a discipline of growing interest and motivating young doctors to secure the promotion of this discipline is increasingly important. Factors harming the growth of this discipline should be immediately addressed. The results of this survey might help leaders in the field to restructure the work environment and medical education according to the actual needs.

[The Diagnosis is Obvious]. / Die Diagnose liegt auf der Hand.

Clinically amyopathic dermatomyositis (CADM) is a rare entity of dermatomyositis. As a rule, CADM presents without muscular involvement. Thus, the level of creatine kinase is most commonly within the normal range. Dermal manifestations of CADM are Gottron's papules and mechanic's hands. In the case of melanoma differentiation-associated gene 5 intracellular pathogen sensor (MDa5 antibodies), CADM is often associated with a rapidly progressive and severe form of interstitial lung disease. Pulmonary function tests reveal restriction and hypoxemia of varying degree. Features of ground-glass opacities, reticulations and consolidations are detected in high-resolution CT scan. Lymphocytes are sometimes predominant in bronchioloalveolar lavage. Pathologists see a picture similar to non-specific interstitial lung disease or organizing pneumonia. Pronounced immunosuppression is the most common therapy. However, sometimes a combination of different immunosuppressive therapies is necessary. A novel strategy to treat CADM with rapidly progressive interstitial lung disease is the Janus kinase inhibitor tofacitinib. Treatment can be monitored with the level of ferritin and MDa5-antibody titer. Mortality is as high as 84 %.

[Crazy Paving Pattern of the Lung]. / Pflastersteine in der Lunge.

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disease. PAP results from impaired surfactant clearance. In adults, autoimmune pulmonary alveolar proteinosis is present in 90 - 95 % of the cases. In 5 - 10 %, other etiologies such as toxins and dust exposure, hematological disorders and infections have to be considered. Men between 30 - 60 years are commonly affected. Typical symptoms are cough, dyspnea and alteration in ventilatory function. CT scan of the lung is characterised by a crazy paving pattern. In serological testing, granulocyte macrophage colony-stimulation factor can be identified in most patients with autoimmune pulmonary alveolar proteinosis. Whole-lung lavage remains the therapy of choice. In the current case, treatment with whole-lung lavage resulted in clinical and functional improvement.

Interstitial lung opacities in patients with severe COVID-19 pneumonia by bedside high-resolution ultrasound in association to CO2 retention.

BACKGROUND: Coronavirus disease 2019 (COVID-19) can cause acute respiratory distress syndrome (ARDS). OBJECTIVE: This single centre cross-section study aimed to grade the severity of pneumonia by bed-side lung ultrasound (LUS). METHODS: A scoring system discriminates 5 levels of lung opacities: A-lines (0 points),≥3 B-line (1 point), coalescent B-lines (2 points), marked pleural disruptions (3 points), consolidations (4 points). LUS (convex 1-5 MHz probe) was performed at 6 defined regions for each hemithorax either in supine or prone position. A lung aeration score (LAS, maximum 4 points) was allocated for each patient by calculating the arithmetic mean of the examined lung areas. Score levels were correlated with ventilation parameters and laboratory markers. RESULTS: LAS of 20 patients with ARDS reached from 2.58 to 3.83 and was highest in the lateral right lobe (Mean 3.67). Ferritin levels (Mean 1885µg/l; r = 0.467; p = 0.051) showed moderate correlation in spearman roh calculation. PaCO2 level (Mean 46.75 mmHg; r = 0.632; p = 0.005) correlated significantly with LAS, while duration of ventilation, Horovitz index, CRP, LDH and IL-6 did not. CONCUSIONS: The proposed LAS describes severity of lung opacities in COVID-19 patients and correlates with CO2 retention in patients with ARDS.

Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): study protocol for a pilot randomised controlled trial.

BACKGROUND: Intensive care unit (ICU) survivors often suffer from cognitive, physical and mental impairments, known as post-intensive care syndrome (PICS). ICU follow-up clinics may improve aftercare of these patients. There is a lack of evidence whether or which concept of an ICU follow-up clinic is effective. Within the PINA study, a concept for an ICU follow-up clinic was developed and will be tested in a pilot randomised controlled trial (RCT), primarily to evaluate the feasibility and additionally the potential efficacy. METHODS/DESIGN: Design: Pilot RCT with intervention and control (usual care) arms plus mixed-methods process evaluation. PARTICIPANTS: 100 ICU patients (50 per arm) of three ICUs in a university hospital (Regensburg, Germany), ≥ 18 years with an ICU stay of > 5 days, a sequential organ failure assessment (SOFA) score > 5 during the ICU stay and a life expectancy of more than 6 months. INTERVENTION: The intervention will contain three components: information, consultation and networking. Information will be available in form of an intensive care guide for patients and next of kin at the ICU and phone support during follow-up. For consultation, patients will visit the ICU follow-up clinic at least once during the first 6 months after discharge from ICU. During these visits, patients will be screened for symptoms of PICS and, if required, referred to specialists for further treatment. The networking part (e.g. special referral letter from the ICU follow-up clinic) aims to provide a network of outpatient care providers for former ICU patients. Feasibility Outcomes: Qualitative and quantitative evaluation will be used to explore reasons for non-participation and the intervention´s acceptability to patients and caregivers. Efficacy Outcomes: Health-related quality of life (HRQOL) will be assessed as primary outcome by the physical component score (PCS) of the Short-Form 12 Questionnaire (SF-12). Secondary outcomes encompass further patient-reported outcomes. All outcomes are assessed at 6 months after discharge from ICU. DISCUSSION: The PINA study will determine feasibility and potential efficacy of a complex intervention in a pilot RCT to enhance follow-up care of ICU survivors. The pilot study is an important step for further studies in the field of ICU aftercare and especially for the implementation of a pragmatic multi-centre RCT. TRIAL REGISTRATION: ClinicalTrials.gov , NCT04186468 . Submitted 2 December 2019.