[The subanalysis of Rheuma-VOR demonstrates a considerable need for rheumatological care]. / Die Subanalyse von Rheuma-VOR zeigt den erheblichen Bedarf der rheumatologischen Versorgung auf.

BACKGROUND: Early diagnosis and treatment of inflammatory rheumatic diseases can prevent consequential damage such as permanently limited mobility and joint or organ damage. Simultaneously, there is an increasing deficit in medical care owing to the lack of rheumatological capacity. Rural regions are particularly affected. OBJECTIVES: The available unconfirmed diagnoses of the study Rheuma-VOR were analysed regarding another definitive inflammatory rheumatic disease. MATERIALS AND METHODS: The returned questionnaires of the rheumatologists participating in Rheuma-VOR were screened for definitive inflammatory rheumatic diseases other than the required diagnosis of rheumatoid arthritis, psoriatic arthritis or spondyloarthritis. RESULTS: Of 910 unconfirmed diagnoses, in 245 patients another definitive diagnosis could be confirmed. A total of 29.8% of the diagnoses corresponded to degenerative joint changes or chronic pain syndrome, whereas 26.1% involved different forms of inflammatory arthritis. The majority of diagnoses (40.5%) were collagenosis or vasculitis, DISCUSSION: The available data show that a rheumatological presentation was indicated for the majority of patients. Owing to the increasing deficits in medical care a prior selection of the patients is crucial to make optimal use of restricted rheumatological capacities.

[Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]. / Leitlinie zur Langzeit-Sauerstofftherapie.

Long-term oxygen therapy is of great importance both for reducing mortality and for improving performance in patients with chronic lung diseases. The prerequisites for Long-term oxygen therapy are adequate diagnostics and clearly defined indication. A causal distinction into chronic hypoxaemic and hypercapnic respiratory failure is reasonable, from which the differential indication for non-invasive ventilation results.The revised guideline covers the diagnostics and indication of chronic lung and heart diseases, the role of oxygen in terminal illness and gives a detailed description of available oxygen devices. The guideline is intended to help avoid undersupply, oversupply and false prescriptions. Furthermore, the chapter "Postacute Oxygen Therapy" discusses the procedure, relevant in everyday life, but not yet clearly defined, for prescribing oxygen therapy for the home at the end of an inpatient stay. Another important point, the correct prescription of mobile oxygen systems, is also presented in the guideline. This document is a revised version of the guideline for longterm oxygen therapy and replaces the version of 2008.

[Technological Innovations in Pulmonology - Examples from Diagnostics and Therapy]. / Expertentreffen COPD: Technologische Innovationen in der Pneumologie ­ Facetten aus Diagnostik und Therapie.

A significant proportion of the current technological developments in pneumology originate from the various areas of information technology. The spectrum ranges from smartphone apps to be used in daily life or in patient care to the use of artificial intelligence in screening and early detection of diseases. The diagnostic accuracy of apps for symptom analysis is currently very limited. Research projects are performed on the integration of symptoms and functional parameters into early detection, but also on mobility measurements as a prognostic marker in COPD. Lung cancer screening using computed tomography represents a major challenge. Here, artificial intelligence can help radiologists to cope with huge amounts of data. However, the quality of the software depends on the sufficient training of the system. Technological developments shape all fields of pneumology. For diagnostic and interventional endoscopy, they offer improved biopsy techniques and microstructural imaging. Advances in lung function measurements allow the differentiated analysis of respiratory mechanical disorders, and they could be transferred to ventilation technology. The translation of basic findings about the lung microbiome into patient care may perspectively help to better understand and treat COPD exacerbations.

[Physical activity, exercise and nutrition in rheumatism : Adjuvant treatment options for inflammatory-rheumatic diseases]. / Körperliche Aktivität, Training und Ernährung bei Rheuma : Adjuvante Behandlungsoptionen bei entzündlich-rheumatischen Erkrankungsbildern.

BACKGROUND AND OBJECTIVES: The positive effects of physical activity, physical training and an adaptation of diet on health have been scientifically proven for many diseases. Focusing on inflammatory rheumatic diseases and their potential comorbidities, positive effects are assumed from these two adjuvant treatment opportunities, which are examined in more detail in this review. MATERIAL AND METHODS: Based on a literature search, randomized controlled trials (RCTs), non-RCT studies, reviews and recommendations from professional societies were included. RESULTS: Physical activity and training show positive effects on the disease itself and also on its comorbidities with existing certainty. In addition, the exercise and training recommendations of the American College of Sports Medicine (ACSM) and the American Heart Association (AHA) provide recommendations, which were adapted by the European League Against Rheumatism (EULAR) to control intensity, duration and training extent. Nutritional medical approaches also provide preventive and rehabilitative beneficial possibilities. DISCUSSION: The increase of physical activity, regular physical training and the adaptation of diet should be a basic additive component of the treatment of inflammatory rheumatic diseases. In individual sub-aspects, the study situation is very heterogeneous and requires further research.

[Expert Workshop COPD: Lungs and Heart - Quite Often Ill Together]. / Expertentreffen COPD: Lunge und Herz ­ ziemlich oft gemeinsam krank!

When caring for patients with respiratory diseases, always think of the heart! This is especially important for COPD patients, but also for a variety of other disorders of the respiratory system. At the workshop "Luftschlösser", held once more at Wiesbaden, Germany in February 2019 the many and important interactions of the lungs and the heart as well as the therapeutic implications were discussed. Based on pathophysiology, the psycho-social consequences of dyspnea, the leading symptom in patients with lung and heart disease became apparent. A particularly demanding diagnostic and therapeutic situation occurs in patients suffering simultaneously of lung and heart disease. It has been shown how frequently the diagnosis myocardial infarction is missed in COPD patients - and vice versa. Surprisingly, this is also the case in asthmatics with coronary heart disease or heart failure, a fact not readily known in clinical practice. In patients with emphysema and no apparent heart disease, hyperinflation leads to significantly restricted heart function. Reducing hyperinflation by inhaling broncholytics thus improves heart function. Biomarkers are increasingly being used for diagnostic purposes. Their role is being investigated in the large German COPD cohort COSYCONET. Lung patients suffering from more severe heart diseases pose a challenge for therapy in intensive care, especially when ventilated, and weaning from the ventilator is prolonged. Lung vessel diseases are "classic" examples of the intimate interaction of the lungs and the heart. In pulmonary arterial hypertension as well as in chronic thrombo-embolic pulmonary hypertension the lag time between the first symptoms and the definite diagnosis is often unacceptably long. For both diseases of the lung vessels therapeutic options have improved significantly over the last years. Pulmonologists should take care of this increasingly important patient group. Sleep-related breathing disorders and heart function are closely intertwined. Both conditions need special attention after the results of the SERVE-HF trial have been published. But there is no doubt that obstructive sleep apnea represents an independent and important risk factor for cardiovascular disease and needs to be treated according to existing guidelines.This workshop demonstrated impressively the multiple interactions of the respiratory system with cardiac function, resulting diagnostic and therapeutic problems, and means to overcome these problems. Guidelines for respiratory diseases should appropriately address cardiac comorbidity.

[Experiences and results from Rheuma-VOR]. / Erfahrungen und Ergebnisse aus Rheuma-VOR.

Rheumatoid arthritis, psoriatic arthritis and axial spondylarthritis are the most common chronic autoimmune rheumatic diseases. For all three diseases an early diagnosis and initiation of treatment is crucial. The proof of concept network study "Rheuma-VOR" is a further developed version of the predecessor project ADAPTHERA and was extended to several federal states. The aim of this prospective study is to improve the early diagnosis of rheumatoid arthritis, psoriatic arthritis and axial spondylarthritis and thus positively impact the quality of care for patients with the help of multidisciplinary coordinating centers. To date 3710 disease-specific questionnaires from patients with the suspected diagnosis of rheumatoid arthritis, psoriatic arthritis or axial spondylarthritis from 1298 different primary care providers were registered in the multidisciplinary coordination centers. A total of 1958 appointments were made with 1 of the 53 participating rheumatology specialists. In 876 patients, 1 of the 3 rheumatic diseases was diagnosed in an early stage. The waiting period was on average 42.5 days depending on the federal state, which is well below the nationwide average. It should also be noted that the coordinated cooperation and risk stratification of the Rheuma-VOR coordination centers relieved the capacity of rheumatology specialists by 1281 appointments (34.5%). In addition, the 2­week Rheuma Bus Tour and the accompanying initiatives in Rhineland-Palatinate (Rheuma-VOR screening app and the triage consultation) are showing first promising positive results.

[Early recognition and screening consultation: a necessary way to improve early detection and treatment in rheumatology? : Overview of the early recognition and screening consultation models for rheumatic and musculoskeletal diseases in Germany]. / Früh- und Screeningsprechstunden: Ein notwendiger Weg zur besseren Frühversorgung in der internistischen Rheumatologie? : Rheumatologische Früh- und Screeningsprechstundenmodelle in Deutschland.

In order to reduce the prognostically relevant time interval between the initial manifestation of a rheumatic and musculoskeletal disease and diagnosis as well as the consecutive initiation of an appropriate treatment, several rheumatological centers in Germany have improved the access to initial rheumatologic evaluation by establishing early recognition/screening clinics at their respective sites. Corresponding models located at Altoetting·Burghausen, Bad Pyrmont, Berlin Buch, Duesseldorf, Heidelberg, Herne, Mannheim as well as supraregional/multicenter initiatives Rheuma Rapid, RhePort and Rheuma-VOR are presented in this overview along with the respective characteristics, potential advantages and disadvantages, but also first evaluation results of several models. The aim of this publication is to promote early detection of rheumatic and musculoskeletal diseases as one of the most important challenges in current rheumatology by encouraging further rheumatologic centers and practices to launch their own early recognition/screening consultation model on the basis of aspects presented herein.

[ADAPTHERA-Statewide cross-sectoral care network for patients with early rheumatoid arthritis shows sustained remission in standard care]. / ADAPTHERA ­ Landesweit transsektorales Versorgungsnetzwerk für Patienten mit früher rheumatoider Arthritis zeigt anhaltende Remissionen in der Regelversorgung.

BACKGROUND/OBJECTIVE: The majority of patients in Germany miss out on the necessity of early diagnosis and initiation of therapy for rheumatoid arthritis (RA) caused by considerable structural deficits in the health care system. The challenge is to reconcile the individual demand for the best possible therapy result with a sustainable expenditure of resources. METHODS: The cross-sectoral regional care network ADAPTHERA aims to improve early RA diagnosis and treatment in Rhineland-Palatinate. The retrospective triage analyses of suspected early onset RA patients was performed by tracing the selection process of all available enquiries (n = 1045). For analysis of the clinical course of the disease, a subset comprising 143 patients with a minimum observation time of 12 months (5 consecutive visits) was available. Clinical and laboratory parameters were collected quarter yearly, self-administered questionnaires were filled out and the treatment was adapted if necessary. RESULTS: A total of 454 patients were included. The mean waiting time was 23.9 (SD = 18) days. The mean observation period in the subcohort was 29.2 (SD = 12.7) months, with about 50% of the patients presenting within 3 months. Almost 75% of the patients were in remission after 2 years. A sustained remission could be described for 74.8% (6 months) and 53.5% (12 months), respectively. Especially patients with rapid remission induction benefited in terms of longer remissions (p = 0.03). A very early stage of the disease (VERA) was associated with a rarely necessary biologic therapy (p = 0.022). DISCUSSION: The approach of a supply network is not a panacea, but it might improve healthcare for patients with early onset RA. In order to minimize resource utilization, a pinpoint referral and accurate triage of potential cases are crucial.

[Depressive symptoms in early rheumatoid arthritis : Within the rheumatism network ADAPTHERA]. / Depressive Symptomatik bei früher rheumatoider Arthritis : Innerhalb des Rheumanetzwerks ADAPTHERA.

BACKGROUND AND OBJECTIVE: For patients with established rheumatoid arthritis and also early arthritis an increased prevalence of depression has been described. For a better understanding of depression in early arthritis patients, depression prevalences of a German early arthritis cohort were examined, with a focus on disease activity, anti-CCP status, disease duration and functional capacity over a period of 2 years. MATERIAL AND METHODS: The evaluation was based on the early arthritis cohort ADAPTHERA from Rhineland-Palatinate. The inclusion criterion was a symptom duration before diagnosis of a maximum of 1 year. Data from the disease activity score 28 (DAS28), the Health Assessment Questionnaire (HAQ, functional status), the WHO-5 Well-Being Index (WHO-5, well-being and depressive symptoms) and the Patient Health Questionnaire-9 (PHQ-9, depressive symptoms) were collected. RESULTS: At the beginning, 43.5% of patients had depressive symptoms (WHO-5 > 28). After the 2 year follow-up the percentage of patients with depressive symptoms had reduced to 20.8%. Correlations with disease activity according to DAS28 and the function of HAQ could be confirmed. There was no correlation between depressive symptoms and anti-CCP status (p = 0.431) or duration from symptom onset to diagnosis (p = 0.671). CONCLUSION: Screening of early arthritis patients for the presence of depressive symptoms is of essential importance. Patients seem to be at high risk of developing depressive symptoms especially at the beginning of the disease and when showing high disability and poor results on disease activity score (DAS28 and visual analog scale).

[Liquid biopsy in human non-small-cell lung cancer : Blood-based analysis of ctDNA methylation]. / Liquid Biopsy im nicht-kleinzelligen Lungenkarzinom : Die blutbasierte Analyse der ctDNA-Methylierung.

BACKGROUND: Use of liquid biopsy for minimal invasive follow-up diagnostics of non-small-cell lung carcinomas (NSCLCs). OBJECTIVES: Systematic search for new putative blood-based hypermethylation biomarkers to discriminate NSCLC patients from patients without a malign disease. METHODS: Quantitative analysis of gene promoter DNA methylation of potential biomarkers from cfDNA (plasma) with pyrosequencing. RESULTS: cfDNA hypermethylation in plasma confirmed significant higher methylation frequencies of the candidate gene CFTR of the NSCLC patients compared to the combined control groups and to NSCLC patients after curative therapy of primary NSCLC (post-NSCLC). ROC-analysis of the best discriminatory CpGs of the CFTR promotor (CpG1-2-4) revealed a sensitivity of 52% in NSCLC patients and a specificity of 90% in the post-NSCLC group (AUC: 0.69; p < 0.05). CONCLUSIONS: Promotor hypermethylation of the potential biomarker CFTR shows a discriminatory potential for differentiation of NSCLC patients to patients without a malign disease and should further be investigated.

[Expert Meeting: Integrated Care of the COPD Patients]. / Expertentreffen COPD: Integriertes Patientenmanagement bei COPD.

Despite considerable progress concerning pharmaceutical therapeutic options, many COPD patients show a markedly reduced quality of life and increased mortality risk. This workshop aimed to identify COPD-specific factors impeding an improved mode of care for patients with COPD. Such factors are: the generally lower social and educational status of the majority of COPD patients; the stigma of COPD as a self-inflicted disease ("smoker's lung"); the strict sectoral separation within the German health care system. In the second part the workshop tried to identify ways to improve the care of COPD patients. Use of health information technology, improved communication between care givers and patients as well as between the health care sectors, integrating rehabilitation and establishing self-management education are factors within an integrated patient-centered approach. In summary, an integrated management of the individual patient with COPD including multi-professional teams should contribute to optimizing the quality of COPD care.

[Noninvasive ventilation in acute respiratory insufficiency]. / Nichtinvasive Beatmung zur Behandlung akuter respiratorischer Insuffizienz.

The use of noninvasive ventilation reduces ventilator-associated complications. Thus, the outcome of patients suffering from acute hypercapnic respiratory insufficiency as well as cardiogenic lung edema can be improved. For the use of noninvasive ventilation to be successful and safe, its correct application is pivotal.

[Guidelines for Non-Invasive and Invasive Home Mechanical Ventilation for Treatment of Chronic Respiratory Failure - Update 2017]. / S2k-Leitlinie: Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz ­ Revision 2017.

Today, invasive and non-invasive home mechanical ventilation have become a well-established treatment option. Consequently, in 2010 the German Society of Pneumology and Mechanical Ventilation (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure". However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines.For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of home mechanical ventilation in paraplegic patients and in those with failure of prolonged weaning.In the current guidelines different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving home mechanical ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.The currently updated guidelines are valid for the next three years, following their first online publication on the home page of the Association of the Scientific Medical Societies in German (AWMF) in the beginning of July 2017. A subsequent revision of the guidelines remains the aim for the future.

[Exacerbation of COPD]. / Expertentreffen COPD: Exazerbation der COPD.

Acute worsenings of chronic obstructive pulmonary disease (COPD) were for a long time regarded as transient deteriorations, although occasionally life-threatening. No connection to disease progression was recognized. Data emerging during the last decade showed that patients had a considerably worse survival outcome after severe exacerbations. This insight was consolidated in 2012 by a large population-based cohort analysis. At present, severe exacerbations are regarded as key risk factors for COPD disease progression. The present article summarises the current knowledge on exacerbations of COPD, as delineated during an expert workshop in February 2017. It comprises pathogenic mechanisms, exacerbation triggers, the characteristics of frequent exacerbators, and the predictors of worse survival outcome. The role of comorbidities is considered more closely. The presentation of the pharmacotherapy of acute exacerbation is supplemented by an overview of ventilatory support. Finally, pharmacological and nonpharmacological preventive measures are summarised.

Differences between prolonged weaning patients from medical and surgical intensive care units.

BACKGROUND: It is not clear whether patients entering a specialized, interdisciplinary weaning unit from surgical or medical intensive care units (ICU) distinguish substantially. The purpose of the present study was to assess differences in patients with prolonged weaning being referred from surgical and medical ICU. METHODS: Data collected from April 2013 to April 2014 was conducted for retrospective analysis. Mortality rates, demographic data, clinical, and microbial differences in 150 patients with prolonged weaning were assessed (80 surgical and 70 medical). RESULTS: Surgical ICU referrals tended to be older (70.7 ± 11.3 vs. 67.3 ± 12.3, P = 0.051) and had fewer underlying pulmonary diseases (45% vs. 60%, P = 0.067). Sodium values at the time of referral to the weaning unit were significantly higher in surgical (147.1 ± 9.6) vs. medical (141.3 ± 6.7 mmol/l) patients (P < 0.001). Each 10-unit increase in sodium at the time of referral to the weaning unit was associated with a 2.5-day (95% CI -0.4, 5.4; P = 0.09) prolongation of stay in the weaning unit. Although significant differences in microbiological agents from tracheal aspiration were seen, the infection rate on the weaning unit was similar in both groups. There was no difference in weaning unit mortality between surgical and medical ICU patients (18% vs. 23%; P = 0.41). CONCLUSION: Few differences were found between patients being referred to a specialized weaning unit from surgical vs. medical ICUs. Besides differences in microbiological characteristics of tracheal secretions, there were also differences in sodium levels, which appear to influence on treatment duration.

Increased treatment persistence and its determinants in women with osteoporosis with prior fracture compared to those without fracture.

SUMMARY: The purpose of this study is to analyze treatment persistence in patients with osteoporosis after fracture diagnosis in German primary care practices. We found that pain increased treatment persistence. One key next step is to demonstrate whether or not this pain is related to fracture. INTRODUCTION: To analyze treatment persistence in patients with osteoporosis after fracture diagnosis in German primary care practices. METHODS: This study included postmenopausal women with osteoporosis aged between 40 and 90 years from 1188 general and 175 orthopedist practices in Germany. Treatment started between 2004 and 2013. The primary outcome measure was treatment persistence within 12 months after therapy initiation. Discontinuation of treatment was defined as a period of at least 90 days without therapy. Persistence analyses were carried out using Kaplan-Meier curves and log-rank tests, and the analyses of the impact of fracture on discontinuation risk were based on Cox regression models (with and without adjustment for pain medications). RESULTS: Thirteen thousand nine hundred seventy-five subjects (mean age = 74.8 years) were included in the group with fracture before therapy initiation and 18,138 (mean age = 72.7 years) in the group without fracture. Within 12 months after treatment initiation, therapy persistence increased with the delay between osteoporosis diagnosis and therapy initiation, rising from 40.7% when the delay was lower than or equal to 12 months to 44.3% when it exceeded 36 months (p value <0.0001). Fracture only decreased the risk of treatment discontinuation when the model was not adjusted for pain medications (HR = 0.95, 95% CI 0.93-0.98, p value <0.0001). CONCLUSIONS: Pain increased treatment persistence in women with osteoporosis and fracture. Further studies are needed to better understand factors influencing persistence.

[Extended coronary dissection caused by severe polytrauma with contusio cordis : Venoarterial ECMO-assisted percutaneous coronary intervention]. / Komplexe Koronardissektion bei Contusio cordis nach Polytrauma : Venoarterielle ECMO-unterstützte interventionelle Versorgung.

Treatment of a patient with acute cardiac failure due to a contusio cordis after polytrauma by an interdisciplinary team is reported. Shortly after admission to our shock room, the patient developed cardiogenic shock caused by an extended coronary dissection. After interim cardiopulmonary resuscitation, the patient was stabilized by venoarterial extracorporeal membrane oxygenation (ECMO) and subsequent complex coronary artery intervention in the heart catheter laboratory. Despite the increased left ventricular function which enabled partial weaning from the ECMO, the patient died of multiple organ failure 10 days after admission.

Vertebroplasty increases trabecular microfractures in elderly female cadaver spines.

UNLABELLED: This study assessed whether vertebroplasty increases trabecular bone microfractures in adjacent vertebrae of elderly female cadavers. Results indicated microfractures were almost two times greater in superior adjacent vertebrae for vertebroplasty treated spines compared to non-treated controls. This finding may aid in developing improved treatments for osteoporotic women with vertebral fractures. INTRODUCTION: Although vertebroplasty may stabilize compression fractures and reduce pain, subsequent vertebral fractures occur in approximately 25 % of patients, reducing the overall safety of this procedure. This is particularly a concern in vertebrae surrounding the treated level where bone cement may cause abnormal transfer of forces to adjacent spinal structures. Therefore, the objective of this study was to quantify the effects of vertebroplasty on local trabecular bone damage in adjacent vertebrae. METHODS: Five level motion segments (T11-L3) from osteopenic/osteoporotic female cadaver spines (T-score -2.9 ± 1.0) were assigned into either vertebroplasty or control (no vertebroplasty) groups (n = 10/group) such that T-score, trabecular microarchitecture, and age were similar between groups. Compression fractures were created in the L 1 vertebra of all specimens and PMMA bone cement was injected into the fractured vertebra of vertebroplasty specimens. All spine segments were subjected to cyclic axial compression (685-1370 N) for 115,000 cycles. Post-testing, trabecular cubes were cut from adjacent (T12 and L2) vertebral bodies and histologically processed. Trabecular microfractures were identified and normalized by bone area in each section. RESULTS: There were significantly more trabecular microfractures (p < 0.001) in superior adjacent vertebral bodies of the vertebroplasty group (0.091 ± 0.025 microfractures/mm(2)) when compared to the control group (0.049 ± 0.018 microfractures/mm(2)). However, there was no difference in trabecular microfractures (p = 0.835) between vertebroplasty (0.045 ± 0.022 microfractures/mm(2)) and control groups (0.035 ± 0.013 microfractures/mm(2)) for inferior adjacent vertebral bodies. CONCLUSIONS: Vertebroplasty specifically impacts the superior adjacent vertebrae of elderly female spines resulting in almost two times more trabecular microfractures when compared to non-treated controls.

Cardiopulmonary bypass considerations for pediatric patients on the ketogenic diet.

BACKGROUND: There is a population of children with epilepsy that is refractory to anti-epileptic drugs. The ketogenic diet, a high-fat, low-carbohydrate regimen, is one alternative treatment to decrease seizure activity. Special considerations are required for patients on the ketogenic diet undergoing cardiopulmonary bypass (CPB) to prevent exposure to glucose substrates that could alter ketosis, increasing the risk of recurrent seizures. CASE STUDY: A 2-year-old, 9 kilogram male with a history of infantile spasms with intractable epilepsy, trisomy 21 status post tetralogy of Fallot repair, presented to the cardiac operating room for closure of a residual atrial septal defect. All disciplines of the surgical case minimized the use of carbohydrate-containing and contraindicated medications. Changes to the standard protocol and metabolic monitoring ensured the patient maintained ketosis. DISCUSSION: All disciplines within cardiac surgery need to be cognizant of patients on the ketogenic diet and prepare a modified protocol. Future monitoring considerations include thromboelastography, electroencephalography and continuous glucose measurement. Key areas of focus with this patient population in the cardiac surgical theater are to maintain a multidisciplinary approach, alter the required CPB prime components, address cardiac pharmacological concerns and limit any abnormal hematological occurrences.

[Airway devices in the intensive care unit]. / Welcher Beatmungszugang für welchen Patienten auf der Intensivstation?

This review presents the potential indications for different airway devices in the intensive care unit (ICU). Since the interface during noninvasive ventilation is located outside the body, sedation is not regularly needed. Therefore, selection of a fitting mask is essential to avoid mask intolerance which is one of the biggest problems during noninvasive ventilation. Full-face masks are the interfaces mostly used for noninvasive ventilation to treat acute respiratory failure; here, mouth breathing is possible which is often necessary during acute respiratory failure. Good alternatives are total face masks and the helmet, whereas nasal masks and mouthpieces are not regularly used on the ICU. Extraglottic airway devices and coniotomy are used for the management of difficult airway situations on the ICU. Endotracheal intubation remains the gold standard procedure for airway management. However, this procedure is associated with a number of complications. Tracheostomy is the airway access of choice when long-term mechanical ventilation is necessary.